Abstract
Purpose
Sexual and gender minority (SGM) individuals have an increased risk of poor health outcomes, in part due to knowledge and training gaps in health care education. This study sought to evaluate the knowledge, attitudes, and practice behaviors of various health care role groups within radiation oncology toward SGM patients.
Methods and Materials
A 38-item web-based survey was emailed to 1045 staff across 2 large radiation oncology departments. The survey assessed demographics, attitudes, knowledge, and practice behaviors. χ2 tests were performed to explore differences in survey responses by age, political affiliation, religious identity, year since graduation, and role groups. One-way analysis of variance tests were conducted to determine differences between respondents’ confidence in knowledge and performance on the knowledge section of the survey. Thematic analysis was applied to the open discussion section.
Results
Of the 223 respondents, 103 clinicians (physicians/advanced practice providers/nurses) and 120 nonclinicians (administrative staff, medical assistants, and other nonmedical staff) participated in the survey (21.3% response rate): 72.6% answered the knowledge questions; 93.5% stated they were comfortable treating sexual minorities, or lesbian, gay, bisexual, and queer + patients; 88% indicated comfort in treating transgender patients; 36.6% stated they were confident in their knowledge of the health needs of transgender patients; and 50.3% expressed confidence in treating lesbian, gay, bisexual, and queer + patients. Fewer nonclinicians than clinicians thought that gender identity, sexual orientation, and sex assigned at birth were important to provide the best care (P < .05). The open comments section identified key themes, including the belief that current educational tools are not helpful, desire for more educational formats (lectures, case-based learning, seminars), and an overall interest in SGM health education.
Conclusions
Most staff feel comfortable in treating SGM patients but are less confident in the distinct needs of this population. Knowledge gaps persist for both clinicians and nonclinicians, indicating a need for further training specific to oncology care.
Introduction
The lesbian, gay, bisexual, transgender, queer (LGBTQ+) population, also known as sexual and gender minorities (SGM), experience disparities in cancer care, treatment, and outcomes.1 There is a growing body of evidence demonstrating that SGM people experience disproportionate rates of certain cancers such as breast, cervical, and anal cancer.2, 3, 4 SGM populations are less likely to engage in cancer screenings, less likely to have an established health care provider, and are more likely to engage in behaviors associated with increased cancer risk, such as smoking, alcohol use, anal receptive sex (among SGM assigned male at birth), and lower rates of exercise.5, 6, 7, 8 Prior stigmatizing experiences in health care contribute to stress and medical mistrust for SGM patients with cancer, perpetuating a system in which SGM people feel the need to avoid or delay treatment. 9, 10, 11, 12 Recent studies have shown that, for transgender patients, their lived experience with a cancer diagnosis is unique, and gender expectations can have a negative effect on the patient experience. Transgender patients are often forced to choose between corrective self-defense or abandonment of self-expression, likely due to the assumption that patients are cisgender.13 Given these studies and recent political movements to restrict health care for transgender people, especially transgender youth, the Human Rights Campaign officially declared a state of emergency for LGBTQ+ Americans in 2023.14 The American Society of Clinical Oncology; National Academies of Science, Engineering, and Medicine; and American Medical Association have also called for increased attention to SGM patients in both general and oncology-specific practice.15, 16, 17
Lack of training in both the clinical and psychosocial needs of SGM people leads to a system in which patients have to educate their clinicians about their own identities and needs.13 Knowledge of the importance of routine collection of sexual orientation and gender identity (SOGI) data can increase quality of care for SGM patients by enabling institutions to track and monitor trends and outcomes.18 Recognition of health disparities by the Association of American Medical Colleges has led them to recommend instituting curricular changes in medical schools to improve care for SGM people. Implementation of LGBTQ+-specific education and the availability of educational material have already suggested effectiveness of such initiatives.19 However, despite recognizing that negative health care experiences are a barrier to providing optimal care to SGM people, most initiatives do not include efforts to educate nonclinicians involved in patient care. Nonclinicians play a vital role in administrative tasks, including the collection of SOGI data. While prior research in knowledge, attitudes, and practice behaviors focused solely on clinicians, nonclinicians (administrative staff, medical assistants, and other nonmedical staff) make a significant contribution to a patient's overall health care experience.20, 21, 22 This study analyzed differences in survey responses across all clinicians and nonclinicians in radiation oncology to identify gaps in knowledge, attitudes, and practice behaviors in the context of role groups.
Methods and Materials
Study population and survey
The study was conducted at 2 radiation oncology departments at a National Cancer Institute's (NCI)-designated comprehensive cancer center, and an institutional review board exception was granted. A link for a 38-item REDCap survey was distributed to 1041 health care clinicians and nonclinicians by email. Clinicians included physicians, advanced practice providers (APP), and nurses. Nonclinicians included medical physicists, radiation therapists, medical assistants, administrative staff, and other role groups in the department. Survey measures related to lesbian, gay, bisexual, and queer (LGBQ+) patients referred to cisgender sexual minority patients, and those inquiring about LGBTQ+ patients referred to all SGM patients, including gender minorities. The survey was available from March 1, 2023, to March 22, 2023.
Survey measures
The survey was developed from validated survey instruments and was divided into 4 sections: demographics (16 questions), attitudes (14 questions), knowledge (5 questions), and open comments (3 questions).20, 21, 22 The survey is included in Appendix E1. The Human Rights Campaign glossary of terms was used as reference for the most inclusive language.23 The knowledge sections consisted of 5 true or false statements related to health care disparities and cancer risk in SGM populations.
The attitudes section consisted of 14 statements covering comfort/confidence in treating LGBTQ+ patients, importance of knowing sexual orientation/gender identity for care, belief of unique health needs, belief in more medical education, willingness to be listed as SGM friendly, and belief that the SGM population is more difficult to treat.
For the attitudes and knowledge sections, respondents were prompted to choose responses based on a Likert scale. The responses were written as follows: strongly disagree, disagree, neutral/don't know, agree, strongly agree.
The open comments section consisted of 3 questions that allowed respondents to elaborate on experiences at their institution, personal experience, and any additional comments they choose to share.
All survey items were taken from published surveys as well as articles on LGBTQ+ health20,21 and reviewed by the diversity, inclusion, and equity committee in the department.
