“I don’t just say, Hi! I’m gay”: Sexual orientation disclosures in oncology clinic settings among sexual minority women treated for breast cancer in the U.S. South

Abstract

Objectives:

Few studies examine sexual orientation disclosures (SODs) among women with breast cancer; fewer examine the impact of culture and geography on disclosure processes. This study explores how sexual minority women (SMW) in the Southern United States engage in SODs with oncology clinicians.

Data Sources:

We conducted in-depth interviews with SMW (e.g., lesbian, bisexual) treated for early-stage (Stage I-III), hormone receptor-positive breast cancer (N=12), using a semi-structured interview guide. Participants completed an online survey prior to the 60-minute interview. Data was analyzed using an adapted pile sorting approach and thematic analysis conventions.

Conclusion:

Average age of participants was 49.5 years (range: 30-69), all self-identified as cisgender; 83.3% as lesbian, 58.3% were married, 91.7% had completed a 4-year college degree or higher, 66.7% identified as non-Hispanic White, 16.7% as Black, and 16.7% as Hispanic/Latina. Half of the sample had not engaged in SODs with an oncology clinician. Key themes were: (1) religious and political conservatism in the South create SOD barriers; (2) oncologist-specific barriers to SODs; (3) “straight passing” as a discrimination mitigation strategy; (4) SOD facilitators in oncology settings (i.e., strategic disclosures, medical privilege, and lesbian, gay, bisexual, and transgender-friendly branding of oncology centers).

Implications for Nursing Practice:

SMW with breast cancer living in the U.S. South navigate unique interpersonal barriers to SODs in oncology settings. Clinicians could encourage SODs by fostering inclusive environments via nonheteronormative language, inclusive intake forms, and respect for SMW’s SOD navigation processes. Oncology clinicians require culturally relevant, geographic-specific communication training to facilitate SODs among SMW.

Introduction

Breast cancer affects approximately 1 in 8 women in the U.S. and is the most frequently diagnosed cancer in women excluding skin cancer. ⁽¹⁾ Sexual minority status data are often not available in national cancer registries and surveys, resulting in little published data on breast cancer incidence and prevalence among individuals with a history of breast cancer who self-identify as sexual minority women (SMW), ⁽²⁾ an umbrella term that includes individuals who identify as lesbian, bisexual, queer/questioning, or other sexual orientations. Weighted prevalence estimates of breast cancer in lesbians and bisexuals are 17.8% and 13.3%, respectively; however, these estimates are limited to California, raising questions about data representativeness and generalizability to other parts of the U.S. ⁽³⁾ SMW with a history of breast cancer report greater distress, relationship challenges, substance abuse, poorer health outcomes, lower quality of life, and less satisfaction with the care received from oncology clinicians than heterosexual women. ^{(4, 5)} Minority stress from cumulative experiences of prejudice, discrimination, intersectional stigma, internalized homophobia, and fear of judgment from clinicians contributes to cancer outcome disparities among SMW. ^{(6, 7)}

SMW with breast cancer report poorer patient-clinician communication with their oncology care team compared to heterosexual patients. ^(8-10) Patient-clinician communication challenges create barriers to sexual orientation disclosures (SODs). ⁽¹¹⁾ For example, nearly one-quarter of oncology clinicians reported assuming their sexual minority patients were heterosexual. ⁽¹²⁾ Both SMW and non-SMW patients believe that being asked about sexual orientation may improve patient-clinician communication and are willing to answer questions about their sexual orientation. ⁽¹³⁾ Yet, most oncology clinicians do not ask about sexual orientation, ⁽¹⁴⁾ leaving the onus of disclosure on SMW. Few studies examine SOD among sexual minority patients in healthcare contexts, with estimates of the proportion of SODs ranging from 28-84% ^{(15, 16)} and rates of nondisclosure significantly greater among bisexuals than lesbians. ⁽¹⁵⁾ However, in a previous study, SODs were often the result of correcting heterosexual assumptions and did not distinguish among cancer types or between sexual minority men and women. ⁽¹⁷⁾ Nondisclosure also occurs at greater frequency among non-White SMW, those who have lower incomes or education, and those who live in rural areas. ⁽¹⁸⁾

