What people who identify as LGBTQ should know about cancer

By Jessica Saenz

Barriers to health care largely due to stigma and discrimination make members of the lesbian, gay, bisexual, transgender, queer and gender-nonconforming community particularly vulnerable to cancer.

Navigating the health care system as an LGBTQ person can be challenging and uncomfortable, but taking steps to find proper care and understanding your cancer risks could save your life.

Here's what you should know about cancer if you identify as LGBTQ:

Barriers to health care contribute to cancer disparities in LGBTQ people.

LGBTQ people have consistently low rates of insurance coverage and are more likely to live below the poverty line, according to the American Cancer Society. These barriers make it more challenging for people who identify as LGBTQ to get the cancer screenings and care they need.

Many LGBTQ people face discrimination from health care professionals. "Unfortunately, health care practitioners have been one of those barriers to LGBTQ people getting good care. LGBTQ people are concerned about facing discrimination, or they have faced flat-out discrimination," says Juliana Kling, M.D., chair of the Women's Health Center at Mayo Clinic in Arizona.

"Unfortunately, health care practitioners have been one of those barriers to LGBTQ people getting good care. LGBTQ people are concerned about facing discrimination, or they have faced flat-out discrimination."

Juliana Kling, M.D.

In a recent study from the American Association for Cancer Research, 16% of people who identify as sexual and gender minorities reported discrimination while seeking health care, and nearly 1 in 5 of those who identify as sexual and gender minorities said they have avoided getting health care out of fear of discrimination.

"Many of the disparities are rooted in stigma and discrimination that have historically been — and continue to be — an issue for the LGBTQ+ population," says Dr. Kling.

Another barrier that contributes to health disparities for people who identify as LGBTQ is the limited knowledge health care professionals have about how cancer impacts LGBTQ people, according to the American Association for Cancer Research.

"Clinicians don't think it relates to them," says Dr. Kling. "But when we look at numbers, specifically for transgender people, the percentage for the general population is about 1.4 million self-identified transgender people in the U.S. There are about 1.2 million type 1 diabetics in the U.S. And most of us know a Type 1 diabetic. So, this is a population we need to be able to take care of."

Coming out to your health care team can help them provide better care.

Finding a health care professional you trust is crucial when it comes to your health and cancer prevention. But talking about your sexual identity and behaviors might not be easy.

"Sometimes it's hard to say the words out loud, but we want to know about you to get you the right care and get you to the right place," says Natalie Erbs, M.D., a Mayo Clinic family medicine physician.

"Sometimes it's hard to say the words out loud, but we want to know about you to get you the right care and get you to the right place."

Natalie erbs, M.D.

Leaving out details about your sexual identity and behaviors when talking to your health care professional can negatively affect your health.

"It affects what type of screenings you might need for certain sexually transmitted infections, depending on the type of sex you're having, and what exposures you might have to other things like HIV," says Dr. Erbs. HIV infection weakens your immune system, making you more likely to develop certain types of cancers.

HPV is another sexually transmitted infection that can increase your risk of certain types of cancer including cervical, anal and penile cancers. If you haven't been vaccinated for HPV, ask your health care professional if it's right for you.

Word-of-mouth recommendations, as well as LGBTQ-friendly health care professional databases and websites, can help you find a health care professional who is knowledgeable about the health of those who identify as LGBTQ.

"Once they find a knowledgeable and trusting clinician, then hopefully they feel that they can be their authentic self and disclose everything about themselves, including their health behaviors, challenges and other things that are impacting their health," says Dr. Kling.

Risk factors vary among different LGBTQ populations.

Anyone can have a combination of cancer risk factors, but the National LGBT Cancer Network says LGBTQ people are more likely to have a cluster of risk factors that contribute to increased cancer incidence and late-stage diagnosis.

These risk factors include:

• Delayed cancer screening.
• Alcohol use.
• Smoking.
• Obesity.
• HIV infection.
• HPV infection.

Though some of these risks affect every subgroup of the population identifying as LGBTQ, each sexual orientation and gender identity has its own cancer risks.

