Next Article in Journal
Diagnostic Accuracy of FebriDx: A Rapid Test to Detect Immune Responses to Viral and Bacterial Upper Respiratory Infections
Previous Article in Journal
History and Outcome of Febrile Neutropenia Outside the Oncology Setting: A Retrospective Study of 76 Cases Related to Non-Chemotherapy Drugs

J. Clin. Med. 2017, 6(10), 93; https://doi.org/10.3390/jcm6100093

Article
Cancer and the LGBTQ Population: Quantitative and Qualitative Results from an Oncology Providers’ Survey on Knowledge, Attitudes, and Practice Behaviors
1
Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
2
Department of Oncologic Sciences, Morsani College of Medicine, University of South Florida, 12901 Bruce B Downs Blvd, Tampa, FL 33612, USA
3
Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
4
Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
*
Author to whom correspondence should be addressed.
Academic Editor: A. Mark Fendrick
Received: 15 August 2017 / Accepted: 25 September 2017 / Published: 7 October 2017

Abstract

:
Background: Despite growing social acceptance, the LGBTQ population continues to face barriers to healthcare including fear of stigmatization by healthcare providers, and providers’ lack of knowledge about LGBTQ-specific health issues. This analysis focuses on the assessment of quantitative and qualitative responses from a subset of providers who identified as specialists that treat one or more of the seven cancers that may be disproportionate in LGBTQ patients. Methods: A 32-item web-based survey was emailed to 388 oncology providers at a single institution. The survey assessed: demographics, knowledge, attitudes, and practice behaviors. Results: Oncology providers specializing in seven cancer types had poor knowledge of LGBTQ-specific health needs, with fewer than half of the surveyed providers (49.5%) correctly answering knowledge questions. Most providers had overall positive attitudes toward LGBTQ patients, with 91.7% agreeing they would be comfortable treating this population, and would support education and/or training on LGBTQ-related cancer health issues. Conclusion: Results suggest that despite generally positive attitudes toward the LGBTQ population, oncology providers who treat cancer types most prevalent among the population, lack knowledge of their unique health issues. Knowledge and practice behaviors may improve with enhanced education and training on this population’s specific needs.
Keywords:
LGBTQ; sexual and gender minorities; providers; attitudes; behaviors; education; training

1. Introduction

The lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community, also referred to as sexual and gender minorities (SGM), is a medically underserved and understudied population in the United States [1,2]. The terms “lesbian”, “gay”, and “bisexual” typically refer to sexual attraction or sexual orientation; “transgender” refers to individuals who do not identify with their assigned sex at birth, as opposed to “cisgender”, in which an individual’s sex at birth aligns with his or her gender identity [3,4]; “queer” can refer to any and all groups in the LGBTQ spectrum; and “questioning” refers to the exploration of either sexual orientation or gender identity [2,5,6]. It is estimated that 3–12% of adults in the United States identify as LGBTQ [1,7]. Despite growing social acceptance, this population continues to face barriers to healthcare including difficulty obtaining and/or affording health insurance coverage, fear of stigmatization by healthcare providers, and healthcare providers’ lack of knowledge about LGBTQ-specific health issues [8]. Moreover, one in five transgender patients seeking healthcare are still turned away by providers [5,9,10]. In addition to facing systematic and provider-related barriers, LGBTQ persons experience a multitude of health disparities. For example, gay, lesbian, and bisexual adults and youth are at increased risk for depression, anxiety, suicide, and substance abuse; lesbian, and bisexual women are more likely to be obese than straight women [11,12,13,14].
In addition to these general mental and physical health disparities, the LGBTQ community also has increased risks for some cancers. A recent review of the literature [2] highlighted seven cancer sites that may disproportionately affect the LGBTQ population: anal, breast, cervical, colorectal, endometrial, lung, and prostate cancers. Briefly, anal cancer may be more prevalent among gay, bisexual, and other men who have sex with men for multiple reasons. First, human papillomavirus (HPV), a sexually transmitted infection (STI), is the primary cause of anal cancer [14,15]. Men who have sex with men (MSM) are at greater risk of HPV transmission due to anal sex practices [16]. In addition, HIV-infected persons are more likely to develop anal cancer, and gay and bisexual men are more likely to be HIV-infected [17,18]. While anal cancer disproportionately affects gay men, breast cancer may affect lesbian and bisexual women at greater rates than heterosexual women. There are limited data that explore these differences; however, lesbian and bisexual women more commonly experience a variety of breast cancer risk factors, including reduced pregnancy rates, smoking, and obesity [5,19]. Furthermore, some studies suggest lesbian and bisexual women are less likely to get mammography due to barriers to healthcare coverage and negative relationships with healthcare providers [20,21,22]. However, more research is needed to determine if these factors correspond to increased breast cancer risk [2]. HPV contributes not only to higher rates of anal cancer among MSM, but also to higher rates of cervical cancer among lesbian and bisexual women [2,23]. Recent studies have shown that STIs may be transmitted through sexual contact between women [24]; further, many women who have sex with women (WSW) have had sexual contact with men in the past [25]. Thus, it is likely for WSW to contract HPV, the leading cause of cervical cancer [23]. Similarly, there may be lower rates of Papanicolaou (Pap) testing among WSW because of the mistaken belief that they are not at risk for cervical cancer [2]. As such, the higher rates of cervical cancer among lesbian and bisexual women may be attributed, in part, to a misconception of HPV transmission resulting in the observed lower rates of Pap testing among this population. Colon and rectal cancers may disproportionately affect the LGBTQ populations due primarily to elevated risk factors, including smoking and obesity, within these groups [26,27,28]. However, further research is necessary to determine if there are differences in colorectal cancer rates between LGBTQ and majority populations [2]. Similar conclusions, or lack thereof, can be made regarding the relationship between LGBTQ status and lung cancer. While the prevalence of smoking, the leading cause of lung cancer, is higher in LGBTQ populations, a lack of research on LGBTQ and lung cancer makes it difficult to determine whether there is an association between the two [29,30]. However, a recent study showed that lung cancer incidence is greater among HIV-infected individuals than in the general population [31]; because HIV is more common in LGBTQ populations, specifically gay and bisexual men, this could highlight an additional distinction in lung cancer occurrence between sexual minority and heterosexual individuals [17]. A lack of published research also characterizes prostate cancer diagnosis in MSM. Unlike the other cancers described, no published data exist that compare risk factors for prostate cancer between gay, bisexual, and heterosexual men [2]. However, studies suggest that screening for prostate cancer with the prostate-specific antigen (PSA) test may be less common in men with HIV and/or some groups of MSM—for example, PSA testing among African American MSM was found to be lower than that of heterosexual African Americans [32,33].
To identify and address potential health disparities among LGBTQ populations, it is imperative to collect accurate sexual orientation and gender identity (SOGI) data which are often not collected in medical records and research databases. When SOGI data are not collected in the healthcare delivery setting, there may be a missed opportunity to discuss prevention, early detection, and screening for LGBTQ subgroups that may be at an increased risk for certain cancers. A lack of collection and nondisclosure can also result in a missed opportunity to discuss potential psychosocial issues specific to members of the LGBTQ population, as well as to make referrals to other health care professionals, such as social workers or psychologists, and community resources, which could have a positive impact on quality of life [34]. As SOGI data collection is currently a somewhat novel concept, it is imperative to develop training for providers and best practices for collection. Ultimately, when SOGI data are collected and subsequently applied in a meaningful and culturally sensitive manner, the quality of cancer care provided to the LGBTQ population can be improved [34].
Despite being an underserved population, few studies have explored healthcare concerns and needs of the LGBTQ population in regards to cancer. The Institute of Medicine also suggests few physicians are knowledgeable about and sensitive to LGBTQ-specific health issues [5]. In this current analysis, we sought to assess quantitative and qualitative responses from a subset of providers who identified as specialists that treat one of the aforementioned seven cancers [2] that may be disproportionate in LGBTQ patients.