Most U.S.-based research about SMW is conducted in urban, metropolitan enclaves in Northeast/Mid-Atlantic and West Coast regions, with only one in ten articles published in the past decade focused on lesbian, gay, bisexual, transgender, and queer (LGBTQ) life in Southern contexts. ⁽¹⁹⁾ The empirical focus is contrary to LGBTQ population demographics. More than one in three LGBTQ adults live in the U.S. South, more than any other region in the nation. ⁽²⁰⁾ The South has the most hostile LGBTQ state policy landscape of any region in the nation, with 93% of LGBTQ Southerners living in a negative- or low-equality state. ⁽²⁰⁾ Specifically, Southern states are far less likely to have LGBTQ-inclusive protections and more likely to have explicitly discriminatory policies. ⁽²⁰⁾ States in the Bible Belt are more strongly influenced by political and religious conservatism; in 14 Southern states, more than one in five counties (23%) are classified as “Evangelical Hubs.” ⁽²⁰⁾ Research also suggests that individuals living in the South are less tolerant of nonheterosexual individuals compared to those living in other U.S. regions. ⁽²¹⁾

To date, little research on SODs among SMW has focused on women with a history of breast cancer or the interplay of culture and geography on SODs in oncology settings. Barriers and facilitators of SODs for SMW in the South are poorly understood, which may compound existing disparities known in the Southern geographic region. ^{(22, 23)} Exploration of SODs among SMW treated for breast cancer in the South must account for minority stress that may prompt concealment of one’s sexual identity ⁽²⁴⁾ as well as recent anti-LGBTQ legislation and its associated public sentiment. To address this research gap, we conducted a qualitative study of SMW treated for breast cancer in the South to explore factors related to self-disclosures in oncology settings. Our aim is to explore preferences, practices, and beliefs surrounding SODs among diverse SMW receiving care within a geographic region that has been understudied and historically less accepting of the LGBTQ community.

Methods

Research Collaborators

Two lesbian women with breast cancer who lived in Memphis, TN were invited to serve as community collaborators on this project. Both women assisted in study recruitment, piloting the semi-structured interview guide, and providing guidance during recruitment challenges and study design changes (due to the COVID-19 pandemic). Community collaborators were compensated $100 for their time.

Study Sample

Self-identified SMW (18 years or older) with a diagnosis of early-stage (Stage I-III), hormone receptor-positive breast cancer, who had been prescribed an adjuvant endocrine therapy medication (e.g., tamoxifen or an aromatase inhibitor) for at least three months residing in U.S. South (16 states designated as southern by the U.S. Census: AL, AR, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV), were eligible for this study. Participants were recruited using a combination of active and passive strategies. Active strategies included direct recruitment by both community collaborators and research team attendance at local breast cancer support group meetings and community events. Passive strategies included social media advertising (e.g., Facebook, Twitter, Instagram), referrals from study participants, referrals from oncology clinicians, and use of Research Match (www.researchmatch.org).

Data were obtained from 12 in-depth interviews conducted between February 2019 and December 2020. We determined a sample size of 12 met the objectives of this study and conventions of data saturation, ⁽²⁵⁾ when the first author noted informational redundancy in the later interviews. ⁽²⁶⁾ Thus, the research team made the determination to end data collection.

Procedures

The first author (JA) conducted all in-depth interviews, using a semi-structed interview guide. Eligible respondents provided informed consent and then completed an online survey that queried their demographic and behavioral characteristics before the interview. In-person interviews were conducted in a private room in a Memphis-based regional oncology center or an alternative location chosen by the study participant (e.g., participant’s home, reserved room in a public library). Virtual interviews were conducted via Zoom. The interview guide was guided by the Minority Stress Model ⁽²⁴⁾ to explore how sexual minority identity influences the breast cancer journey and SODs. Interviews lasted approximately 60 minutes; principles of bracketing were followed during in-depth interviews through regular check-ins and summarizations of participants’ comments to ensure they had the opportunity to correct potential misinterpretations in real time. Participants were given a $50 gift card to offset time and expenses associated with study participation.