Statistical analysis
Descriptive statistics (frequencies and percentages) were used to quantify survey responses. Stratified analyses were performed to explore differences in survey responses by age (≤44 and ≥45), political affiliation, religious identity, year since graduation, and role group (clinician and nonclinician) using χ2 tests. Regarding the use of the term “nonclinician”, we recognize that certain nonclinician role groups (eg, radiation therapists) may have substantial contact with patients. We defined clinicians to include those role groups that are primarily engaging in health care decisions. Having confidence of LGBTQ+ knowledge was categorized as agree versus neutral/disagree, and the mean number of correct responses in each of these categories was calculated on 5 LGBTQ+ knowledge-based questions. One-way analysis of variance tests were conducted to determine the association of confidence in LGBTQ+ knowledge to the mean number of correct responses. For the open discussion section, responses were categorized into key themes based on common meaning. A code list was developed by 2 independent coders (BG and AS). The code list was subsequently compared and discussed, resulting in a final code list. The final code list was applied to the open discussion responses, and each code corresponded to a broader theme. For example, one theme identified was “need for more education”. IBM SPSS 28.0 was used for all analyses.
Results
Demographics
Two hundred twenty-three staff completed the survey with a 21.9% response rate (Table 1). The median age of respondents was 41 (range, 22-72). Of those, 223 respondents (50.8%) were clinicians (medical doctor, APP, or nurse). Regarding sexual orientation, the majority of respondents identified as heterosexual (82.4%). Most of the respondents are non-Hispanic (86.7%) and White/Caucasian (68.1%). Physicians account for the largest percentage of respondents in this survey (29.6%). Even though there was a broad range of age of respondents, most of them graduated from their highest level of education between 2000 and 2009 (27.0%), and nearly half of the respondents were politically liberal (49.8%). Ninety-six percent of respondents indicated they had a family member or friend that identified as LGBTQ+, suggesting that having connections with the SGM community could potentially encourage their response to this kind of survey. Of note, the majority of respondents (56%) stated that 0% to 5% of patients identified as LGBTQ+.
Table 1.
Characteristics of the surveyed health care role groups (N = 223)
| Characteristic | N (%) |
|---|---|
| Age group (y) | |
| ≤44 | 106 (47.5) |
| 45-54 | 31 (13.9) |
| ≥55 | 44 (19.7) |
| Missing | 42 (18.8) |
| Gender* | |
| Woman | 135 (65.5) |
| Man | 67 (32.5) |
| Transgender/Gender expansive | 10 (5.0) |
| Something else | 2 (1.0) |
| Missing | 17 (7.6) |
| Sexual orientation* | |
| Heterosexual | 169 (82.4) |
| Gay | 6 (2.9) |
| Lesbian | 5 (2.4) |
| Bisexual | 12 (5.9) |
| Asexual | 2 (1.0) |
| Queer | 5 (2.4) |
| Not sure/questioning | 5 (2.4) |
| Something else | 0 (0.0) |
| Prefer not to answer | 6 (2.9) |
| Missing | 18 (8.1) |
| Race* | |
| White or Caucasian | 139 (68.1) |
| Black or African American | 11 (6.4) |
| American Indian or Alaska Native | 0 (0.0) |
| Asian | 28 (13.7) |
| Native Hawaiian or Other Pacific Islander | 0 (0.0) |
| Something Else | 14 (6.9) |
| Prefer not to answer | 16 (7.8) |
| Missing | 19 (8.5) |
| Ethnicity | |
| Hispanic | 12 (5.9) |
| Non-Hispanic | 176 (86.7) |
| Prefer not to answer | 15 (7.4) |
| Religious identity* | |
| Atheist/agnostic | 52 (25.2) |
| Buddhist | 1 (0.5) |
| Christian | 99 (48.1) |
| Hindu | 3 (1.5) |
| Jewish | 15 (7.3) |
| Muslim | 4 (1.9) |
| Something else | 14 (6.8) |
| Prefer not to answer | 28 (13.6) |
| Missing | 17 (7.6) |
| Role group | |
| Administrative staff | 27 (13.3) |
| Advanced practice provider | 10 (4.9) |
| Dosimetrist | 9 (4.4) |
| Medical assistant | 1 (0.5) |
| Nurse | 33 (16.3) |
| Radiation therapist | 32 (15.8) |
| Physician | 60 (29.6) |
| Physicist | 9 (4.4) |
| Something else | 22 (10.8) |
| Missing | 20 (9.0) |
| Highest level of education graduation year | |
| Before 1989 | 24 (12.0) |
| 1990-1999 | 26 (13.0) |
| 2000-2009 | 54 (27.0) |
| 2010-2014 | 34 (17.0) |
| 2015-2022 | 62 (31.0) |
| Missing | 23 (10.3) |
| Cancer sites treated* | |
| Breast | 75 (37.1) |
| Head and neck | 76 (37.6) |
| Central nervous system | 77 (38.1) |
| Genitourinary | 105 (52.0) |
| Lymphoma | 70 (34.7) |
| Sarcoma | 71 (35.1) |
| Gastrointestinal | 85 (42.1) |
| Pediatrics | 36 (17.8) |
| Thoracic | 81 (40.1) |
| Something else | 9 (4.5) |
| Not applicable | 59 (29.2) |
| Missing | 21 (9.4) |
| Age groups treated* | |
| Pediatrics | 35 (17.1) |
| Young adults | 76 (37.1) |
| Adult | 149 (72.7) |
| Prefer not to answer | 2 (1.0) |
| Not applicable | 51 (24.9) |
| Missing | 18 (8.1) |
| Patients seen per week | |
| 0-25 | 67 (33.5) |
| 26-50 | 50 (26.0) |
| 51-75 | 14 (7.0) |
| 76-100 | 7 (3.5) |
| >100 | 8 (4.0) |
| Not applicable | 52 (26.0) |
| Missing | 23 (10.3) |
| Percentage of patients seen identify as LGBTQ+ | |
| None | 31 (16.6) |
| 0-5 | 104 (55.6) |
| 6-10 | 43 (23.0) |
| 11-15 | 6 (3.2) |
| 16-20 | 2 (1.1) |
| >20 | 1 (0.5) |
| Missing | 36 (16.1) |
| Family member identifies at LGBTQ+ | |
| Yes | 102 (50.2) |
| No | 96 (47.3) |
| Prefer not to answer | 5 (2.5) |
| Missing | 20 (9.0) |
| Friend identifies as LGBTQ+ | |
| Yes | 187 (92.6) |
| No | 12 (5.9) |
| Prefer not to answer | 3 (1.5) |
| Missing | 21 (9.4) |
| Political affiliation | |
| Conservative | 9 (4.4) |
| Moderate | 50 (22.6) |
| Liberal | 101 (49.8) |
| Prefer not to answer | 43 (21.2) |
| Missing | 20 (9.0) |
Abbreviation: LGBTQ+ = lesbian, gay, bisexual, transgender, queer +.