2. Materials and Methods

Study Population and Survey

The 33-item web-based survey was developed based on existing literature on LGBTQ health and healthcare experiences [3,35]. Details on the development and administration of the survey are reported elsewhere [35]. Briefly, the original sample included all Medical Doctors (MDs), Physician Assistants (PAs), and Nurse Practitioners (NPs) practicing at Moffitt Cancer Center (Tampa, FL, USA) using the Dillman Method [34]. In this study, we sought to examine those providers who specialized in one or more of the seven cancer sites (i.e., anal, breast, cervical, colorectal, endometrial, lung, and prostate cancers) that may disproportionally affect LGBTQ persons [2]. Chesapeake institutional review board (Columbia, MD, USA) approved the study and a waiver of documentation of written informed consent was provided.
The survey included five sections: demographics (eleven questions), knowledge (six questions), attitudes (five questions), practice (seven questions), and open comments (four questions). Three questions were removed for this analysis due to possible ambiguity in the way they were worded. The knowledge, attitudes, and practice behaviors sections included statements with the following response options: strongly disagree, disagree, neutral/don’t know, agree, and strongly agree.
The demographics section assessed gender, age group, sexual orientation, race, religious identity, licensure, year of graduation from professional school, specialty/clinic, average number of patients per week, and percentage of patients who have identified as LGBTQ. The knowledge section of the survey included six statements regarding LGBTQ patient-provider communication, risks of HPV and breast cancer among lesbians, screening tests for men who have sex with men (MSM), LGBTQ mental health issues, and transgender health insurance trends. The attitudes section consisted of five statements which assessed comfort in treating LGBTQ patients, belief of unique health needs, desire for LGBTQ-specific continuing education, willingness to be listed as an LGBTQ-friendly provider, and belief that the LGBTQ population is more difficult to treat. The practice behaviors section of the survey contained seven statements about practice activities toward LGBTQ patients. These statements examined providers’ habits of inquiring about patients’ sexual orientation, belief in the importance of knowing the sexual orientation and gender identity of patients, belief that being LGBTQ leads to increased cancer risks, assumption of patients’ heterosexuality, feeling well-informed about LGBTQ health needs, and belief there should be mandatory educational events in the workplace on LGBTQ cancer health needs.
The open comments section included four questions that asked about personal experiences treating LGBTQ patients, reservations in treating this population, suggestions for improving the cancer care of this population, and additional comments.

3. Statistical Analysis

Descriptive statistics (counts and percentages) were used to quantify survey responses using Stata/MP 12.1 (StataCorp LP, College Station, TX, USA). Open-ended comments were coded using content analysis (Atlas TI) and categorized based on key themes. Two coders initially reviewed all comments to generate a preliminary code list. The initial code list was validated by a third coder and discrepancies were discussed until a consensus was made. The final code list was applied by two coders with an inter-rater reliability of 0.90.