The University of Tennessee Health Science Center Institutional Review Board approved the study (17-05479-XP-IAA).

Data Analysis

Interviews were audio recorded and transcribed verbatim using a third-party vendor. The third author reviewed all transcriptions to ensure fidelity to audio files and revised text files when needed prior to coding. The first three authors (JA, AP, and AR) read each transcript and independently conducted line-by-line coding to develop in vivo codes. ⁽²⁷⁾ The research team met to discuss the relevance of codes for each transcript, clarified codes and descriptions, and resolved discrepancies based on alternative interpretations of data. JA and AP engaged in an adapted “pile sorting approach” to identify themes. ⁽²⁸⁾ Codes and corresponding participant quotes were organized by domains in the semi-structured interview guide. ^(29-31) In separate Excel files, JA and AP sorted codes and quotes into “piles” for similarity to identify thematic patterns in the data that corresponded to interview guide domains (e.g., SODs, cancer care environment). Content of “piles” for each co-author were compared; differences were noted, discussed, and resolved to reach consensus about thematic patterns from coded data. Coders followed recommendations to reduce bias by engaging in reflexive journaling and peer debriefing to examine how each other’s positionalities may influence interpretation of data as well as identify and mitigate potential biases and/or personal challenges during the coding process. Final analysis yielded themes as well as categories and sub-categories for themes.

Disclosure Statement

The five-person research team consisted of three cisgender women and two cisgender men; two identify as sexual minorities.

Results

Participant Characteristics

Table 1 describes participant characteristics. All participants self-identified as cisgender; most self-identified as lesbian (n=10, 83.3%). All participants had disclosed their sexual orientation to some family and friends; seven had disclosed to all family and friends. Half of the study sample had not disclosed their sexual orientation to their oncologist. Among the seven participants who had disclosed their sexual orientation to all family and friends, two had not engaged in an SOD with their oncologist.

Table 1.

Participant Characteristics

	Mean or N	SD or %
Age (mean, SD)	49.5	10.5
Sexual Orientation (N, %)
Bisexual	2	16.7%
Lesbian	10	83.3%
Education (N, %)
4-year college degree or more	11	91.7%
Relationship Status (N, %)
Married or exclusive	7	58.3%
Single	4	33.3%
Other	1	8.3%
Race/Ethnicity (N, %)
Non-Hispanic White	8	66.7%
Black	2	16.7%
Hispanic	2	16.7%
Gender (N, %): Cisgender	12	100.0%
Religion (N, %)
Buddhist	1	8.3%
Christian	8	66.7%
None	3	25.0%
State Residence During Treatment
AL	1	8.3%
GA	3	25.0%
TN	6	50.0%
TX	2	16.7%
Male Primary Care Physician (N, %)	7	58.3%
Male Oncologist (N, %)	6	50.0%
Disclosed Sexual Orientation
To oncologists	6	50.0%

Thematic Findings

Barrier to sexual orientation disclosures: religious and political conservatism in the U.S. South

All participants acknowledged the potential for prejudicial or discriminatory treatment once they “outed” themselves, highlighting the need for discernment when deciding if and when to initiate a SOD. Half of the sample reported experiencing prejudice, stigma, or discrimination after a SOD in a range of settings, including employment, church, and medical settings; two women reported experiencing sexual stigma while receiving oncology and gynecology care. Several participants expressed beliefs that SODs were difficult in some parts of the U.S. South with strong conservative, religious cultures, especially in small towns away from urban centers (see Table 2). Participants discussed how SODs were easier in metro areas than nearby towns or rural locales. One participant said, “I think if I had stayed up in [small town in Georgia], I probably would have been more hesitant to bring up the issue. And part of that hesitancy would have been because I don't trust the doctors as much. And part of it is because it's always a toss up in [small town in Georgia]. You got to be careful with doctors you go to.” One participant reported refraining from SODs to non-medical professionals (e.g., front office staff) with known conservative, religious beliefs.