Percentages exceed 100% because of multiple responses for each question.
Attitudes
Among all the respondents, 94% of them (N = 157) indicated that they were comfortable treating LGBQ+ patients. Of note, this number dropped to 88% (N = 146) regarding treating transgender patients (Table 2a, Fig. 1a, b). In terms of their knowledge of the health needs of LGBQ+ patients, 50% of respondents (N = 84) expressed that they were not confident with the current knowledge and training experiences to treat this group of patients. Fewer respondents indicated they were confident in the health needs of transgender patients (35%, N = 57). Eighty percent of respondents (N = 132) stated that they would be interested in education regarding the unique health needs of LGBTQ+ patients. Eighty percent of respondents (N = 130) would also be interested in being listed as an LGBTQ+-friendly provider. In the survey of practice behaviors, 41% of the respondents (N = 67) thought that it is important to know the sexual orientation of patients to provide the best care. Furthermore, 64% of the respondents (N = 107) stated that knowing the gender of patients was important to provide the best care. When asked about knowing the patient's sex assigned at birth, 55% (N = 89) agreed that this is important to provide the best care. Most of the individuals reported that they did not believe LGBTQ+ patients were more difficult to treat. Regarding assumptions about heterosexuality, 55% (N = 92) indicated that they do not assume a patient is heterosexual upon first encounter. Fewer than 1 in 4 (24%, N = 39) respondents thought that religion plays a role in clinical practice and treatment of patients. Finally, 66% (N = 108) thought that there should be mandatory education on LGBTQ+ needs at their workplace.
Table 2a.
Attitudes and practice behaviors toward lesbian, gay, bisexual, transgender, queer + (LGBTQ+) health among surveyed role groups
| Survey | N (%)* |
|---|---|
| Overall | |
| 1. I am comfortable treating LGBQ+ patients | |
| Strongly Disagree/Disagree | 2 (1.2) |
| Neutral | 4 (2.4) |
| Strongly Agree/Agree | 157 (93.5) |
| Do not know/Prefer not to answer | 5 (3.0) |
| 2. I am comfortable treating transgender patients | |
| Strongly Disagree/Disagree | 4 (2.4) |
| Neutral | 9 (5.4) |
| Strongly Agree/Agree | 146 (88.0) |
| Do not know/Prefer not to answer | 7 (4.2) |
| 3. I am confident in my knowledge of health needs of LGBQ+ patients | |
| Strongly Disagree/Disagree | 21 (12.6) |
| Neutral | 56 (33.5) |
| Strongly Agree/Agree | 84 (50.3) |
| Do not know/Prefer not to answer | 6 (3.6) |
| 4. I am confident in my knowledge of the health needs of transgender patients | |
| Strongly Disagree/Disagree | 41 (24.8) |
| Neutral | 60 (36.6) |
| Strongly Agree/Agree | 57 (34.7) |
| Do not know/Prefer not to answer | 6 (3.7) |
| 5. I would be interested in education regarding the unique health needs of LGBTQ+ patients | |
| Strongly Disagree/Disagree | 10 (6.0) |
| Neutral | 21 (12.7) |
| Strongly Agree/Agree | 132 (79.5) |
| Do not know/Prefer not to answer | 3 (1.8) |
| 6. I would be willing to be listed as an LGBTQ+-friendly provider | |
| Strongly Disagree/Disagree | 10 (6.2) |
| Neutral | 10 (6.2) |
| Strongly Agree/Agree | 130 (80.2) |
| Do not know/Prefer not to answer | 18 (11.1) |
| 7. The LGBTQ+ population is often more difficult to treat | |
| Strongly Disagree/Disagree | 93 (56.3) |
| Neutral | 42 (25.5) |
| Strongly Agree/Agree | 14 (8.5) |
| Do not know/Prefer not to answer | 16 (9.7) |
| 8. It is important to know the sexual orientation of my patients to provide the best care | |
| Strongly Disagree/Disagree | 40 (24.3) |
| Neutral | 49 (29.7) |
| Strongly Agree/Agree | 67 (40.6) |
| Do not know/Prefer not to answer | 9 (5.5) |
| 9. It is important to know the gender identity of my patients to provide the best care | |
| Strongly Disagree/Disagree | 19 (11.6) |
| Neutral | 31 (18.8) |
| Strongly Agree/Agree | 107 (64.4) |
| Do not know/Prefer not to answer | 8 (4.8) |
| 10. It is necessary to know the patient's sex assigned at birth to provide the best care | |
| Strongly Disagree/Disagree | 24 (14.7) |
| Neutral | 36 (22.0) |
| Strongly Agree/Agree | 92 (56.1) |
| Do not know/Prefer not to answer | 12 (7.3) |
| 11. It is important to know the patient's sex assigned at birth to provide the best care | |
| Strongly Disagree/Disagree | 22 (13.5) |
| Neutral | 40 (25.4) |
| Strongly Agree/Agree | 89 (54.9) |
| Do not know/Prefer not to answer | 10 (6.2) |
| 12. Upon first encounter, I assume a patient is heterosexual | |
| Strongly Disagree/Disagree | 92 (55.8) |
| Neutral | 29 (17.6) |
| Strongly Agree/Agree | 37 (22.4) |
| Do not know/Prefer not to answer | 7 (4.2) |
| 13. Religion plays a role in clinical practice and/or treatment of patients | |
| Strongly Disagree/Disagree | 67 (41.4) |
| Neutral | 44 (27.2) |
| Strongly Agree/Agree | 39 (24.1) |
| Do not know/Prefer not to answer | 12 (7.4) |
| 14. There should be mandatory education on LGBTQ+ health needs at my workplace | |
| Strongly Disagree/Disagree | 20 (12.2) |
| Neutral | 31 (18.8) |
| Strongly Agree/Agree | 108 (65.5) |
| Do not know/Prefer not to answer | 6 (3.6) |
Totals do not add up to 223 due to missing data.