4. Results

4.1. Demographics

Of the 388 providers contacted, 108 completed the survey, resulting in a 27.8% response rate. For this analysis, we focused on 36 (33.3%) of the 108 respondents who identified as specialists in the seven cancer types with known or suspected LGBTQ-specific disparities [2]: breast, gastrointestinal, genitourinary, gynecological, and thoracic oncology. As presented in Table 1, respondents were primarily male (52.8%), between the ages of 35 and 44 (61.1%), heterosexual (91.7%), non-Hispanic Caucasian (61.1%), Christian (55.6%), and medical doctors (75.0%) who graduated from professional school between 2000 and 2009 (50.0%). Over 44% reported a patient load of between 26 and 50 patients per week, and the majority (72.2%) reported that one to five percent of their patients had identified as LGBTQ in the past year.

4.2. Knowledge

Thirteen respondents (36.1%) correctly identified that LGBTQ patients avoid accessing healthcare due to difficulty communicating with healthcare providers (Table 2). 58.3% correctly recognized that HPV-associated cervical dysplasia can be found in lesbians with no history of heterosexual intercourse.
Twenty respondents (55.3%) correctly identified that regularly screening gay and bisexual men for anal cancer through anal Pap testing can increase life expectancy. Seventeen respondents (47.2%) correctly recognized that transgender individuals are less likely to have health insurance than cisgender individuals.

4.3. Attitudes

Thirty-three providers (91.7%) stated they were comfortable treating LGBTQ patients (Table 3) and 91.7% believed the LGBTQ population had unique health risks and needs. Twenty-eight (77.8%) agreed there should be more education in health professional schools on LGBTQ health needs. Twenty-three (63.8%) would be willing to be listed as an LGBTQ-friendly provider. Few respondents (four, or 11.1%) believed the LGBTQ population was more difficult to treat.

4.4. Practice

Thirteen providers (36.1%) actively inquired about a patient’s sexual orientation when taking a history (Table 4). Twenty-one (58.3%) either agreed or strongly agreed it was important to know the sexual orientation of their patients to provide the best care; only ten providers (27.8%) agreed or strongly agreed with this statement in reference to gender identity. Twenty-six (72.2%) stated that upon first encounter, they assumed a patient was heterosexual. Seventeen (47.2%) agreed or strongly agreed they were well-informed on the health needs of LGBTQ patients. Thirteen (36.1%) agreed or strongly agreed there should be mandatory educational events at the cancer center on LGBTQ health needs.

4.5. Open Comments

The open comments section revealed themes related to: disbelief knowing SOGI about patients was important; need for additional education about the importance of knowing and what to do with that information; and lack of knowledge of LGBTQ health needs. The first theme centered on the idea that knowing SOGI was not important in their practice: the majority of providers explained they treat all patients the same regardless of their sexual orientation. For example, the quote below is illustrative of a typical response:
“LGBT patients are no different than heterosexual patients; I treat everyone the same.”
(Thoracic oncology provider)
The second theme centered on the need for provider education and training to understand the importance of knowing a patient’s sexual orientation and gender identity and then how to use that information to provide quality care to patients. These quotes illustrate a typical response:
“I guess I need training as to why this (sexual orientation and gender identity) is important and how I should address it in my practice.”
(Breast oncology provider)
“Obviously I deal with the body parts that relate to sexual acts, but I don’t ask my patients to disclose and I wouldn’t be sure how to apply that information if they did tell me.”
(Gynecologic oncology provider)
Another theme was oncology providers’ lack of knowledge and awareness of LGBTQ cancer-related health issues. The quote below is representative of the lack of knowledge that LGBTQ patients have higher rates of smoking than cisgender and heterosexual populations. The quote from the GI provider shows a lack of knowledge about survivorship and quality of life issues in men who have sex with men and their sexual practices.
“I treat lung cancer patients. Not sure these questions are relevant to my specific area of focus… I imagine GYN and GI oncologist would have differing concerns/areas that need focusing than I.”
(Thoracic oncology provider)
“I see a lot of MSM in my practice but don’t know that knowing their sexual behaviors would change the way I would treat their cancer.”
(Gastrointestinal oncology provider)