Table 2.

Themes with illustrative quotes from participants

Theme	Examples
Barrier to sexual orientation disclosures: religious and political conservatism in the U.S. South	“You know, through the years, you have to look at the state of affairs and being gay around here. So, you have to take that into consideration whether you’re just gonna [disclose].”
	“I guess I'm being a little prejudiced but I come from a very small town in rural Georgia so I make those assumptions, unfortunately they're often true. The metropolitan area is pretty good.”
	“…maybe you don’t want to freak out the [large city in Tennessee] Baptist woman at the front desk. And why should I care? But for some reason, it’s ingrained in me.”
	“Because regardless of what you think, and even living in Austin, and you want to think about how open it is, the fact is people have prejudices against being gay and lesbian. I'm still in Austin city limits, but out here where I'm at, this is like Trump Republican redneck country.”
Barriers to sexual orientation disclosures to oncologists
(a) Relevance	“It wasn't like I walked in and said, "Hey, we're gay. This is my girlfriend." I didn't do that with him. I didn't do that when I went up for chemo. I didn't do that in the operating room. Like I just don't know that it was a necessary cog in the wheel.”
(b) Lack of oncologist initiation	“My oncologist does not know that I am … He may know whether I'm married or not married from whatever I wrote on the original paperwork or whatever. We've never discussed whether or not I had a partner, whether it be male or female. We've never discussed anything related to ongoing sexual [health]. And this is the same oncologist that I've had since the very beginning.”
(c) Fear of discrimination	“Sometimes I would go to my oncologist alone and I did want to tell him. I'm like, ‘I want to tell you that I'm gay, but I also don't want this to go into my record…’ But my fear was that if I tell him, what if I start getting treated bad? So that fear was there and because I didn't want to deal with the fear, I never said anything.”
Discrimination mitigation strategy: “straight passing”	“The short gray hair that you see, that is one of those…when I see women out on the street, my gaydar goes off. (shaking head) ‘Sister, sister, sister.’ My hair has always been colored, and it has always been long. I dress in the more feminine look, makeup always.”
	“When you just see me, people don't typically think, ‘Oh, she's got to be gay.’ But when I'm with [partner], I'm certain that the default goes to that. She’s six one and skinny and butch.”
	“…kind of like straight people don’t go in and say, ‘I’m straight.’ Unless it was asked, I don’t really volunteer the information.”
Facilitators of sexual orientation disclosures in oncology settings
(a) Spouse/partner introduction	“But from the get-go, when I went to my very first medical oncologist, I said, ‘this is my partner, [partner’s name].”’
(b) Inclusive medical intake forms	“They need to have something besides ‘common law marriage.’ They need to have ‘domestic partnership’ because that says queer.”
(c) Clinician queries about contraceptive use	“[My doctor] came in and said, ‘Are you sure there’s no chance you’re pregnant?’ And I said, ‘I’m sure.’ ‘Well, are you, you know, are you absolutely sure?’ And I said, ‘Listen, if I’m pregnant, we’ve got a bigger problem here…(laughs), not cancer.‘”
(d) Medical privilege	“There’s some people that are suspicious or leery of the medical community. And if you grow up in it, you’re not.”
(e) “LGBTQ-friendly” branded healthcare centers	“I would more likely want to go to them because I know that they'd be accepting, and understanding and, well, at least have some idea of what my needs are.”

Several participants also explicitly discussed how political conservatism in the South contributed to SOD hesitancy (see Table 2): “Well, I mean let's face it, around these parts it's no secret that the much of the religious community is not friendly to us. And they're coming right out and saying it with their votes. There's a rise in racism. There's a rise in homophobia, there's a rise in, in people … White power feeling empowered. Or white, whatever they call themselves. Redneck idiots. Uh, so, so you know it's a weird time.” Participants reported concerns about “strange, conservative backlash” made SODs in oncological settings more difficult.