Figure 1.
(A, B) Horizontal bar chart of responses to attitude questions and (C) horizontal bar chart of responses to knowledge questions.
Among certain attitude measures, significant differences were found by role group (Table 2b). Stratified analyses were performed on attitude measures relevant to nonclinicians (interest in LGBTQ+ education, the importance of SOGI documentation, assumptions of sexual orientation, and belief that LGBTQ+ education should be mandatory). Clinicians were more likely than nonclinicians to believe that it is important to know the patient's sexual orientation, gender identity, and sex assigned at birth to provide the best care (all P < .001; Table 2b). When stratifying attitude measures based on political affiliation, a higher percentage of liberal respondents would be interested in education regarding LGBTQ+ health needs, believe it is important to know the sexual orientation and gender identity to provide the best care, and thought that there should be mandatory education on LGBTQ+ health needs compared with respondents who identify as moderate or conservative (all P < .05; Table 2c). There were no significant differences by age and year of graduation for the attitude measures.
Table 2b.
Attitudes and practice behaviors toward lesbian, gay, bisexual, transgender, queer + (LGBTQ+) health among surveyed role groups
| Survey | N (%) | Role group | ||
|---|---|---|---|---|
| Overall | Clinicians | Nonclinicians | P value | |
| 1. I would be interested in education regarding the unique health needs of LGBTQ+ patients | ||||
| Strongly agree/Agree | 132 (79.5) | 76 (78.4) | 56 (81.8) | .09 |
| Neutral | 21 (12.7) | 13 (13.4) | 7 (10.6) | |
| Strongly disagree/Disagree | 10 (6.0) | 6 (6.2) | 4 (6.06) | |
| Do not know/Prefer not to answer | 3 (1.8) | 2 (2.1) | 1 (1.5) | |
| 2. It is important to know the sexual orientation of my patients to provide the best care | ||||
| Strongly agree/Agree | 67 (40.6) | 50 (51.6) | 17 (25.0) | <.001 |
| Neutral | 49 (29.7) | 28 (28.9) | 21 (30.9) | |
| Strongly disagree/Disagree | 40 (24.3) | 18 (18.6) | 22 (32.4) | |
| Do not know/Prefer not to answer | 9 (5.5) | 1 (1.0) | 8 (11.8) | |
| 3. It is important to know the gender identity of my patients to provide the best care | ||||
| Strongly agree/Agree | 107 (64.4) | 76 (78.3) | 31 (45.6) | <.001 |
| Neutral | 31 (18.8) | 11 (11.3) | 20 (29.4) | |
| Strongly disagree/Disagree | 19 (11.6) | 9 (9.3) | 10 (14.7) | |
| Do not know/Prefer not to answer | 8 (4.8) | 1 (1.0) | 7 (10.3) | |
| 4. It is important to know the patient's sex assigned at birth to provide the best care | ||||
| Strongly agree/Agree | 89 (54.9) | 67 (69.8) | 22 (33.3) | <.001 |
| Neutral | 41 (25.3) | 18 (18.8) | 23 (34.8) | |
| Strongly disagree/Disagree | 92 (55.8) | 57 (59.4) | 35 (50.7) | |
| Do not know/Prefer not to answer | 10 (6.2) | 3 (3.1) | 7 (10.6) | |
| 5. Upon first encounter, I assume a patient is heterosexual | ||||
| Strongly agree/Agree | 37 (22.4) | 22 (21.9) | 15 (21.7) | .36 |
| Neutral | 29 (17.6) | 15 (15.6) | 14 (20.3) | |
| Strongly disagree/Disagree | 20 (12.2) | 13 (13.6) | 7 (10.1) | |
| Do not know/Prefer not to answer | 7 (4.2) | 2 (2.1) | 5 (7.2) | |
| 6. There should be mandatory education on LGBTQ+ health needs at my workplace | ||||
| Strongly agree/Agree | 108 (65.5) | 63 (65.6) | 45 (65.2) | .36 |
| Neutral | 31 (18.8) | 18 (18.8) | 13 (18.8) | |
| Strongly disagree/Disagree | 20 (12.2) | 13 (13.6) | 7 (10.1) | |
| Do not know/Prefer not to answer | 6 (3.6) | 2 (2.1) | 4 (5.8) | |
Totals do not add up to 223 due to missing data.
P values were calculated using χ2 test, comparing strongly agree/agree to all other responses. Missing responses were not included in stratified analyses. Bold P values indicate statistical significance with alpha level of <.05. Certain questions were excluded from stratified analyses due to lack of applicability to nonclinicians.
Table 2c.