5. Discussion

In this analysis we assessed knowledge, attitudes, and practice behaviors among a unique sub-group of providers who identified as specialists in one of seven cancer sites that may disproportionately affect LGBTQ populations. Our results suggest all provider groups had poor knowledge of LGBTQ-specific health needs exemplified by less than half of the cancer specialists correctly answering the questions. Additionally, only 47.2% of surveyed providers believed they were well-informed on LGBTQ health needs.
Previous studies have identified similar trends in providers treating LGBTQ patients. For example, prior studies have reported health providers often lack knowledge of LGBT health needs [36,37], and that LGBT patients themselves have to educate their providers on these matters. A survey by Kitt et al. [38] of residents and attending physicians revealed knowledge gaps similar to those found in our study. A report by Stott [39] using interviews and focus groups of general practitioners and LGB individuals, as well as a survey of medical students, also revealed that general practitioners lacked knowledge of the specific health needs of their LGB patients.
With regard to attitudes toward LGBTQ patients, the majority of providers in our study reported they would be willing to be listed as LGBTQ-friendly. As many LGBTQ patients seek LGBTQ-friendly providers, this willingness demonstrates another level of acceptance, as it could potentially increase the number of patients who identify as LGBTQ [40]. A study by VandenLangenberg et al. [41] studied LGB individuals and their genetic counseling experiences through a series of telephone interviews and saw similar results. Specifically, one theme noted that identification as a LGB-friendly provider through LGB-friendly symbols, such as books or stickers, made patients more comfortable with disclosing sexual orientation [41]. LGB-friendly symbols increase patient comfort and foster a welcoming environment. Other ways to make LGB patients feel more comfortable include: providing unisex bathrooms, using gender-neutral intake forms and inclusive language, and LGBTQ-specific posters in waiting rooms [42]. These, along with institutional policies, such as allowing all patients to choose who can visit them in the hospital, opposing “conversion” and other similar therapies for LGBTQ patients [15] may help improve providers’ relationships with LGBTQ patients. Most providers in our study had overall positive attitudes toward the LGBTQ population; however, other studies have found varying results regarding attitudes. Similarly, Lapinski et al. [43] reported that most medical students had positive personal and treatment attitudes toward the LGBTQ population, while other studies have found providers to be less accepting. A recent study by Sabin et al. [44] examined attitudes among healthcare providers toward lesbian women and gay men through the Implicit Association Test [45], which measures the implicit social associations people make between concepts and attributes. The study found heterosexual providers always implicitly preferred heterosexual people over gay and lesbian people. Accordingly, many LGB individuals reported having negative experiences with healthcare providers, often due to perceived providers’ homophobic attitudes [46]. As education and awareness can help providers overcome these implicit biases, this further highlights the need for more education in the area of LGBTQ healthcare.
Oncology providers’ lack of knowledge regarding LGBTQ issues may translate into suboptimal practice behaviors. First, just over half of providers believed it is important to know the sexual orientation or gender identity of patients to provide the best care, and only one-third of surveyed providers actively inquired about sexual orientation when taking a history. However, multiple studies have indicated the importance of knowing patients’ sexual orientation; disclosure has been shown to increase patient satisfaction, improve quality of care, and increase patients’ use of routine care [47,48,49,50]. Other studies have similarly highlighted providers’ lack of inquiry, and have also noted patients are reluctant to disclose sexual orientation on their own [50,51].
While many organizations, including the American Medical Association, recommend providers discuss sexual orientation with patients, our results highlight such guidelines are not always put into practice [48,49]. Other groups and organizations are working to address the cancer burden in the LGBTQ population in various ways—for example, the National Summit on Cancer in the LGBT Communities [52] resulted in recommendations addressing sexual orientation and gender identity data collection, care of LGBT individuals, provider awareness and knowledge, and research on cancer in the LGBT population. The American Cancer Society has created a cancer control program that will work to increase awareness of their resources for the cancer-related needs of the LGBT population and, similar to the National Summit’s Cancer Action Plan, to dedicate research to some of the cancer-related disparities this population faces [53].
The survey’s open comments further highlighted providers lack of knowledge of LGBTQ health needs and how to tailor patient care based on knowing their sexual orientation. Further, the open comment responses suggest latent heteronormativity and do not acknowledge that all patients are individual and as such should be treated according to their specific needs, rather than the same as everyone else. However, the theme of equality also emerged in these comments, as multiple providers explained they treated patients the same way regardless of their sexual orientation. Other studies have found similar results. Specifically, interviews of general practice physicians by Beagan et al. [54] revealed some physicians do not believe sexual or gender identity makes a difference when treating a patient, and that patients should not be labeled by these characteristics. Furthermore, the majority of the Moffitt providers surveyed tend to automatically assume that a patient is heterosexual (72% of respondents). Thus, even when physicians do believe that sexual orientation and gender identity make a difference in caring for a patient, such assumptions can lead providers not to ask questions about sexual orientation and gender identity in the first place. While it is important not to discriminate based on patient sexual orientation or gender identity, it is also important to recognize that LGBTQ individuals have health concerns as the individuals they are and should be treated in a way that respects their identity and individual needs, which may or may not be same as heterosexual and cisgender patients. The provision of quality healthcare is dependent upon not equality, but equity. Specifically, patients should not all be given the same treatment, but quality treatment based on their own individual needs [55,56].
Furthermore, the fact that the vast majority of surveyed providers feel comfortable treating LGBTQ patients, despite knowledge deficits, demonstrates a lack of general awareness of LGBTQ health issues—and therein another potential area of improvement in LGBTQ care. Providers’ support of continuing education/training on LGBTQ-specific cancer related health needs reveals practical ways to improve knowledge of and behaviors toward LGBTQ patients. The Association of American Medical Colleges supports continuing medical education on LGBTQ-related health issues and notes its contribution to an improving providers’ awareness and knowledge of needs, as well as the quality of patient care [57]. Nonetheless, several studies suggest medical education on LGBTQ health is lacking. White et al. [58] found that 67.3% of medical students who took their survey viewed their LGBT-related medical school curriculum as “fair” or worse.
Medical students may be educated on LGBTQ health issues through didactic lectures such as lectures dedicated to LGBTQ health throughout the medical school curriculum, or including issues related to LGBTQ health within the curriculum. Other opportunities include interacting with and interviewing standardized patients who identify as LGBTQ, LGBTQ patient panel discussions, and case studies. A greater focus on medical students’ ability to take a thorough gender identity and sexual and personal history could lessen the barriers physicians report in discomfort in asking for patients’ sexual orientation or gender identity.
We acknowledge several limitations to this study including providers from a single institution, a modest response rate (27.8%), and the low numbers of providers within each of the cancer site specialties. Those who completed the study may have been more familiar with LGBTQ health issues and/or more comfortable with the LGBTQ population than providers who opted not to respond. Clinicians with a more vested interest in LGBTQ cancer health may have been more likely to contribute their time to complete the survey to advance research in this field.
Although this analysis focused on specialists who treat cancers that may disproportionately affect LGBTQ populations, education and training regarding LGBTQ health is important in all medical fields. All oncology providers should be sensitive to and knowledgeable of how to encourage disclosure of sexual orientation and gender identity with their patients.

