Each year, the American Cancer Society (ACS) puts out an annual report with extensive up-to-date information on cancer, its incidence, treatment and other pertinent facts. Cancer Facts & Figures 2024 includes something new: a separate special section on cancer in the LGBTQ+ community.
According to this report, LGBTQ+ people dealing with cancer face additional obstacles not faced by other patients because of widespread prejudicial attitudes and actions. The report says, “LGBTQ+ individuals with cancer experience disparate outcomes across the cancer continuum, including prevention, screening and early detection, diagnosis, treatment, and palliative care.”
Information about cancer’s impact on the LGBTQ+ community and the special challenges those individuals face is incomplete because, the report says, “Population-based data are unavailable for incidence and mortality because sexual orientation and gender identity are not consistently collected in medical records.”
The special section of this year’s ACS report is an attempt to provide “the latest information on the prevalence of major modifiable cancer risk factors and screening in the LGBTQ+ population, as well as challenges faced by LGBTQ+ individuals with cancer based on current data.”
Risk Factors
Some of the things increasing the risk of cancer in LGBTQ+ people include smoking, excess body weight and physical inactivity, alcohol, infectious agents and minority stress.
Smoking has long been known to be a major risk factor for cancer. Data shows that smoking (and vaping) is significantly more prevalent among LGBTQ people than among heterosexual people. The ACS report states that gays and lesbians are 27% more likely to smoke than heterosexual individuals, while bisexuals are 66% more likely.
Obesity is a risk factor for developing at least 12 types of cancer. Lesbian and bisexual women are more likely to have excess body weight than heterosexual women, while gay men are less likely to have excess body weight than heterosexual men. However, the report cautions against drawing conclusions from this, saying, “…some social scientists caution action against the characterization of lesbians as ‘at risk’ for obesity or other health conditions until more extensive high-quality research is available.”
Excessive alcohol consumption increases the risk of liver, esophageal, colorectal, oral, stomach and female breast cancers. While there is a great deal of anecdotal evidence about the prevalence of alcohol abuse in the LGBTQ+ community, there is a dearth of hard data from which reliable conclusions can be drawn.
The risk of cancers caused by infectious agents is of particular concern to the LGBTQ+ community because of the dangers inherent in HIV infection. Some of the infections that increase the risk of cancer include human papillomavirus (HPV) and hepatitis B and C. The risks of cancers from chronic HPV or hepatitis infections are significantly increased if someone is immunocompromised because of HIV. Data shows that LGBTQ+ individuals are much more at risk of exposure to these infectious agents.
The final factor impacting cancer risk in the LGBTQ+ community is perhaps the most insidious: minority stress. The report cites IH Meyer’s definition of minority stress, which is “the discrepancy and conflict that arises between the values of a historically minoritized group and the dominant culture or society.” Minority stressors can include overt prejudice, rejection, discrimination and internalized homophobia.
The report says, “Exposure to these stressors may lead to increased prevalence of mental health or substance use disorders and unhealthy behaviors that increase cancer risk.” These stressors have also been found to cause biochemical and genetic changes in people that increases cancer risk.
The report goes on to suggest, “Reducing minority stressors by implementing interventions at the structural, interpersonal, and individual level is a crucial component of mitigating cancer disparities in LGBTQ+ communities. These interventions include establishing institutional safe spaces for LGBTQ+ individuals and programs designed to increase knowledge and empathy among providers.”
Barriers to Cancer Care
While progress has been made in making healthcare for LGBTQ+ individuals more equitable, according to the report, one of the greatest remaining barriers remains the presumption of discrimination held by many LGBTQ+ people. That presumption is not unfounded. There are nine states where it is still legal for healthcare providers to refuse care based on sexual orientation or gender identity. Those states are Arkansas, Florida, Illinois, Mississippi, Montana, Ohio, South Carolina and Tennessee — unsurprisingly all states with Republican-majority state legislatures and/or governors.
Transgender patients, in particular, face difficulty accessing equitable healthcare. A recent survey of medical students showed that 30% are not comfortable caring for transexual patients, while only 1 in 4 were confident with regard to the health needs of trans people.
A similar survey of oncologists working at NCI-designated comprehensive cancer centers, showed only 40% were confident in their knowledge of the health needs of lesbian, gay or bisexual individuals, while a shockingly low 20% had similar confidence regarding trans people. This presumption of discriminatory care, particularly among trans people, means they are more likely to be diagnosed with advanced stage disease, less likely to receive treatment, and have poorer survival compared to cisgender individuals.
The problem is discriminatory care is exacerbated if the LGBTQ+ person is also from another minority. For example, one recent study found that among women with abnormal mammogram results or a breast cancer diagnosis, Black women who were sexual minorities were five times more likely to experience delays in care than white heterosexual women.
Cancer Screening
Trans people have specific issues regarding screening procedures. With trans men, hormone therapy causes atrophy of the vagina and cervix, making the standard Pap test unreliable for screening for cancer-causing HPV infections. The report suggests that screening every five years with a primary HPV test is particularly important for trans men. Also, prostate cancer screening guidelines do not account for trans women, whose hormone therapies would impact screening test results.
Lack of education and emotional and financial distress are common deterrents to screening among LGBTQ+ people, with 65% unsure of which screenings they should receive, and 70% unsure about when to begin cancer screening.
Disparities in Cancer Occurence
The report posits that lesbian and bisexual women may have a higher risk of breast cancer due to an elevated prevalence of risk factors: fewer childbirths, higher alcohol use, excess body weight — though the report is quick to point out the need for further research to confirm this hypothesis. Data concerning breast cancer among trans people have been mixed and thus inconclusive. Trans women on hormone treatment appear to be at higher risk than cisgender men. Trans men also seem to be at higher risk for breast cancer than cisgender men, particularly in the absence of top surgery (that is, surgery on the breasts as part of the masculinization or feminization process).
Trans men may retain their risk of gynecological cancers, and it is hypothesized that testosterone therapy may increase the risk of certain cancers because the hormone can be converted by the body into estrogen — though necessary confirming data is scarce or non-existent. Valid fears of prejudice and possible mistreatment can lead to delayed diagnosis and negative health outcomes for trans people.
Studies on the prevalence of prose cancer among gay and bisexual men compared to heterosexual men have yielded mixed results. Some studies have suggested that a history of STDs and multiple sexual partners may increase the risk of prostate cancer, but those findings are very preliminary. Trans women remain at risk even after receiving hormone treatment; they seem to be at lower risk than cisgender men—but when they do get it, it seems to be a more aggressive, thus more life-threatening, variety.
Cancer Survivorship
LGBTQ+ people have negative factors and stressors in their lives, and in their health care process. As a result, compared to the general public, LGBTQ+ cancer survivors are more likely to have poor physical and mental health, ultimately resulting in a lower rate of cancer survival. These negative outcomes are more common for Black and Hispanic LGBTQ+ persons with cancer, as well as those living in the South.
Summarizing its findings, the report says, “Insufficient access to high-quality care, limited provider knowledge of LGBTQ+ patient needs, discrimination in the health care setting, and a lack of population-based cancer occurrence data are all barriers to health equity that need to be addressed. Additionally, further research building on findings reported herein is warranted.”
Resources
Cancer Survivors Network: csn.cancer.org
Cancer Care: cancercare.org/tagged/lgbtq+
National LGBT Cancer Network: cancer-network.org