"Some research shows that lesbian and bisexual women may be at a higher risk for breast cancer than heterosexual women," says Dr. Kling.

Lesbian and bisexual women also are at a higher risk for colorectal, skin, cervical, endometrial and ovarian cancer. The National LGBT Cancer Network says this may be due to higher rates of tobacco and alcohol use and obesity, as well as nulliparity, a term for someone who has delayed childbirth or never given birth. These higher rates are likely influenced by the effects of discrimination and minority stress, which can increase risks of mood disorders and other such outcomes.

"Another example is men who have sex with men — particularly those who are HIV-positive. They are at increased risk for anal cancer," says Dr. Kling.

She adds that awareness of your personal risk factors is important, but she hopes it can lead to action. "What gets tricky is that there is limited guidance about routine anal cancer screening for this population of men. So it falls to us in the medical community to talk about that and figure out how to best serve this group."

Transgender people have unique cancer risks.

Delaying or avoiding cancer screenings can lead to late detection of cancer, which can mean worse outcomes. While this is true for everyone, transgender and gender-non-conforming people are more likely to forgo their cancer screenings and care, which puts them at a higher risk of late-stage cancer diagnosis and cancer death.

"For our transgender patients, that can be a much more sensitive topic because you may no longer identify with the organs you have. And if you don't identify with those organs, you might not want to come in and have them examined," says Dr. Erbs.

But current cancer screening guidelines aren't tailored to transgender and gender-non-conforming people. And many factors should be considered when you and your health care professional decide which screenings are best for you, how often you should receive them and — if you are transitioning — when you should receive them.

When you find a health care professional you can trust, consider sharing these details to help them recommend the best care plan for you:

• The organs you have that correspond with the gender you were assigned with at birth.
• Family history of cancer or family cancer syndromes you might be aware of.
• Medical and sexual history.
• Past or current hormone therapy to match your gender identity.

Cancer risks are associated with hormone therapy, but there isn't enough research to understand how significant these risks are, or how masculinizing and femininizing hormones influence cancer risk in sex-specific organs and other organs.

It can be overwhelming to weigh all your risk factors and understand the steps you need to take, but the right health care professional can guide and reassure you.

More research is needed to understand how cancer affects LGBTQ people.

Research and knowledge about cancer in LGBTQ people is limited and historically has focused on HIV and AIDS, according to the National Institutes of Health's Sexual & Gender Minority Research Office. This gap makes it challenging for health care professionals to provide adequate cancer care and screening to people who identify as LGBTQ, especially those who are part of LGBTQ subgroups, and underrepresented and underserved populations like racial minorities, people with disabilities, and people with low income.

Health care professionals agree that more investigation is needed to better understand how to provide effective and considerate cancer care to LGBTQ people.

A national survey of oncologists found that 95.3% of participants felt comfortable treating people who identify as lesbian, gay and bisexual, but only 53.1% reported they felt confident in their knowledge of their health needs. It also reported that 82.5% of oncologists felt comfortable treating patients who identify as transgender, but only 36.9% reported feeling confident in their knowledge of their health needs.

Health care organizations, including Mayo Clinic, are working to expand research about LGBTQ health and cancer care and better equip health care professionals with the training and resources to close the gap on LGBTQ cancer disparities.

---

The health care community has a long way to go to successfully meet the needs of every LGBTQ person, but you can take charge of your well-being by taking an active role in your health and working closely with your health care professional.

"We're actively working on providing a more inclusive and culturally agile experience at Mayo Clinic for our LGBTQ patients," says Dr. Kling. "We want you to feel like this is an environment where you can be your authentic self, and share your medical history and the lifestyle habits that may influence your cancer care."

Watch this "Mayo Clinic Q&A" podcast video to hear Dr. Kling discuss cancer screening, prevention and treatment for LGBTQ people, and the importance of finding a trusted health care team:

Learn more

Learn more by reading these articles:

• "Why you should come out as LGBTQ to your health care team."
• "The importance of cancer screenings for the LGBTQ community."
• "Gynecological care for trans men."
• "Resources for LGBTQ+ people with cancer."