Attitudes and practice behaviors toward lesbian, gay, bisexual, transgender, queer + (LGBTQ+) health by political affiliation
| Survey | N (%) | Political affiliation |
|||
|---|---|---|---|---|---|
| Overall | Conservative | Moderate | Liberal | P value | |
| 1. I am comfortable treating LGBQ+ patients | |||||
| Strongly agree/Agree | 126 (95.5) | 7 (87.5) | 40 (97.5) | 79 (95.2) | .22 |
| Neutral | 2 (1.5) | 1 (12.5) | 0 (0.0) | 1 (1.2) | |
| Strongly disagree/Disagree | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | |
| Do not know/Prefer not to answer | 4 (3.0) | 0 (0.0) | 1 (2.4) | 3 (3.6) | |
| 2. I am comfortable treating transgender patients | |||||
| Strongly agree/Agree | 116 (89.2) | 6 (75.0) | 37 (92.5) | 73 (89.0) | .60 |
| Neutral | 7 (5.4) | 1 (12.5) | 2 (5.0) | 4 (4.9) | |
| Strongly disagree/Disagree | 2 (1.5) | 0 (0.0) | 0 (0.0) | 2 (2.4) | |
| Do not know/Prefer not to answer | 5 (3.8) | 1 (12.5) | 1 (2.5) | 3 (3.7) | |
| 3. I am confident in my knowledge of health needs of LGBQ+ patients | |||||
| Strongly agree/Agree | 65 (50.4) | 2 (25.0) | 18 (43.9) | 45 (54.9) | .64 |
| Neutral | 43 (33.3) | 3 (37.5) | 18 (43.9) | 22 (26.8) | |
| Strongly disagree/Disagree | 17 (13.2) | 0 (0.0) | 4 (9.8) | 13 (15.8) | |
| Do not know/Prefer not to answer | 4 (3.1) | 1 (12.5) | 1 (2.4) | 2 (2.4) | |
| 4. I am confident in my knowledge of health needs of transgender patients | |||||
| Strongly agree/Agree | 43 (33.9) | 4 (50.0) | 13 (33.3) | 26 (32.1) | .74 |
| Neutral | 49 (38.6) | 3 (37.5) | 17 (43.6) | 29 (35.8) | |
| Strongly disagree/Disagree | 33 (26.0) | 0 (0.0) | 8 (20.5) | 25 (30.6) | |
| Do not know/Prefer not to answer | 2 (1.6) | 0 (0.0) | 1 (2.6) | 1 (1.2) | |
| 5. I would be interested in education regarding the unique health needs of LGBTQ+ patients | |||||
| Strongly agree/Agree | 111 (85.4) | 3 (37.5) | 35 (87.4) | 73 (89.0) | <.001 |
| Neutral | 12 (9.2) | 4 (50.0) | 4 (10.0) | 4 (4.9) | |
| Strongly disagree/Disagree | 6 (4.6) | 1 (12.5) | 1 (2.5) | 4 (4.9) | |
| Do not know/Prefer not to answer | 1 (0.8) | 0 (0.0) | 0 (0.0) | 1 (1.2) | |
| 6. I would be willing to be listed as an LGBTQ+-friendly provider | |||||
| Strongly agree/Agree | 107 (84.9) | 4 (50.0) | 33 (84.6) | 70 (88.6) | .06 |
| Neutral | 5 (4.0) | 4 (50.0) | 0 (0.0) | 1 (1.3) | |
| Strongly disagree/Disagree | 1 (0.8) | 0 (0.0) | 0 (0.0) | 1 (1.3) | |
| Do not know/Prefer not to answer | 13 (10.3) | 0 (0.0) | 6 (45.4) | 7 (8.9) | |
| 7. The LGBTQ+ population is often more difficult to treat | |||||
| Strongly agree/Agree | 10 (7.8) | 0 (0.0) | 1 (2.5) | 10 (12.3) | .35 |
| Neutral | 35 (27.3) | 4 (50.0) | 9 (22.5) | 22 (27.2) | |
| Strongly disagree/Disagree | 71 (55.5) | 2 (25.0) | 25 (62.5) | 44 (54.3) | |
| Do not know/Prefer not to answer | 12 (9.4) | 2 (25.0) | 5 (12.5) | 5 (6.2) | |
| 8. It is important to know the sexual orientation of my patients to provide the best care | |||||
| Strongly agree/Agree | 51 (39.5) | 2 (25.0) | 7 (17.5) | 42 (51.8) | .01 |
| Neutral | 41 (31.8) | 1 (12.5) | 17 (42.5) | 23 (28.4) | |
| Strongly disagree/Disagree | 30 (1202) | 4 (50.0) | 13 (32.5) | 13 (16.0) | |
| Do not know/Prefer not to answer | 7 (5.4) | 1 (12.5) | 3 (7.5) | 3 (3.7) | |
| 9. It is important to know the gender identity of my patients to provide the best care | |||||
| Strongly agree/Agree | 87 (67.4) | 3 (37.5) | 20 (50.0) | 64 (28.0) | .01 |
| Neutral | 23 (17.8) | 1 (12.5) | 10 (25.0) | 12 (14.8) | |
| Strongly disagree/Disagree | 13 (10.1) | 3 (37.5) | 7 (17.5) | 3 (3.7) | |
| Do not know/Prefer not to answer | 6 (4.7) | 1 (12.5) | 3 (7.5) | 2 (2.5) | |
| 10. It is necessary to know the patient's sex assigned at birth to provide quality care | |||||
| Strongly agree/Agree | 69 (53.9) | 5 (67.5) | 17 (42.5) | 47 (58.8) | .33 |
| Neutral | 29 (22.7) | 0 (0.0) | 10 (25.0) | 19 (23.8) | |
| Strongly disagree/Disagree | 20 (15.6) | 2 (25.0) | 8 (20.0) | 10 (12.5) | |
| Do not know/Prefer not to answer | 10 (7.8) | 1 (12.5) | 5 (12.5) | 4 (5.0) | |
| 11. It is important to know the patient's sex assigned at birth to provide the best care | |||||
| Strongly agree/Agree | 70 (55.1) | 5 (67.5) | 17 (42.5) | 48 (60.7) | .41 |
| Neutral | 32 (25.2) | 0 (0.0) | 10 (25.0) | 22 (27.8) | |
| Strongly disagree/Disagree | 17 (13.4) | 2 (25.0) | 8 (20.0) | 7 (8.9) | |
| Do not know/Prefer not to answer | 8 (6.3) | 1 (12.5) | 5 (12.5) | 2 (2.5) | |
| 12. Upon first encounter, I assume a patient is heterosexual | |||||
| Strongly agree/Agree | 33 (25.4) | 4 (50.0) | 12 (30.0) | 17 (20.0) | .09 |
| Neutral | 20 (15.4) | 2 (25.0) | 8 (20.0) | 10 (12.3) | |
| Strongly disagree/Disagree | 70 (63.8) | 0 (0.0) | 18 (45.0) | 52 (64.2) | |
| Do not know/Prefer not to answer | 7 (5.4) | 3 (25.0) | 2 (5.0) | 2 (2.5) | |
| 13. Religion plays a role in clinical practice and/or treatment of patients | |||||
| Strongly agree/Agree | 29 (22.8) | 1 (12.5) | 10 (25.6) | 18 (22.6) | .89 |
| Neutral | 33 (26.0) | 3 (37.5) | 10 (25.6) | 20 (25.0) | |
| Strongly disagree/Disagree | 58 (46.7) | 3 (37.5) | 16 (41.0) | 39 (48.8) | |
| Do not know/Prefer not to answer | 7 (5.5) | 1 (12.5) | 3 (7.7) | 3 (3.8) | |
| 14. There should be mandatory education on LGBTQ+ health needs at my workplace | |||||
| Strongly agree/Agree | 91 (70.5) | 2 (25.0) | 27 (67.5) | 62 (76.5) | .01 |
| Neutral | 24 (18.6) | 3 (37.5) | 10 (25.0) | 11 (13.6) | |
| Strongly disagree/Disagree | 11 (8.5) | 2 (25.0) | 2 (5.0) | 7 (8.6) | |
| Do not know/Prefer not to answer | 3 (2.3) | 1 (12.5) | 1 (2.5) | 1 (1.2) | |
Totals do not add up to 223 due to missing data.
