Commentary

Coming out for better care: Improving cancer treatment for LGBT patients

Oncologists are increasingly becoming aware of the needs of patients with cancer who identify as lesbian, gay, bisexual and transgender.

Those seeking to educate themselves in order to improve the cultural competency of their practices can, and should, take advantage of many available resources.

The AMA maintains an LGBT health resource page for practitioners seeking information about LGBT health and training. Additionally, the Fenway Institute, Gay and Lesbian Medical Association Health Professionals Advancing LGBT Equality, and the World Professional Association for Transgender Health provide numerous resources for LGBT health education.

Nelson Sanchez, MD
Nelson Sanchez

The National LGBT Cancer Network specifically addresses the concerns of LGBT people with cancer and trains health care providers on LGBT culturally competent care. National conferences, such as the LGBT Health Workforce Conference, are another opportunity for practitioners to share best practices in the care of LGBT patients and learn about educational advancements in the training of healthcare providers.

It is also important that individual academic health centers, hospitals and clinics develop unique resources that best meet the needs of their staff, trainees and patients.

At Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine, we developed an in-person and online LGBT Allies Training Program to increase the overall campus community’s understanding of and capacity to address issues faced by LGBT people. We also videotaped scripted clinical encounters to teach trainees communication skills used in the care of LGBT patients, which can be found on YouTube.

Key first questions

Completing an inclusive history is the first step providers can take to provide quality care to LGBT patients.

Providers should start by asking open-ended questions to obtain information about a patient’s identity and family. Questions such as “Who do you include in your family?” “Who do you live with?” and “Do you have a partner or spouse?” are ways to introduce topics pertaining to sexuality and gender identity.

Some patients will volunteer information related to their identity, whereas others may remain guarded. It may take several visits and greater relationship building before a patient reveals information pertaining to their sexuality or gender identity.

It is important that providers ask directed questions when clinically appropriate, but also respect a patient’s level of comfort with discussions of sexuality and gender identity. Some patients are unsure how providers will use personal information. Will it be shared with clinical staff, family members, their employers or their insurance provider? It is paramount that providers make every effort to ensure that patients’ clinical information is protected at every level of the clinical encounter.

Oncology practitioners need to know who will be a patient’s support system during treatment and planning of care. A patient’s support system consists of family and friends who assist with appointment planning, medication compliance, home care and emotional well-being.

Some LGBT patients may be disenfranchised from their family and community and, thus, are at increased risk for debilitating physical and mental comorbidities resulting from cancer diagnosis and treatment. Inclusive communication skills will help identify a patient’s support system, benefiting the coordination of care and treatment compliance.

Transgender patients

Oncology practitioners should also familiarize themselves with specific LGBT health concerns. For transgender patients, providers should thoroughly review any and all hormones they may be using. Practitioners need to specifically ask about hormone use, as some patients may not report hormone use when asked about current medications.

Providers should also review their patients’ access to hormones, as some patients use hormones without medical supervision. This will serve as an opportunity to improve a transgender patient’s access to safe hormone usage.

Additionally, providers should inquire about any gender-affirming surgeries. Before initiating a physical exam, providers should review the necessary elements of the proposed exam and only proceed if the patient gives permission.

Some elements of a physical exam may be particularly distressing for a transgender patient and should only be proposed if medically indicated. All measures should be taken to make a transgender patient comfortable with a physical exam, such as allowing the patient to have a support person in the room.

LGBT–specific health concerns

All LGBT patients should have access to appropriate cancer screenings, such as mammography and colonoscopies. Due to misconceptions about lesbian and bisexual women’s sexual behaviors, some providers have not offered cervical cancer screening to women who have sex with women. All women should receive age appropriate cervical cancer screening counseling and education from their providers.

One area of cancer screening that has received minimal attention is anal cancer screening. Although the overall incidence of anal cancer remains small, patients with HIV are much more likely to get anal cancer than those not infected with the virus. Although it is not universally accessible, the anal Pap test is an easy to perform screening test that should be offered to high-risk patients.

Oncology practitioners should also be mindful of other LGBT health concerns not traditionally associated with cancer care. This is specifically important for oncology practitioners who serve as a patient’s primary medical provider. Sexual health maintenance includes the treatment of sexual dysfunctions secondary to some cancer treatments. Providers should be knowledgeable of HIV and sexually transmitted infection screenings, safer sex practices, and the utilization of pre-exposure prophylaxis for HIV–negative patients at high risk for HIV transmission.

Additionally, providers should assess and treat tobacco, alcohol and recreational drug use; provide regular mental health assessments; update vaccinations; screen for domestic violence; and counsel on diet and nutrition.

Everyday practice changes

Practitioners can take numerous steps to be LGBT affirming. On an individual level, providers can wear a pin on their white coat displaying the flag of the LGBT movement. Within their office, they can post LGBT “Safe Zone” signs or posters of LGBT people and their families accessing medical care. They can also maintain a referral directory of local providers that are LGBT friendly.

