Abstract
BACKGROUND:
Because of concerns about sexual minorities’ poor cancer survivorship, this study compared cancer survivors’ health outcomes in relation to multiple intersecting social positions, namely gender, sexual orientation, and race/ethnicity.
METHODS:
This secondary data analysis used 2014–2019 Behavior Risk Factor Surveillance Survey data. The survey respondents consisted of 40,482 heterosexual and sexual minority men and 69,302 heterosexual and sexual minority women who identified as White, Black, or Hispanic. Logistic regression models compared White, Black, and Hispanic male and female cancer survivors’ health status, depression, and health-related quality of life by sexual orientation. Models were adjusted for sociodemographic characteristics and access to care.
RESULTS:
Mental health findings showed consistency, with sexual minority male and female cancer survivors having 2 to 3 times greater odds of depression and/or poor mental health among White, Black, and Hispanic survivors. Among White women, sexual minorities reported greater odds of fair or poor health, poor physical health, and poor activity days, whereas White sexual minority men showed similar odds in comparison with their heterosexual counterparts. Among Black and Hispanic sexual minority men and women, differences in the odds of fair or poor health, poor physical health, and poor activity days in comparison with their heterosexual counterparts were mostly explained by sociodemographic and access-to-care factors.
CONCLUSIONS:
Physical and mental health outcomes vary in relation to sexual orientation and race/ethnicity among both female and male cancer survivors. Clinicians, researchers, and health care administrators must better understand and address the unique needs of cancer survivors in relation to multiple axes of social inequality to advance cancer equity.
Keywords: cancer survivorship, depression, disparities, intersectionality, neoplasm, quality of life, sexual and gender minorities
INTRODUCTION
In 2019, there were an estimated 16.9 million cancer survivors in the United States; it is projected that there will be more than 22 million by 2030.1 Among them are an unknown number of sexual minority persons (eg, lesbians, gays, and bisexuals), about whom there is growing research attention.2 Current evidence highlights sexual minority female cancer survivors’ poor access to health care, which negatively affects their physical and mental health.3–6 Despite an emerging interest in sexual minorities and cancer, the intersection of race/ethnicity and sexual orientation has hardly been examined within the context of cancer control and prevention.7
In the US population overall, pronounced racial/ethnic inequities exist across the cancer continuum. Studies show that marginalized racial/ethnic groups (eg, Black, Indigenous, and Hispanic) have lower access to quality cancer care and a higher likelihood of a later stage cancer diagnosis, with serious consequences for survival, in comparison with their White counterparts.8 Moreover, several studies have also identified racial/ethnic inequities in quality of life and other health outcomes, with Black and Hispanic survivors reporting worse outcomes than White survivors.9–12
However, despite evidence of both sexual orientation and racial/ethnic inequities in physical and mental health and cancer care among cancer survivors, studies have neglected to examine how multiple intersecting social positions—gender, sexual orientation, and race/ethnicity—and corresponding social inequities and power relations (eg, sexism, heterosexism, and racism) are related to health outcomes among cancer survivors. Given this major gap in the scientific literature, we conducted a secondary analysis by using a large population-based survey, the US Behavioral Risk Factor Surveillance System (BRFSS), to better characterize the unique health experiences of cancer survivors at the intersection of gender, sexual orientation, and race/ethnicity. We were particularly interested in understanding sexual orientation inequities in health outcomes in relation to race/ethnicity among women and men and in identifying the specific experiences and needs of Black and Hispanic sexual minority female and male cancer survivors. This study was guided by intersectionality, which is rooted in Black feminist theory and practice and addresses how mutually constitutive social positions (eg, gender, race/ethnicity, and sexual orientation) and related social inequities and power relations (eg, sexism, racism, and heterosexism) simultaneously influence multiply marginalized individuals’ lived experiences.13,14
MATERIALS AND METHODS
Data Source and Study Population
The BRFSS is an annual, cross-sectional, population-based health survey overseen by the Centers for Disease Control and Prevention (CDC). Eligible individuals include noninstitutionalized adults aged 18 years or older residing in the United States, the District of Columbia, and US territories. In 2013, the CDC developed a standard optional module on sexual orientation and gender identity for the BRFSS; local authorities had the option to administer this module beginning in 2014.
We pooled 2014–2019 BRFSS data and used data from Guam and the 39 states that used the optional sexual orientation and gender identity module. We excluded respondents who were not administered the standard optional modules by design (eg, out-of-state cell phone respondents), declined to answer, or answered “don’t know/not sure” on the question about their sexual orientation; we retained individuals who reported their sexual orientation as heterosexual, lesbian/gay, bisexual, or other. Because of the small sample size, we excluded individuals who reported their gender as transgender or gender-nonconforming and retained cisgender individuals who reported male or female gender, although we recognize that, before 2016, interviewers had the option to assign male or female gender on the basis of voice timbre without asking.15 We then restricted the sample to those who responded affirmative to the following question: “Have you ever been told that you have cancer, other than skin cancer?” Because of the small numbers of other race/ethnicity groups among sexual minority men and women (eg, 22 sexual minority men and 19 sexual minority women reported as Asian), we limited the sample to non-Hispanic White, non-Hispanic Black, and Hispanic cancer survivors; this resulted in a final analytic sample of 109,784 cancer survivors.