Acknowledgments

We gratefully acknowledge Luisa Duarte Arevalo and Julie Rathwell, MPH for editorial assistance. This work has also been supported in part by a Cancer Center Support Grant (CCSG) at the H. Lee Moffitt Cancer Center and Research Institute; an NCI designated Comprehensive Cancer Center (grant number P30-CA76292).

Author Contributions

CLT performed the analyses and co-authored the paper. GPQ and MBS conceptualized and supervised the study and co-authored the paper. JAS co-authored the paper. All authors approved the final submission.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Fredriksen-Goldsen, K.I.; Kim, H.J.; Barkan, S.E.; Muraco, A.; Hoy-Ellis, C.P. Health disparities among lesbian, gay, and bisexual older adults: Results from a population-based study. Am. J. Public Health 2013, 103, 1802–1809. [Google Scholar] [CrossRef] [PubMed]
  2. Quinn, G.P.; Sanchez, J.A.; Sutton, S.K.; Vadaparampil, S.T.; Nguyen, G.T.; Green, B.L.; Kanetsky, P.A.; Schabath, M.B. Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. CA Cancer J. Clin. 2015, 65, 384–400. [Google Scholar] [CrossRef] [PubMed]
  3. Johnson, C.V.; Mimiaga, M.J.; Bradford, J. Health care issues among lesbian, gay, bisexual, transgender and intersex (LGBTI) populations in the United States: Introduction. J. Homosex. 2008, 54, 213–224. [Google Scholar] [CrossRef] [PubMed]
  4. Spectrum Center. LGBT Terms and Definitions. 2015. Available online: http://internationalspectrum.umich.edu/life/definitions (accessed on 20 July 2015).
  5. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding; National Academies Press: Washington, DC, USA, 2011. [Google Scholar]
  6. Institute of Medicine. Collecting Sexual Orientation and Gender Identity Data in Electronic Health Records: Workshop Summary; National Academies Press: Washington, DC, USA, 2013. [Google Scholar]
  7. Gates, G.J. How Many People Are Lesbian, Gay, Bisexual and Transgender? The Williams Institute, Los Angeles School of Law, Univerity of California: Los Angeles, CA, USA, 2011. [Google Scholar]
  8. Jowett, A.; Peel, E. Chronic Illness in Non-Heterosexual Contexts: An Online Survey of Experiences. Fem. Psychol. 2009, 19, 454–474. [Google Scholar] [CrossRef]
  9. National LGBT Cancer Network. Barriers to Health Care. 2013. Available online: http://www.cancer-network.org/cancer_information/cancer_and_the_lgbt_community/barriers_to_lgbt_healthcare.php (accessed on 16 June 2016).
  10. Snowdon, S. Healthcare Equality Index 2013: Promoting Equitable and Inclusive Care for Lesbian, Gay, Bisexual, and Transgender Patients and Their Families; Human Rights Campaign: Washington, DC, USA, 2013. [Google Scholar]
  11. Conron, K.J.; Mimiaga, M.J.; Landers, S.J. A population-based study of sexual orientation identity and gender differences in adult health. Am. J. Public Health 2010, 100, 1953–1960. [Google Scholar] [CrossRef] [PubMed]
  12. Lewis, N.M. Mental health in sexual minorities: Recent indicators, trends, and their relationships to place in North America and Europe. Health Place 2009, 15, 1029–1045. [Google Scholar] [CrossRef] [PubMed]
  13. Anderson, S.; Mcnair, R.P.; Mitchell, A. Addressing Health Inequalities in Victorian Lesbian, Gay, Bisexual and Transgender Communities; Australian Health Promotion Association: Melbourne, Australia, 2003.
  14. Center for Disease Control. Lesbian, Gay, Bisexual, and Transgender Health. 2014. Available online: https://www.cdc.gov/lgbthealth/youth.htm (accessed on 16 June 2016). [Google Scholar]
  15. Daniel, H.; Butkus, R.; Health and Public Policy Committee of American College of Physicians. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann. Intern. Med. 2015, 163, 135–137. [Google Scholar] [CrossRef] [PubMed]
  16. Machalek, D.A.; Poynten, M.; Jin, F.; Fairley, C.K.; Farnsworth, A.; Garland, S.M.; Hillman, R.J.; Petoumenos, K.; Roberts, J.; Tabrizi, S.N.; et al. Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: A systematic review and meta-analysis. Lancet Oncol. 2012, 13, 487–500. [Google Scholar] [CrossRef]
  17. Center for Disease Control. Estimated HIV Incidence in the United States, 2007–2010; HIV Surveillance Supplemental Report; Centers for Disease Control: Atlanta, GA, USA, 2012; Volume 17.
  18. Grulich, A.E.; Hillman, R.; Brotherton, J.M.L. Time for a strategic research response to anal cancer. Sex Health 2012, 9, 628–631. [Google Scholar] [CrossRef] [PubMed]