Providers should also make their worksite LGBT friendly. Patients receive signals of acceptance and inclusion at every level of a clinical encounter: at check-in and registration, nursing encounters or diagnostic testing.

If a provider is LGBT friendly but the remaining worksite staff is not, a patient will not feel comfortable accessing care at a clinic or hospital. All clinic and hospital staff should receive LGBT sensitivity training. Nondiscrimination policies and inclusive visitation policies should be posted in waiting areas and online.

Registration forms should be modified so patients can self-identify their sexual orientation and gender identity. This demographic data can also be used by researchers to assess community health disparities.

On an organizational level, health professionals can create a steering committee that oversees LGBT inclusion initiatives at a hospital or clinic. In 2007, the Human Rights Campaign created the Healthcare Equality Index (HEI), a national LGBT benchmarking tool that evaluates health care facilities’ policies and practices related to the equity and inclusion of their LGBT patients, visitors and employees.

Hospitals and clinics should use the standards formulated by the HEI to guide institutional programming that meets the needs of their LGBT community members.

References:

American Medical Association LGBT health resource page. Available at: www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/glbt-resources.page. Accessed on Sept. 13, 2016.

The Fenway Institute. Available at: www.lgbthealtheducation.org. Accessed on Sept. 13, 2016.

GLMA Health Professionals Advancing LGBT Equality. Available at: www.glma.org. Accessed on Sept. 13, 2016.

LGBT Allies Training Program. Available at: weill.cornell.edu/diversity/communities/lgbt-communities/safe-zone-lgbt-allies-training.html. Accessed on Sept. 20, 2016.

The National LGBT Cancer Network. Available at: www.cancer-network.org. Accessed on Sept. 13, 2016.

World Professional Association for Transgender Health. Available at: www.wpath.org. Accessed on Sept. 13, 2016.

LGBT Health Workforce Conference. Available at: http://bngap.org/lgbthwfconf/

For more information:

Nelson Sanchez, MD, is assistant professor of medicine at Weill Cornell Medicine and assistant attending physician at Memorial Sloan Kettering Cancer Center. He chairs Weill Cornell Medicine’s LGBT Steering Committee and Memorial Sloan Kettering’s LGBT Employee Resource Network, and serves as chairman of the LGBT Health Workforce Conference’s executive committee. He can be reached at sanchezn@mskcc.org.

Disclosure: Sanchez reports no relevant financial disclosures.

Oncologists are increasingly becoming aware of the needs of patients with cancer who identify as lesbian, gay, bisexual and transgender.

Those seeking to educate themselves in order to improve the cultural competency of their practices can, and should, take advantage of many available resources.

The AMA maintains an LGBT health resource page for practitioners seeking information about LGBT health and training. Additionally, the Fenway Institute, Gay and Lesbian Medical Association Health Professionals Advancing LGBT Equality, and the World Professional Association for Transgender Health provide numerous resources for LGBT health education.

Nelson Sanchez, MD
Nelson Sanchez

The National LGBT Cancer Network specifically addresses the concerns of LGBT people with cancer and trains health care providers on LGBT culturally competent care. National conferences, such as the LGBT Health Workforce Conference, are another opportunity for practitioners to share best practices in the care of LGBT patients and learn about educational advancements in the training of healthcare providers.

It is also important that individual academic health centers, hospitals and clinics develop unique resources that best meet the needs of their staff, trainees and patients.

At Memorial Sloan Kettering Cancer Center and Weill Cornell Medicine, we developed an in-person and online LGBT Allies Training Program to increase the overall campus community’s understanding of and capacity to address issues faced by LGBT people. We also videotaped scripted clinical encounters to teach trainees communication skills used in the care of LGBT patients, which can be found on YouTube.

Key first questions

Completing an inclusive history is the first step providers can take to provide quality care to LGBT patients.

Providers should start by asking open-ended questions to obtain information about a patient’s identity and family. Questions such as “Who do you include in your family?” “Who do you live with?” and “Do you have a partner or spouse?” are ways to introduce topics pertaining to sexuality and gender identity.

Some patients will volunteer information related to their identity, whereas others may remain guarded. It may take several visits and greater relationship building before a patient reveals information pertaining to their sexuality or gender identity.

It is important that providers ask directed questions when clinically appropriate, but also respect a patient’s level of comfort with discussions of sexuality and gender identity. Some patients are unsure how providers will use personal information. Will it be shared with clinical staff, family members, their employers or their insurance provider? It is paramount that providers make every effort to ensure that patients’ clinical information is protected at every level of the clinical encounter.

Oncology practitioners need to know who will be a patient’s support system during treatment and planning of care. A patient’s support system consists of family and friends who assist with appointment planning, medication compliance, home care and emotional well-being.

Some LGBT patients may be disenfranchised from their family and community and, thus, are at increased risk for debilitating physical and mental comorbidities resulting from cancer diagnosis and treatment. Inclusive communication skills will help identify a patient’s support system, benefiting the coordination of care and treatment compliance.