P values were calculated using Fisher exact test, comparing strongly agree/agree to all other responses.
Missing responses were not included in stratified analyses. Bold P values indicate statistical significance with alpha level of <0.05.
Knowledge
Knowledge regarding LGBTQ+ health was assessed via 5 questions of which only 7.4% of respondents correctly answered all 5 questions; among clinicians, 8.5% correctly answered all 5 knowledge questions. Table 3 summarizes responses of individual knowledge-based questions. As such, 69% (N = 112) correctly identified that LGBTQ+ patients avoid accessing health care due to difficulty communicating with providers; 63% (N = 103) correctly indicated that human papillomavirus–associated cervical dysplasia is not only found in women who have had heterosexual intercourse; 51% (N = 82) correctly indicated that regularly screening gay and bisexual men for anal cancer can increase life expectancy; and 17% (N = 27) correctly indicated that LGBTQ+ individuals tend to have a higher prevalence of smoking compared with non-LGBTQ+ individuals. Finally, 37% correctly indicated that transgender individuals are less likely to have health insurance than cisgender individuals (Fig. 1c).
Table 3.
Knowledge of lesbian, gay, bisexual, transgender, queer + (LGBTQ+) health among surveyed role groups
| Survey | N (%) | Role group |
||
|---|---|---|---|---|
| Overall | Clinicians | Nonclinicians | P value | |
| 1. LGBTQ+ patients avoid accessing health care due to difficulty communicating with providers | ||||
| Strongly agree/Agree* | 112 (68.7) | 67 (72.1) | 45 (64.3) | .37 |
| Neutral | 16 (9.8) | 10 (10.8) | 6 (8.6) | |
| Strongly disagree/Disagree | 14 (8.5) | 9 (9.7) | 5 (7.1) | |
| Do not know/Prefer not to answer | 21 (12.9) | 7 (7.5) | 14 (20.0) | |
| 2. HPV-associated cervical dysplasia is only found in women who have had heterosexual intercourse | ||||
| Strongly Agree/Agree* | 103 (62.8) | 73 (77.6) | 30 (42.9) | <.001 |
| Neutral | 12 (7.3) | 5 (5.3) | 7 (10.0) | |
| Strongly disagree/Disagree | 6 (3.6) | 4 (4.1) | 2 (2.9) | |
| Do not know/Prefer not to answer | 43 (26.2) | 12 (12.8) | 31 (44.3) | |
| 3. Regularly screening gay and bisexual men for anal cancer through the anal Pap testing can increase life expectancy | ||||
| Strongly agree/Agree* | 82 (50.6) | 49 (52.1) | 33 (48.5) | .19 |
| Neutral | 23 (14.2) | 17 (18.1) | 6 (8.8) | |
| Strongly disagree/Disagree | 1 (0.6) | 1 (1.1) | 0 (0.0) | |
| Do not know/Prefer not to answer | 56 (34.6) | 27 (28.7) | 28 (42.6) | |
| 4. LGBTQ+ individuals tend to have a higher prevalence of smoking compared with non-LGBTQ+ individuals | ||||
| Strongly agree/Agree* | 27 (16.6) | 20 (26.3) | 7 (10.1) | .03 |
| Neutral | 39 (23.9) | 25 (26.6) | 14 (20.3) | |
| Strongly disagree/Disagree | 20 (12.3) | 9 (9.6) | 11 (15.9) | |
| Do not know/Prefer not to answer | 77 (47.2) | 40 (42.6) | 37 (53.6) | |
| 5. Transgender individuals are less likely to have health insurance than other individuals | ||||
| Strongly agree/Agree* | 60 (37.1) | 41 (44.1) | 19 (27.5) | .07 |
| Neutral | 27 (16.7) | 13 (14.0) | 14 (20.3) | |
| Strongly disagree/Disagree | 17 (10.5) | 7 (7.6) | 10 (14.5) | |
| Do not know/Prefer not to answer | 58 (35.8) | 32 (34.4) | 26 (37.7) | |
Question 2 is false/incorrect. All other questions are true/correct.
Totals do not add up to 223 due to missing data.
P values were calculated using χ2 test, comparing correct responses to all other responses.
Missing responses were not included in stratified analyses. Bold P values indicate statistical significance alpha level of 0.05.
When stratifying the knowledge section by role group (Table 3), there was a statistically significant difference by role group for 2 questions: 78% of clinicians and 43% of nonclinicians correctly answered that human papillomavirus–associated cervical dysplasia can be found in lesbian and bisexual women (P < .001) and 26% of clinicians and 10% of nonclinicians correctly state that LGBTQ+ individuals tend to have a higher prevalence of smoking compared with non-LGBTQ+ individuals (P = .03).
Confidence to knowledge analysis
For all respondents, the mean number of correct responses in the knowledge section of the survey was 2.09 (Table 4). Although 84 respondents (50.3%) were confident in the health needs of LGBQ+ patients, the mean number of correct responses among respondents who were confident was lower than for respondents who were not confident in their knowledge of LGBQ+ health needs (1.73 vs 2.18; P = .02). For knowledge of the health needs of transgender patients, there was no association between a respondent's reported confidence and their performance on knowledge questions (2.33 vs 2.01; P > .05).