  19. Zaritsky, E.; Dibble, S.L. Risk factors for reproductive and breast cancers among older lesbians. J. Womens Health 2010, 19, 125–131. [Google Scholar] [CrossRef] [PubMed]
  20. Brown, J.P.; Tracy, J.K. Lesbians and cancer: An overlooked health disparity. Cancer Causes Control 2008, 19, 1009–1020. [Google Scholar] [CrossRef] [PubMed]
  21. Hart, S.L.; Bowen, D.J. Sexual orientation and intentions to obtain breast cancer screening. J. Womens Health 2009, 18, 177–185. [Google Scholar] [CrossRef] [PubMed]
  22. Hutchinson, M.K.; Thompson, A.C.; Cederbaum, J.A. Multisystem factors contributing to disparities in preventive health care among lesbian women. J. Obstet. Gynecol. Neonatal. Nurs. 2006, 35, 393–402. [Google Scholar] [CrossRef] [PubMed]
  23. Schiffman, M. Integration of human papillomavirus vaccination, cytology, and human papillomavirus testing. Cancer 2007, 111, 145–153. [Google Scholar] [CrossRef] [PubMed]
  24. Gorgos, L.M.; Marrazzo, J.M. Sexually transmitted infections among women who have sex with women. Clin. Infect. Dis. 2011, 53, S84–S91. [Google Scholar] [CrossRef] [PubMed]
  25. Waterman, L.; Voss, J. HPV, cervical cancer risks, and barriers to care for lesbian women. Nurse Pract. 2015, 40, 46–53. [Google Scholar] [CrossRef] [PubMed]
  26. Boehmer, U.; Bowen, D.J. Examining factors linked to overweight and obesity in women of different sexual orientations. Prev. Med. 2009, 48, 357–361. [Google Scholar] [CrossRef] [PubMed]
  27. Haggar, F.A.; Boushey, R.P. Colorectal cancer epidemiology: Incidence, mortality, survival, and risk factors. Clin. Colon Rectal Surg. 2009, 22, 191–197. [Google Scholar] [CrossRef] [PubMed]
  28. President’s Cancer Panel. 2006–2007 Annual Report: Promoting Healthy Lifestyles: Policy, Program, and Personal Recommendations for Reducing Cancer Risk; Department of Health and Human Services: Washington, DC, USA, 2009.
  29. Dela Cruz, C.S.; Tanoue, L.T.; Matthay, R.A. Lung cancer: Epidemiology, etiology, and prevention. Clin. Chest Med. 2011, 32, 605–644. [Google Scholar] [CrossRef] [PubMed]
  30. Drabble, L.; Trocki, K. Alcohol consumption, alcohol-related problems, and other substance use among lesbian and bisexual women. J. Lesbian Stud. 2005, 9, 19–30. [Google Scholar] [CrossRef] [PubMed]
  31. Hou, W.; Fu, J.; Ge, Y.; Du, J.; Hua, S. Incidence and risk of lung cancer in HIV-infected patients. J. Cancer Res. Clin. Oncol. 2013, 139, 1781–1794. [Google Scholar] [CrossRef] [PubMed]
  32. Heslin, K.C.; Gore, J.L.; King, W.D.; Fox, S.A. Sexual orientation and testing for prostate and colorectal cancers among men in California. Med. Care 2008, 46, 1240–1248. [Google Scholar] [CrossRef] [PubMed]
  33. Shiels, M.S.; Goedert, J.J.; Moore, R.D.; Platz, E.A.; Engels, E.A. Reduced risk of prostate cancer in U.S. Men with AIDS. Cancer Epidemiol. Biomarkers Prev. 2010, 9, 2910–2915. [Google Scholar] [CrossRef] [PubMed]
  34. Schabath, M.B.; Curci, M.B.; Kanetsky, P.A.; Vadaparampil, S.T.; Simmons, V.N.; Sanchez, J.A.; Sutton, S.K.; Wheldon, C.; Quinn, G.P. Ask and Tell: The Importance of the Collection of Sexual Orientation and Gender Identity Data to Improve the Quality of Cancer Care for Sexual and Gender Minorities. J. Oncol. Pract. 2017, 13, 542–546. [Google Scholar] [CrossRef] [PubMed]
  35. Shetty, G.; Sanchez, J.A.; Lancaster, J.M.; Wilson, L.E.; Quinn, G.P.; Schabath, M.B. Oncology healthcare providers’ knowledge, attitudes, and practice behaviors regarding LGBT health. Patient Educ. Couns. 2016, 99, 1676–1684. [Google Scholar] [CrossRef] [PubMed]
  36. Bockting, W.O.; Robinson, B.E.; Rosser, B.R. Transgender HIV prevention: A qualitative needs assessment. AIDS Care 1998, 10, 505–525. [Google Scholar] [CrossRef] [PubMed]
  37. Mathieson, C.M. Lesbian and bisexual health care. Can. Fam. Physician 1998, 44, 1634–1640. [Google Scholar] [PubMed]
  38. Kitts, R.L. Barriers to optimal care between physicians and lesbian, gay, bisexual, transgender, and questioning adolescent patients. J. Homosex. 2010, 57, 730–747. [Google Scholar] [CrossRef] [PubMed]
  39. Stott, D.B. The training needs of general practitioners in the exploration of sexual health matters and providing sexual healthcare to lesbian, gay and bisexual patients. Med. Teach. 2013, 35, 752–759. [Google Scholar] [CrossRef] [PubMed]
  40. Wilkerson, J.M.; Rybicki, S.; Barber, C.A.; Smolenski, D.J. Creating a culturally competent clinical environment for LGBT patients. J. Gay Lesbian Soc. Serv. 2011, 23, 376–394. [Google Scholar] [CrossRef]