Barriers to sexual orientation disclosures to oncologists

Half of our study participants had not disclosed their sexual orientation to their oncologists; both Latinas and one of two Black women had not engaged in SODs. Participants cited several reasons for their lack of disclosure: beliefs that sexual orientation is irrelevant to their oncology care (n=3), they had not been explicitly asked about sexual orientation by their oncologist (n=2), and anticipated stigma or discrimination by their oncologist (n=1) (see Table 2).

Relevance.

Several participants questioned the medical relevance of their clinicians’ knowledge about their sexual orientation and called out the heteronormative bias in healthcare that does not require SODs from heterosexual patients. Nonetheless, these participants acknowledged the importance of these disclosures if germane to their cancer treatment or so that spouses/romantic partners can duly participate in medical decision-making.

Lack of oncologist initiation.

Two participants reported not telling their oncologists about their sexual minority status simply because they had not been asked. One participant stated matter-of-factly: “I guess I've just never disclosed because it was never asked.” One participant expressed surprise that her oncologist had never inquired about her sexual orientation, considering their 10-year clinical relationship and her persistent treatment-related sexual symptoms.

Fear of discrimination.

One participant reported that her hesitancy to engage in a SOD with her female oncologist was due to her clinician’s heteronormative comments about dating and potential reproduction after breast cancer treatment: “…when I would see my oncologist, she would say, ‘You know, you can date. You can live your life and have a dating life. Next time I see you I want you to come and tell me that you're dating some boy.’ ” This same participant reported no SOD to a previous male oncologist because of her dual fear of poor treatment by the clinician and anticipated discriminatory treatment by future clinicians if her sexual orientation was included in her medical record.

Of note, one participant’s reason for not disclosing her sexual orientation to her oncologist reflected all three subthemes, which highlights the nuanced, layered nature of SODs in Southern oncology settings for SMW. She said, “I can see where people wouldn't disclose that because they are afraid. I mean, that's not the reason that I didn't. I didn't because it shouldn't matter what I am, what my orientation is on how to treat me. If it came up, I would have mentioned it. But it never really came up.”

Discrimination mitigation strategy: “straight passing”

Nearly half of participants (n=5) discussed the impact of personal aesthetics on SODs. One participant expressed beliefs that her appearance made her sexual orientation obvious to clinicians, negating the need for SODs: “I mean, I’m sure they can look at you and tell, but it’s not something you run around telling everybody.” Another participant stated that masculine-presenting SMW may be more vulnerable to clinician bias: “I can see where somebody who’s, uh, you know, real butch or something like that might feel…I can see where they would be scared that they may be treated differently.”

Three participants, all of whom had not engaged in SODs to their oncologists, described both intentional and unconscious ways they conceal their sexual minority status from clinicians. For these participants, “straight passing” became a discrimination mitigation strategy (see Table 2).

One participant, a White lesbian woman, reported frequent experiences of discrimination since disclosing: “People discriminate. They do. There's very few people that I have come across in my life since I have come out that have not in some way discriminated when they know. So, I don't tell people.” As a result of those experiences, she described how intentional image management has helped her avoid people’s assumptions about her sexuality and circumvent SODs.

Another participant, a White lesbian woman who admitted to not being “out” to everyone in her family and social circles, described how she “assimilates well” in medical and non-medical settings because her aesthetic “blends in well.” Yet, this participant expressed how her “straight passing” strategy is less effective when she is with her Black, masculine-presenting partner. She reported being sensitive to differences in interactions with clinicians when her partner accompanies her to oncology care visits, yet she forgoes her “straight passing” strategy for her partner’s support during visits.

Another participant, a Black bisexual woman who is married to a man, did not report intentional activation of a “straight passing” strategy during healthcare visits, yet she acknowledged that she has purposely not disclosed her sexual orientation to her oncologist. She reported that clinicians do not readily assume she is a SMW because her husband accompanies her to clinic visits. She admitted that her clinicians’ assumptions of heterosexuality are not dispelled.