Table 4.
Knowledge of lesbian, gay, bisexual, transgender, queer + (LGBTQ+) health needs by confidence level
| Survey | Mean number of correct responses (out of 5) | P value |
|---|---|---|
| I am confident in the health needs of LGBQ+ patients | ||
| Agree | 1.73 | .02 |
| Neutral | 2.30 | |
| Disagree | 2.05 | |
| I am confident in the health needs of transgender patients | ||
| Agree | 2.33 | .22 |
| Neutral | 1.92 | |
| Disagree | 2.19 | |
Open discussion
Seventy-eight respondents completed 1 or more open discussion questions (Table 5). Across the 3 open discussion questions, the most common theme was a need for more LGBTQ+-specific education. This included the mention of case-based educational sessions, seminars, lectures, and clinical knowledge specific to transgender health; pediatric, adolescent and young adult health; and sexual health for SGM patients. In response to the question, “What suggestions do you have for improving the cancer care of the LGBTQ+ population”, many respondents suggested improving SOGI data collection across all electronic medical record platforms, including radiation treatment record and verification systems, resources for staff regarding SGM cancer care, and an overall suggestion of more education. Other themes included suggestions to show allyship through pronoun pins and pride flags and including SGM populations in research. Some respondents took the opportunity to share personal experiences.
Table 5.
Major themes and representative quotations identified in open discussion of lesbian, gay, bisexual, transgender, queer + (LGBTQ+) health among role groups
| Theme | Quotation |
|---|---|
| Need for more education/educational formats | “[Need for] better education regarding cancer treatment challenges/options for this population (for example, I had a female patient transitioning to a male who had to put a hold on plans to transition due to cancer treatment, stated her doctors did not really know how to best treat her).” |
| Inclusive policies and procedures | “I have a good friend recently treated for prostate cancer…he went with the provider who proactively addressed the effects of prostate RT on his life as a gay man and the impact on his physical relationship with his husband.” |
| Sharing of personal experiences | “As someone who is transgender myself, I've personally experienced quite a bit of discriminatory behavior from medical providers in the past, as has virtually every other LGBTQ person I know.” |
| Concerns | “There are many vulnerable populations and we should be equally attendant to them and their needs…They are each important and require education.” |
| Treating all patients the same | “I have treated and interacted with patients the same regardless of orientation or being transgender.” |
A few respondents indicated that sexual orientation and gender identity did not, and should not, affect the way care is given (treat everyone equally). When asked, “Is there anything else you would like to add regarding the topic of SGM health”, some respondents expressed that we should not focus solely on one minoritized group over another in terms of health care disparities and equity efforts.
Discussion
As both clinicians and nonclinicians (including administrative staff, radiation therapists, and other medical support staff) have an important role in radiation oncology care, we conducted a survey of attitudes, practice behaviors, and knowledge of SGM health needs among staff in 2 large radiation oncology departments. Overall, most respondents indicated comfort in treating both LGBQ+ and transgender patients. While most respondents expressed comfort, only half of respondents expressed confidence in their knowledge of the health needs of LGBQ+ patients, and approximately one-third had confidence in their knowledge of the health needs of transgender patients. Less than 1 in 10 clinicians answered all of the knowledge questions correctly. Further, respondents who expressed confidence in their knowledge of LGBQ+ health needs demonstrated lower performance on knowledge questions, indicating that some respondents may overestimate their knowledge of the topic. Respondents who expressed confidence in their knowledge of transgender health did not perform better on the knowledge section than those who were not confident in their knowledge, suggesting that respondents may not be aware of their knowledge gaps. While we regard these findings as preliminary and hypothesis generating, a potential explanation for these findings would be the Dunning-Kruger effect, which describes a phenomenon in which nonexperts are unaware of their lack of competence in a given field and may have an inflated self-assessment of their own abilities.24 This effect was described in a recent article related to the COVID-19 pandemic, where cognitive bias led people to contribute to a controversial public narrative regarding vaccines and outbreak response. To reduce this type of cognitive bias, the authors suggest that those who are experts should pay extra attention toward explaining concepts in the simplest of terms, using plain language and accessible formats to reach the greatest number of audience members.25 In the setting of providing SGM health education, it may be beneficial to ensure that essential concepts are being incorporated into existing staff training, rather than relying on staff to have an awareness of their own limitations and seek out optional training sessions.
Compared with previously published studies using surveys distributed among providers in other NCI-designated cancer centers, 66% of respondents agreed that SGM education should be mandatory compared with approximately 45% of respondents from other studies.20, 21, 22 This difference could be due to the increased attention to SGM health needs in recent years and the widespread acknowledgment that there are disparities in cancer care and outcomes among SGM patients by national cancer organizations, like the American Society of Clinical Oncology and the American Cancer Society.15,26 A June 2023 report of SGM patients with cancer and survivors by the American Cancer Society found that nearly half of respondents chose not to disclose SOGI due to concerns related to discrimination and how it may impact the care they receive.26 This indicates a need for oncology clinics to demonstrate that they have the training and experience to provide welcoming and affirming care to SGM patients.
A greater proportion of clinicians than nonclinicians thought it was important to know a patient's sexual orientation (52% vs 25%), gender identity (78% vs 46%), or sex assigned at birth (70% vs 33%) to provide the best care. This association was significant and indicated that more education could be beneficial to all staff, especially nonclinicians, who play a vital role in collecting SOGI data. The collection of SOGI data, which includes sexual orientation, gender identity, sex assigned at birth, and preferred name and pronouns, can directly or indirectly improve quality of care for SGM patients.18,27,28 Indirectly, these data are necessary to understand cancer incidence and mortality trends among the LGBTQ+ population. SOGI data are not currently reported in major cancer registries, such as the NCI Surveillance, Epidemiology, and End Results Program, which provides information on incidence, mortality, and survival.29 SGM patients directly benefit from SOGI data collection efforts, for example, when staff use a patient's preferred name and pronouns to address them with respect, when a patient's partner or partners are expressly welcomed to attend appointments, or when a clinician who is aware of the patient's gender identity or sexual orientation is able to tailor counseling based on that patient's needs.10,18,30, 31, 32 Thus, it is necessary for all health care team members to have SGM training that incorporates evidence-based tools to reduce implicit bias and best practice for providing support to SGM individuals with cancer.33
In the open discussion section, one theme that arose was staff hesitation about asking SOGI questions, especially for older patients. This misbelief among clinicians that asking about SOGI will make cisgender heterosexual patients uncomfortable has been previously reported.32 However, studies show that the majority of patients report favorable perceptions regarding answering SOGI questions, regardless of age.27,34,35 In a study from 2020, approximately 70% of participants reported a preference for verbal questions about their gender and sex assigned at birth.27 Hesitancy among staff in asking SOGI questions may also reflect their own feelings of unpreparedness to have conversations about gender or sexuality. Future staff training can include introducing studies that demonstrate that most patients are comfortable with SOGI data collection and why collection of these data are important in addition to giving staff opportunities to practice these skills.