  41. VandenLangenberg, E.; Veach, P.M.; LeRoy, B.S.; Glessner, H.D. Gay, lesbian, and bisexual patients’ recommendations for genetic counselors: A qualitative investigation. J. Genet. Couns. 2012, 21, 741–747. [Google Scholar] [CrossRef] [PubMed]
  42. Lutwak, N. Opportunity Also Knocks in the Emergency Room: Improved Emergency Department Culture Could Dramatically Impact LGBT Perceptions of Healthcare. LGBT Health 2014, 1, 149–150. [Google Scholar] [CrossRef] [PubMed]
  43. Lapinski, J.; Sexton, P.; Baker, L. Acceptance of lesbian, gay, bisexual, and transgender patients, attitudes about their treatment, and related medical knowledge among osteopathic medical students. J. Am. Osteopath. Assoc. 2014, 114, 788–796. [Google Scholar] [CrossRef] [PubMed]
  44. Sabin, J.A.; Riskind, R.G.; Nosek, B.A. Health Care Providers’ Implicit and Explicit Attitudes Toward Lesbian Women and Gay Men. Am. J. Public Health 2015, 105, 1831–1841. [Google Scholar] [CrossRef] [PubMed]
  45. Nosek, B.A.; Smyth, F.L.; Hansen, J.J.; Devos, T.; Lindner, N.M.; Ranganath, K.A.; Smith, C.T. Pervasiveness and correlates of implicit attitudes and stereotypes. Eur. Rev. Soc. Psychol. 2007. [Google Scholar] [CrossRef]
  46. Eliason, M.J.; Schope, R. Original research: Does “don’t ask don’t tell” apply to health care? Lesbian, gay, and bisexual people’s disclosure to health care providers. J. Gay Lesbian Med. Assoc. 2001, 5, 125–134. [Google Scholar] [CrossRef]
  47. Barbara, A.M.; Quandt, S.A.; Anderson, R.T. Experiences of lesbians in the health care environment. Women Health 2001, 34, 45–62. [Google Scholar] [CrossRef]
  48. Diamant, A.L.; Schuster, M.A.; Lever, J. Receipt of preventive health care services by lesbians. Am. J. Prev. Med. 2000, 19, 141–148. [Google Scholar] [CrossRef]
  49. Klitzman, R.L.; Greenberg, J.D. Patterns of communication between gay and lesbian patients and their health care providers. J. Homosex. 2002, 42, 65–75. [Google Scholar] [CrossRef] [PubMed]
  50. Meckler, G.D.; Elliott, M.N.; Kanouse, D.E.; Beals, K.P.; Schuster, M.A. Nondisclosure of sexual orientation to a physician among a sample of gay, lesbian, and bisexual youth. Arch. Pediatr. Adolesc. Med. 2006, 160, 1248–1254. [Google Scholar] [CrossRef] [PubMed]
  51. Boehmer, U.; Case, P. Physicians don’t ask, sometimes patients tell: Disclosure of sexual orientation among women with breast carcinoma. Cancer 2004, 101, 1882–1889. [Google Scholar] [CrossRef] [PubMed]
  52. Burkhalter, J.E.; Margolies, L.; Sigurdsson, H.O.; Walland, J.; Radix, A.; Rice, D.; Buchting, F.O.; Sanchez, N.F.; Bare, M.G.; Boehmer, U.; et al. The National LGBT Cancer Action Plan: A White Paper of the 2014 National Summit on Cancer in the LGBT Communities. LGBT Health 2016, 3, 19–31. [Google Scholar]
  53. Wender, R.; Sharpe, K.B.; Westmaas, J.L.; Patel, A.V. The American Cancer Society’s Approach to Addressing the Cancer Burden in the LGBT Community. LGBT Health 2015. [Google Scholar] [CrossRef] [PubMed]
  54. Beagan, B.; Fredericks, E.; Bryson, M. Family physician perceptions of working with LGBTQ patients: Physician training needs. Can. Med. Educ. J. 2015, 6, e14–e22. [Google Scholar] [PubMed]
  55. Quinn, G.P.; Schabath, M.B.; Sanchez, J.A.; Sutton, S.K.; Green, B.L. The importance of disclosure: Lesbian, gay, bisexual, transgender/transsexual, queer/questioning, and intersex individuals and the cancer continuum. Cancer 2015, 121, 1160–1163. [Google Scholar] [CrossRef] [PubMed]
  56. VHA Office of Health Equity. Lesbian, Gay, Bisexual & Transgender (LGBT) Veterans Internal Healthcare Fact Sheet. Available online: http://www.lgbthealtheducation.org/wp-content/uploads/VHA-LGBT-VETERANS-INTERNAL-HEALTH-CARE-FACT-SHEET.pdf (accessed on 31 July 2015).
  57. Association of American Medical Colleges. Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators; Association of American Medical Colleges: Washington, DC, USA, 2014. [Google Scholar]
  58. White, W.; Brenman, S.; Paradis, E.; Goldsmith, E.S.; Lunn, M.R.; Obedin-Maliver, J.; Stewart, L.; Tran, E.; Wells, M.; Chamberlain, L.J.; et al. Lesbian, Gay, Bisexual, and Transgender Patient Care: Medical Students’ Preparedness and Comfort. Teach. Learn. Med. 2015, 27, 254–263. [Google Scholar] [CrossRef] [PubMed]
Table 1. Provider demographics in indicated specialties (N = 36).
Table 1. Provider demographics in indicated specialties (N = 36).
