Good cancer treatment is not just brilliant diagnostics, treatment, and follow-up care, but includes treating and caring for the whole person, which can include understanding a patient’s sexual orientation and gender identity.
Should the approach of healthcare professionals treating patients who identify as lesbian, gay, bisexual, or transgender (LGBT) be different? Absolutely, they should, according to Liz Margolies, LCSW, founder and director of National LGBT Cancer Network.
“The essence of good cancer treatment is not just brilliant diagnostics, skillful surgery, fabulous chemotherapy, and follow-up care, but it includes treating and caring for the whole person,” Margolies said. “That includes understanding, for example, who her support system is, what her sexual orientation is, and what her gender identity is.”
Margolies gave her presentation last week at the Oncology Nursing Society (ONS) 41st Annual Congress, “The Same Only Scarier: Cancer Care and the LGBT Community,” in which she discussed discrimination within the healthcare system and some of the unique challenges that LGBT patients face.
People who fall under the LGBT umbrella are two different groups of people who are different from the “mainstream” by either their sexual orientation or by their gender identity. To draw an analogy, Margolies compared it to starting a club for people who love ice cream or love to hike. There may be some people who love to hike and love ice cream, but not everyone who loves to hike loves ice cream or vice versa. In other words, a person’s gender identity does not necessarily have anything to do with their sexual orientation.
A discussion of sexual orientation involves two people. Sexual orientation involves who a person is attracted to physically, emotionally, and sexually. It is not a description of behavior but of identity, she said.
“There was a large study in New York City of men who identify as heterosexual and about 10% of them had had sex with a man within the last year,” Margolies said. “Finding out someone’s sexual identity does not tell you everything about their behavior and does not tell you all the information about health risks.”
In contrast, gender identity is about a single person and their internal experience of being male, female, or neither. Those identifying as the sex they were assigned at birth are cisgender. People who feel their true gender does not match the gender they were assigned at birth are transgender.
Margolies said that healthcare workers may encounter people who are at different stages of transition. Some patients may be fully transitioned and others only starting their transition; however, it is important to remember that providers do not set the standard that a patient must meet before they can be called male or female. Instead, they should accept the gender identity of each patient as they wish it to be.
Discrimination against LGBT people occurs within the healthcare system. Margolies cited studies that estimated that 37% of transgender people reported being harassed or disrespected in the doctor’s office, and that one in five transgender people report being sent away by a healthcare provider.
“Discrimination,” Margolies said, “is not just unpleasant, but it is bad for your health.”
Many patients who identify as LGBT face discrimination or the fear of discrimination throughout the cancer care continuum, with each new physician, nurse, or treatment center that they are referred to. This discrimination leads not only to the avoidance of the healthcare system but to individual behaviors that might increase people’s cancer risk.
Once a cancer diagnosis is made, members of the LGBT community also face additional challenges.
Once a cancer diagnosis is made, patients do not have a lot of time to think about where they feel safe or who they would like treating them, but instead have to dive into treatment whether they feel safe or not.
“LGBT enter cancer treatment particularly wary, looking for signs of welcome or signs of discrimination,” Margolies said. In fact, she mentioned hearing from a gay man who was worried that a homophobic doctor might not remove all of his lesions during surgery, or that a homophobic nurse might make him wait longer for pain medications. Because of these fears, he chose to conceal his sexual orientation while he underwent treatment.
“LGBT people are often forced into a ‘Sophie’s choice’ between the best person who is known to be a horrible homophobic or transphobic vs a young, hip, less-experienced, LGBT-friendly person,” Margolies said.
Many LGBT patients have support systems that are different than those traditionally seen. Therefore, it is important for healthcare workers to ask each patient: Who is important to you? Who is your support system? Who do you want in the room with you? Who is going to be taking care of you?
These questions can really matter when addressing important aspects of treatment and follow-up care.
Margolies pointed out that many things related to cancer treatment can be gender-based, or assumptions are made based on typical gender expression. For example, some men have reported being uncomfortable with or unable to relate to the “battle” metaphor or the idea of battling cancer.
Similarly, when the treatment for breast cancer is housed in a placed called the Women’s Cancer Center, that can be alienating for transgender men or for gender non-conforming people who are being treated for breast cancer.
In some situations, LGBT people being treated for cancer may not have access to culturally appropriate information. Margolies discussed an example where a man with prostate cancer might experience erectile dysfunction after treatment.
“If the patient was brave enough to tell you that he was gay, would you know that he would need a firmer erection for anal sex. Would you know what it meant if they were the anal receptive partner in the relationship?” Margolies said. “First, you have to encourage your patients to say who they are, and then it is your job to know how to answer these questions, even if that means you have to get back to them.”
Margolies praised session attendees for making the choice to attend the session on LGBT issues and encouraged them to continue to learn to be an ally to LGBT patients and to answer questions about sexuality, fertility, and relationships.
In addition, oncology nurses should broadcast their welcome to LGBT patients instead of waiting for a patient to build the courage to disclose LGBT status.