Another theme identified in the open discussion section was some staff believing that they should treat patients equally, regardless of LGBTQ+ identity. This sentiment is sometimes expressed as a reason not to ask about SOGI or to tailor care for SGM patients. Further, most respondents in this study stated that 0% to 5% of patients identified at LGBTQ+, although the most recent data shows that between 7% and 12% of Americans identify as such.36 This underestimate could be, in part, due to the inconsistent collection of SOGI data collection across cancer centers and misrepresentation of the true proportion of patients who identify as LGBTQ+. Given the Association of American Medical Colleges guidelines for patient-centered care and the disparities among individuals in the LGBTQ+ population who have cancer, it is important to recognize differences appropriately and strive for equity.19 Health equity “requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”37,38 Given what is known about the disparities in outcome among SGM patients, training that includes defining and framing health equity in context of SGM health can help clinicians and nonclinicians understand why learning about SGM health needs is important for improving care.39
Our study demonstrates that nonclinician staff are interested in education, and they should receive training in interacting with SGM patients as a component of onboarding or continuing education training on addressing implicit bias and reducing health disparities for all underrepresented populations. Based on comments from the open discussion section, live lectures or interactive sessions led by experienced staff may be most effective in keeping staff engaged and imparting knowledge. However, online training modules may be the most practical and scalable approach to ensure that all staff receive training. The current body of literature cites educational gaps as a potential explanation for the lower quality of care for SGM patients.12,40,41 A recent study of the Curriculum for Oncologists on LGBT populations to Optimize Relevance and Skills demonstrated significant improvement in knowledge, attitudes, and affirming practice behaviors based on pre and posttraining assessments.42,43 LGBTQ+-related clinical practices were assessed in this study during both pre- and posttraining measured from previously evaluated gay affirmative practice scale but were adapted to include language that pertained to all LGBTQ+ identities. Overall, posttraining surveys indicated a greater endorsement of affirmative practices.43 Future curricula should also be tailored to nonclinicians, including administrative staff, medical assistants, and other supportive staff. Barriers to implementing new curricula and systematic collection of SOGI data include lack of leadership support, few dedicated resources, and attitudes of the individuals within the organization.18
Overall, the results of this study are consistent with previously published studies using surveys distributed among providers in other NCI-designated cancer centers.20, 21, 22 Taken together, with 223 respondents from the department of radiation oncology at multiple institutions, this study provides the first assessment, to our knowledge, of clinicians and nonclinicians about their knowledge, attitudes, and practice behaviors toward LGBTQ+ patients with cancer. Such data provide valuable evidence to develop a culturally sensitive and clinically relevant curriculum for both clinicians and nonclinicians who interface with patients.
Limitations of this study
This study had several limitations. First, this study was conducted at 2 partner institutions in the urban area in the northeast region of the United States and include staff at the academic teaching hospitals and affiliated satellite community clinics. As such, our findings may not be generalizable to institutions in other geographic locations within and outside the United States. Nearly half of respondents self-identified as liberal, 22.6% self-identified as moderate, and just a small proportion (<5%) identified as conservative. Similarly, due to the small cohort of respondents who identify as APPs (N = 10) compared with nurses (N = 33) and physicians (N = 60), we did not include an analysis between clinician role groups. Future studies may look to include this analysis in a way that equally represents these role groups and can therefore make more sound conclusions regarding similarities and differences related to LGTBQ+ knowledge, attitudes, and practice behaviors. This survey was available to all clinicians and nonclinicians in the department, and we gathered data from those who may not interact with patients. Examples of these groups include physicists, some administrative staff, and nonclinical researchers. Thus, certain questions were not applicable, and respondents were given the option to leave a question blank. Additionally, while we had 223 respondents, the response rate was relatively low at 21.3%. However, this is within range of similar studies.20,21 The low response rate may reflect a myriad of factors, including survey fatigue, lack of incentivization to complete the survey, and concern for survey respondent anonymity. Therefore, we are unable to make inferences about the knowledge, attitudes, and practice behaviors of nonresponders. As with many survey-based studies, there could have been response bias based on respondents selecting what they believed to be the most socially desirable response (response acquiescence). Finally, as the knowledge assessment was limited to 5 validated true or false statements regarding SGM health, these results are not a comprehensive assessment of a respondent's overall knowledge or ability to interact with patients. However, this study offers a unique insight into the knowledge, attitudes, and practice behaviors of radiation oncology staff toward SGM patients.
Conclusion
This is the first survey to investigate the knowledge, attitudes, and practice behaviors of radiation oncology staff across all department role groups toward SGM patients. Staff across role groups (clinicians and nonclinicians) reveal a high interest in receiving SGM and oncology-specific education. Knowledge gaps persist for both clinicians and nonclinicians, and fewer nonclinicians believe that knowing SOGI data are important for providing the best care. Further studies that include patient experiences can give insight into the health care reality for SGM patients and evaluate the implementation and effectiveness of training curricula. Additionally, future efforts can attempt to tailor SGM health curricula to the needs of specific role groups within radiation oncology.
Disclosures
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Presented at the Science Health Equity for Sexual and Gender Minorities Symposium at New York University on October 7, 2023.
Sources of support: This work had no specific funding.
Research data are not available at this time.
A.C.S. and J.Y.W contributed equally to this work.
Supplementary material associated with this article can be found in the online version at doi:10.1016/j.adro.2024.101461.
Appendix. Supplementary materials
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