Facilitators of sexual orientation disclosures in oncology settings

Strategies for navigating SODs in oncology settings varied among participants. In most instances, women favored implicit, strategic disclosures over explicit declarations of their sexual minority status (see Table 2).

Spouse/partner introduction.

Most participants (n=7) engaged in passive SODs by introducing their spouse or long-term partner by first name or title (e.g., “wife”) during initial clinic visits with oncologists.

Inclusive medical intake forms.

Two participants said that medical intake forms that query a patient’s relationship status and the gender of their current partner is preferrable to explicit, verbal SODs. These participants said that relationship-inclusive intake forms that reflect a diversity of relationships statuses—beyond typical, heteronormative single, married, divorced categories—allow SMW being treated for breast cancer to engage in SODs vis-a-vis their same-gender romantic partnerships, without using potentially stigmatizing terms like homosexual. However, one participant explicitly named medical intake forms as a source of sexual stigma and attributed her resistance to SODs to fear that her sexual orientation would be included in her electronic health record and discussed by her oncologist in clinic visits (within earshot of her family members). She said providing sensitive, sexuality information in medical intake forms would be “intimidating.”

Medical privilege.

All participants discussed how trust and familiarity with their oncologists had some degree of influence on their SOD decisions. Two women in our study reported medical privilege, having oncologists and other specialized healthcare professionals in their families and inner social circles who had “some kind of investment in you other than just being a patient.” Both participants expressed beliefs that medical privilege insulated them from stigma or discrimination based on their sexual minority status and lessened risks associated with SODs. Both women also reported that SODs to oncology clinicians with whom they had personal relationships were often easier and safer than disclosures to family and friends. “It didn’t feel like there’d be judgement. It was a necessary piece of information,” said one participant about her SOD to her breast oncologist. These participants reported medical privilege enhanced their patient-clinician communication and overall cancer care

“LGBTQ-friendly” branded healthcare centers.

All participants acknowledged the importance of inclusive, affirming cancer care environments for LGBTQ patients. The majority (n=7) reported that “LGBTQ-friendly” branding is relevant to patients in their community, although several (n=5) said that such branding was not necessary for them and would not influence their personal healthcare-seeking behaviors. Nevertheless, women expressed beliefs that LGBTQ-friendly branded healthcare facilities may allay some patients’ concerns about physical safety or subpar, discriminatory treatment, especially in small towns or rural areas. Two participants, neither of whom had disclosed to their oncologists, reported they would be more likely to go to a cancer care facility that explicitly branded itself as LGBTQ friendly. Participants identified characteristics of inclusive cancer care environments that may facilitate SODs, including clinician body language, use of inclusive language, and non-stigmatizing questions about holistic health. Participants also stressed the importance of such organizations earning their branding by requiring clinician training in sexual minority sensitivity, implementing real-time evaluation of clinician interactions with sexual minority patients, and enforcing consequences against clinicians who use stigmatizing, discriminatory language.

Discussion

In this qualitative study of SMW with early-stage breast cancer, we explored the interpersonal nature of SODs within the context of oncology care in the U.S. South. Findings from this study suggest SMW with breast cancer treated in the U.S. South are buttressed by facilitators but also confronted with barriers to self-disclosure. Barriers included a more conservative Southern culture that promotes fear of discrimination and conflicting views about the benefit or relevance of sexual orientation for breast cancer treatment decisions. Facilitators for SODs in oncology settings included strategic disclosures, such as introducing partners, inclusive patient intake forms, medical privilege, and LGBTQ-friendly branding of oncology centers.