Characteristic 1N (%)Characteristic 1N (%)
Specialty/Moffitt Clinic Religious Identity
Breast Oncology6 (17)Atheist/Agnostic1 (3)
Gastrointestinal Oncology15 (42)Buddhist1 (3)
Genitourinary Oncology4 (11)Christian20 (56)
Gynecologic Oncology4 (11)Hindu1 (3)
Thoracic Oncology7 (19)Jewish5 (14)
Muslim3 (8)
Other and Missing5 (14)
Gender Licensure
Female17 (47)MD27 (75)
Male19 (53)PA4 (11)
NP5 (14)
Age Group Year of Graduation from Professional School
25–341 (3)2010–20141 (3)
35–4422 (61)2000–200918 (49)
45–549 (25)1990–199914 (39)
55–643 (8)1980–19891 (3)
65–741 (3)1970–19792 (6)
Sexual Orientation Average Number of Patients Seen Per Week
Heterosexual33 (97)0–2512 (33)
Gay1 (3)26–5016 (44)
51–756 (17)
75–1002 (6)
Race Percentage of Your Patients in the Past Year Who Have Identified Themselves as LGBTQ
Asian5 (14)None1 (3)
Black or African American2 (6)1–5%26 (74)
Multiracial1 (3)6–10%5 (14)
Hispanic or Latino3 (8)11–15%1 (3)
White or Caucasian22 (61)16–20%0 (0)
Other/Not sure3 (8)>20%2 (6)
1 Not all categories add up to 36 due to missing data.
Table 2. Knowledge of LGBTQ health among indicated providers (N = 36).
Table 2. Knowledge of LGBTQ health among indicated providers (N = 36).
N (%) 1
LGBTQI patients avoid accessing healthcare due to difficulty communicating with providers.
Strongly Disagree5 (13.9)
Disagree7 (19.5)
Don’t Know11 (30.5)
Agree Strongly11 (30.5)
Agree2 (5.6)
HPV-associated cervical dysplasia can be found in lesbians with no history of heterosexual intercourse.
Strongly Disagree0 (0.0)
Disagree5 (13.9)
Don’t Know10 (27.8)
Agree Strongly14 (38.9)
Agree7 (19.4)
Regularly screening gay and bisexual men for anal cancer through anal Pap testing can increase life expectancy.
Strongly Disagree0 (0.0)
Disagree2 (5.6)
Don’t Know14 (38.9)
Agree Strongly16 (44.4)
Agree4 (11.1)
Transgender individuals are less likely to have health insurance than heterosexual individuals.
Strongly Disagree1 (2.8)
Disagree3 (8.7)
Don’t Know14 (40.0)
Agree Strongly16 (45.7)
Agree1 (2.8)
1 Not all responses add up to 36 due to missing data.
Table 3. Attitudes regarding LGBTQ patients and healthcare among indicated providers (N = 36).
Table 3. Attitudes regarding LGBTQ patients and healthcare among indicated providers (N = 36).
N (%) 1
I am comfortable treating LGBTQ patients.
Strongly Disagree0 (0.0)
Disagree1 (2.9)
Don’t Know1 (2.9)
Agree Strongly13 (37.1)
Agree20 (57.1)
The LGBTQ population has unique health risks and needs.
Strongly Disagree0 (0.0)
Disagree1 (2.9)
Don’t Know1 (2.9)
Agree Strongly25 (71.4)
Agree8 (22.8)
There should be more education in health professional schools on LGBTQ health needs.
Strongly Disagree1 (2.9)
Disagree1 (2.9)
Don’t Know5 (14.2)
Agree Strongly19 (54.3)
Agree9 (25.7)
I would be willing to be listed as an LGBTQ-friendly provider.
Strongly Disagree0 (0.0)
Disagree2 (5.9)
Don’t Know9 (26.5)
Agree Strongly12 (35.3)
Agree11 (32.3)
The LGBTQ population is often more difficult to treat.
Strongly Disagree4 (11.4)
Disagree19 (54.4)
Don’t Know8 (22.8)
Agree Strongly4 (11.4)
Agree0 (0.0)
1 Not all responses add up to 36 due to missing data.
Table 4. LGBTQ-related practice behaviors among indicated providers (N = 36).
Table 4. LGBTQ-related practice behaviors among indicated providers (N = 36).
N (%) 1
I actively inquire about a patient’s sexual orientation when taking a history.
Strongly Disagree5 (13.9)
Disagree7 (19.4)
Don’t Know11 (30.6)
Agree11 (30.6)
Strongly Agree2 (5.6)
It is important to know the sexual orientation of my patients to provide the best care.
Strongly Disagree0 (0.0)
Disagree5 (13.9)
Don’t Know10 (27.8)
Agree14 (38.9)
Strongly Agree7 (19.4)
It is important to know the gender identity of my patients to provide the best care.
Strongly Disagree3 (8.3)
Disagree10 (27.8)
Don’t Know13 (36.1)
Agree9 (25.0)
Strongly Agree1 (2.8)
Upon first encounter I assume a patient is heterosexual.
Strongly Disagree1 (2.8)
Disagree0 (0.0)
Don’t Know9 (25.0)
Agree19 (52.8)
Strongly Agree7 (19.4)
I am well informed on the health needs of LGBTQ patients.
Strongly Disagree1 (2.8)
Disagree3 (8.7)
Don’t Know14 (40.0)
Agree16 (45.7)
Strongly Agree1 (2.8)
There should be mandatory educational events at Moffitt on LGBTQ health needs.
Strongly Disagree5 (13.9)
Disagree7 (19.4)
Don’t Know11 (30.6)
Agree11 (30.6)
Strongly Agree2 (5.6)
1 Not all responses add up to 36 due to missing data.

© 2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Back to TopTop