Transgender patients

Oncology practitioners should also familiarize themselves with specific LGBT health concerns. For transgender patients, providers should thoroughly review any and all hormones they may be using. Practitioners need to specifically ask about hormone use, as some patients may not report hormone use when asked about current medications.

Providers should also review their patients’ access to hormones, as some patients use hormones without medical supervision. This will serve as an opportunity to improve a transgender patient’s access to safe hormone usage.

Additionally, providers should inquire about any gender-affirming surgeries. Before initiating a physical exam, providers should review the necessary elements of the proposed exam and only proceed if the patient gives permission.

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Some elements of a physical exam may be particularly distressing for a transgender patient and should only be proposed if medically indicated. All measures should be taken to make a transgender patient comfortable with a physical exam, such as allowing the patient to have a support person in the room.

LGBT–specific health concerns

All LGBT patients should have access to appropriate cancer screenings, such as mammography and colonoscopies. Due to misconceptions about lesbian and bisexual women’s sexual behaviors, some providers have not offered cervical cancer screening to women who have sex with women. All women should receive age appropriate cervical cancer screening counseling and education from their providers.

One area of cancer screening that has received minimal attention is anal cancer screening. Although the overall incidence of anal cancer remains small, patients with HIV are much more likely to get anal cancer than those not infected with the virus. Although it is not universally accessible, the anal Pap test is an easy to perform screening test that should be offered to high-risk patients.

Oncology practitioners should also be mindful of other LGBT health concerns not traditionally associated with cancer care. This is specifically important for oncology practitioners who serve as a patient’s primary medical provider. Sexual health maintenance includes the treatment of sexual dysfunctions secondary to some cancer treatments. Providers should be knowledgeable of HIV and sexually transmitted infection screenings, safer sex practices, and the utilization of pre-exposure prophylaxis for HIV–negative patients at high risk for HIV transmission.

Additionally, providers should assess and treat tobacco, alcohol and recreational drug use; provide regular mental health assessments; update vaccinations; screen for domestic violence; and counsel on diet and nutrition.

Everyday practice changes

Practitioners can take numerous steps to be LGBT affirming. On an individual level, providers can wear a pin on their white coat displaying the flag of the LGBT movement. Within their office, they can post LGBT “Safe Zone” signs or posters of LGBT people and their families accessing medical care. They can also maintain a referral directory of local providers that are LGBT friendly.

Providers should also make their worksite LGBT friendly. Patients receive signals of acceptance and inclusion at every level of a clinical encounter: at check-in and registration, nursing encounters or diagnostic testing.

If a provider is LGBT friendly but the remaining worksite staff is not, a patient will not feel comfortable accessing care at a clinic or hospital. All clinic and hospital staff should receive LGBT sensitivity training. Nondiscrimination policies and inclusive visitation policies should be posted in waiting areas and online.

Registration forms should be modified so patients can self-identify their sexual orientation and gender identity. This demographic data can also be used by researchers to assess community health disparities.

On an organizational level, health professionals can create a steering committee that oversees LGBT inclusion initiatives at a hospital or clinic. In 2007, the Human Rights Campaign created the Healthcare Equality Index (HEI), a national LGBT benchmarking tool that evaluates health care facilities’ policies and practices related to the equity and inclusion of their LGBT patients, visitors and employees.

Hospitals and clinics should use the standards formulated by the HEI to guide institutional programming that meets the needs of their LGBT community members.

References:

American Medical Association LGBT health resource page. Available at: www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/glbt-advisory-committee/glbt-resources.page. Accessed on Sept. 13, 2016.

The Fenway Institute. Available at: www.lgbthealtheducation.org. Accessed on Sept. 13, 2016.

GLMA Health Professionals Advancing LGBT Equality. Available at: www.glma.org. Accessed on Sept. 13, 2016.

LGBT Allies Training Program. Available at: weill.cornell.edu/diversity/communities/lgbt-communities/safe-zone-lgbt-allies-training.html. Accessed on Sept. 20, 2016.

The National LGBT Cancer Network. Available at: www.cancer-network.org. Accessed on Sept. 13, 2016.

World Professional Association for Transgender Health. Available at: www.wpath.org. Accessed on Sept. 13, 2016.

LGBT Health Workforce Conference. Available at: http://bngap.org/lgbthwfconf/

For more information:

Nelson Sanchez, MD, is assistant professor of medicine at Weill Cornell Medicine and assistant attending physician at Memorial Sloan Kettering Cancer Center. He chairs Weill Cornell Medicine’s LGBT Steering Committee and Memorial Sloan Kettering’s LGBT Employee Resource Network, and serves as chairman of the LGBT Health Workforce Conference’s executive committee. He can be reached at sanchezn@mskcc.org.

Disclosure: Sanchez reports no relevant financial disclosures.