Half of our participants had not disclosed their sexual orientation to their oncologist, a nondisclosure proportion similar to a recent study of self-disclosures to any healthcare clinician among Southern lesbians. ⁽³²⁾ Consistent with our results, a recent systematic review of SODs in healthcare⁽¹¹⁾ found that patients who perceive their disclosure is relevant to their healthcare are more likely to engage in SODs than those who believe sexual orientation is irrelevant to care. We found that SODs made by SMW with breast cancer to their oncologists invoke concerns about stigma, discrimination, and changes to the patient-clinician relationship that could impact the quality of oncology care received. Studies suggest that lesbian women frequently witness clinician discomfort after a SOD, causing them to reconsider their willingness to disclose in subsequent medical encounters. ⁽³³⁾ Nearly all participants expressed at least some personal concern about discrimination from their oncologist because of their sexual minority status, given previous experiences within various medical contexts. Findings suggest SMW treated for breast cancer in the U.S. South are aware of the potential for discrimination in the oncology setting and manage potentially discriminatory experiences differently: from explicit SODs to disclosure avoidance.

SODs from SMW are often hindered by anticipated or perceived discrimination from clinicians, including microinvalidations that exclude or nullify their experiences (e.g., failing to inquire about sexual orientation and gender identity or creating space for SODs). ^{(34, 35)} In our study, SMW described microinvalidations from oncologists who made heteronormative assumptions about romantic/sexual partners, dating, and fertility desires. Clinicians’ microinvalidations indicate their lack of basic cultural competence about appropriate, inclusive communication with LGBTQ patients with cancer may communicate that the medical environment is unsafe for SODs. Cultural humility is preferable, for it often promotes patient-clinician relationships based self-reflexivity, challenges asymmetries in patient-clinician power dynamics, and may restore patient’s epistemic authority about their breast cancer experience.⁽³⁶⁾ Yet, awareness and acceptance of sexual diversity is limited in some U.S. Southern contexts and may subject SMW with breast cancer to a distinctive form of invisibility within cis-heterodominant spaces, like oncology care settings.

In a recent qualitative synthesis, Franco-Rocha et al.⁽³⁶⁾ found that cisheteronormativity impacts the cancer care experience for LGBTQ individuals by creating tensions around SOD and concealment processes. Concealment of one’s sexual minority status via “straight passing” is a mitigation strategy to anticipated sexual stigma that may serve to insulate some SMW from negative impacts of discrimination.⁽³⁷⁾ This practice may be seen as a way of adapting within cis-heterodominant cultures, including healthcare settings. ⁽³⁸⁾ SMW are more likely to unintentionally pass than male sexual minorities; bisexuals are more likely to intentionally and unintentionally pass, due in part to the straight-gay dichotomy in the U.S. cultural imaginary that often ignores bisexuality.⁽³⁷⁾ Medical privilege is an additional factor that may insulate SMW from the negative impacts of discrimination or prejudice within medical contexts. Having oncology clinicians and other healthcare professionals in one’s social networks may allow some SMW to leverage personal relationships to increase care quality while lessening perceived risks associated with SODs. As such, medical privilege facilitates patient trust and patient-centered communication, making SODs easier.

SODs are often encouraged because of the association with improved mental health ⁽³⁹⁾ and greater satisfaction with care. ⁽⁴⁰⁾ Yet, Black and Latina SMW are less likely to engage in nonfamily SODs than their White counterparts, ^{(15, 41)} a finding supported by this study. For racialized SMW, SODs to healthcare clinicians may not always be beneficial because of the increased likelihood of exposure to intersectional stigma and discrimination, which could lead to compounded distress and diminished mental and psychosocial wellness. ⁽²⁴⁾ For instance, Black lesbians who engage in nonfamily SODs are more likely to report depression than White or Latina lesbians. ⁽⁴¹⁾ Future research should continue to explore how ethnoracial, cultural, and regional factors influence within and between group SOD patterns among sexual minority breast cancer survivors.

Nonetheless, participants in this sample described engaging in contextual navigation, ⁽³⁸⁾ which is a concept that reflects the ongoing, adaptive processes of identity negotiation (e.g., breast cancer survivor, sexual minority) to the unique experiences of SMW treated for breast cancer in Southern states as they navigate SODs in oncology settings with clinicians. SMW in this study reported using their understandings of the sociopolitical and cultural temperature of their geographic surrounding (e.g., small towns, rural areas) as well as clinician “vibes” and language to make self-disclosure decisions based on clinical relevance and personal safety.

When patients are comfortable making SODs, Venetis et al. ⁽⁴²⁾ found that SODs occur at two key points in a medical encounter: introductions or medical history, which supports our findings that the primary way that SMW with breast cancer disclose their sexual orientation to an oncologist is by referencing their romantic partner. Although clinicians’ questions about sexual health and sexual activity have been found to prompt SODs, ⁽⁴²⁾ most of our participants reported few, if any, conversations about sexual health with their oncologists, which limited opportunities for SODs. Instead, medical intake forms that collect sexual orientation and gender identity (SOGI) data were a preferred method for SODs among some SMW with breast cancer. Concerns raised about SOGI-related information in electronic health records highlight the need for additional research to parse the interconnectedness of disclosure and data privacy and management. Oncology centers collecting this data may want to consider adding disclaimer language about how SOGI information will be used and securely stored.

Finally, despite not emerging as a facilitator in the current study, Boehmer and Case ⁽¹⁴⁾ posit that female clinicians who identify as a sexual minority may provide the best-case scenario for SODs among SMW patients. In this study, participants suggested that oncologists could create inclusive cancer care environments through LGBTQ-sensitive language, avoidance of heteronormative assumptions, and ongoing training in LGBTQ health. A recent study provides support for clinician certification in LGBTQ health. ⁽⁴³⁾ Our findings also highlight the need for inter-organizational regulatory policies to ensure SMW patients receive non-discriminatory, high-quality oncology care. Grievance mechanisms are necessary to support organizational policies and provide correction for clinicians who fail to provide LGBTQ-inclusive care to patients. ⁽⁴⁴⁾

Limitations of the present study should be noted. We did not explicitly recruit women who were born/raised in the South, so it is possible that SMW raised outside the South but now living in the region may have different perspectives. Additionally, we only recruited participants who felt comfortable to disclose their sexual orientation, which was intrinsically required to be included in the study. It is likely that SMW who are not comfortable disclosing their identities to participate in a research study have different perspectives; thus, their voices are absent from our findings.

Implications for Nursing Practice

Understanding how SMW with breast cancer in the U.S. South navigate interpersonal relationships with oncology team members to make SOD decisions may be critical to improving screening, treatment, and survivorship among SMW. However, only one in five oncology centers routinely collects SOGI data, ⁽⁴⁵⁾ which limits our ability to understand disparities along the cancer continuum for LGBTQ patients. Our findings identify key barriers, including anticipated or perceived discrimination and microinvalidations from clinicians. These patient-clinician interpersonal challenges may hinder SMW’s willingness to disclose this information. ^{(46, 47)}

Facilitators include creating an affirming cancer care environment for LGBTQ patients. To facilitate SODs, healthcare professionals in oncology centers must be trained in non-stigmatizing approaches to SOGI data collection. Patient perception of their oncology clinician as accepting of SMW is a significant facilitator of SODs ⁽¹¹⁾; however, LGBTQ patients report they often feel being in the South makes it more difficulty to access quality medical care. Moreover, disclosing their sexual minority status changes how healthcare professionals interact with them. ⁽⁴⁸⁾ Oncology clinicians acknowledge the utility of LGBTQ sensitivity and communication training to improve their patient-clinician communication with SMW and expressed willingness to identify as an LGBTQ-friendly provider after more training.⁽⁴⁹⁾ Considering the sociopolitical and legislative landscape in the U.S. South remains adversarial to LGBTQ rights, clinicians practicing in the region require culturally relevant, geographic-specific training and routine evaluation in LGBTQ health competencies, patient-centered communication, explicit and implicit bias, and critical self-reflection (50) to better engage with SMW breast cancer survivors.

Conclusion

This study adds to our understanding of the ways in which Southern culture influences the dynamic SOD decisional process of SMW with breast cancer. Findings suggest several ways interpersonal and organizational factors may encourage SODs by fostering supportive, inclusive clinical environments.