This study’s use of existing public use data is considered non–human subjects research and was, therefore, exempt from institutional review board review.
Measures
We created a dichotomous sexual orientation measure that consisted of heterosexual versus sexual minority individuals according to their self-reported lesbian, gay, bisexual, or other sexual identities. We considered non-Hispanic White, non-Hispanic Back, and Hispanic individuals of any race. We stratified the data by gender and included sociodemographic characteristics with known associations with cancer survivors’ quality of life (eg, age, education, marital status, and employment); we retained BRFSS response categories or combined categories on the basis of prior research to avoid small cell sizes.
The BRFSS assesses 4 dimensions of access to care: 1) not having health insurance, 2) delaying care (defined as not having a routine checkup in the past year), 3) avoiding care because of costs, and 4) lacking a trusted physician. We coded these into dichotomous (yes or no) responses. In agreement with prior research, we derived a dichotomous summary measure of poor access to care or an access deficit.4,16 Survivors were defined as having poor access to care if they were lacking any of the 4 access-to-care conditions.
Outcomes consisted of the standard 4-item set of Healthy Days questions, which constituted the CDC HRQOL-4 measure. The items were 1) self-reported health and the number of days in the past 30 days that the respondent, 2) felt physically unhealthy, 3) felt mentally unhealthy, and 4) had limited usual activities.17 Respondents’ physical and mental health status was derived from their reports of the number of days in the preceding 30 days during which their physical (or mental) health was not good. To capture overall health, we considered individuals’ reports of the number of days their physical or mental health interfered with daily activities. In agreement with earlier studies, we dichotomized daily activities, physical health days, and mental health days as 14 or more days (an indication of frequent activity, physical, or mental health problems) or 13 or fewer days (an indication of infrequent health problems).18 We distinguished respondents who reported their general health as fair or poor versus good or better. To capture survivors’ depression, we used yes or no responses to the following question: “Has a doctor, nurse, or other health professional ever told you had a depressive disorder (including depression, major depression, dysthymia, or minor depression)?”
Statistical Analysis
BRFSS provides weights designed to account for sampling fraction and survey nonresponse. As recommended in BRFSS documentation,19 we modified these weights to account for including multiple years from several states and also for split-sample weighting whenever possible. In brief, when split-sample weights were available, we used those, and when split-sample weights were not available, we used the full sample weight. When multiple years (and/or split samples) were included from a given state, the weight was multiplied by the proportion of the total state-level sample in that year and/or split sample. Additionally, because primary sampling unit (_psu) and stratification (_ststr) variables are recycled from one year to another without necessarily retaining the same meaning, we created a sampling unit variable by concatenating the data year with _psu (yearpsu), and we examined stratification variables and created new stratification levels when the stratification scheme changed from one year to the next (combinedstrata).
We first calculated weighted frequencies and standard errors for categorical variables by performing non-directional statistical tests for each sexual orientation identity and racial/ethnic subgroup stratified by gender (Tables 1 and 2). Given the importance of access to care, we also examined differences by race/ethnicity within sexual orientation groups (Supporting Table 1). To examine the prevalence of the outcomes, we calculated weighted frequencies and 95% confidence intervals (Supporting Table 2) by sexual orientation identity and race/ethnicity among cisgender men (N = 40,482) and cisgender women (N = 69,302). Lastly, we computed odds ratios and odds ratios adjusted for all covariates with 95% confidence intervals by using logistic regression to estimate the association between sexual orientation identity (reference: heterosexual) and each outcome for White, Black, and Hispanic cisgender men and women (Table 3). All statistical analyses were performed with proc surveyfreq and proc surveylogistic in SAS software (version 9.4; SAS Institute, Cary, North Carolina).
TABLE 1.
Characteristics of Cisgender Male Cancer Survivors (N = 40,482)
| White Heterosexual, % (SE) | White Sexual Minority, % (SE) | Black Heterosexual, % (SE) | Black Sexual Minority, % (SE) | Hispanic Heterosexual, % (SE) | Hispanic Sexual Minority, % (SE) | |
|---|---|---|---|---|---|---|
| Unweighted N | 35,604 | 1263 | 2512 | 95 | 937 | 71 |
| Age, mean (SE), y | 67.26 (0.14) | 62.16 (0.86)a | 64.66 (0.52) | 56.94 (2.09)a | 57.64 (1.45) | 49.20 (3.08)b |
| Age | ||||||
| 18–44 y | 5.48 (0.28) | 12.25 (2.09)a | 6.37 (1.31) | 25.27 (7.69)b | 22.53 (3.33) | 31.62 (10.61)b |
| 45–64 y | 28.44 (0.52) | 41.65 (3.11) | 36.75 (1.99) | 41.56 (7.63) | 35.55 (3.29) | 54.61 (12.46) |
| ≥65 y | 66.07 (0.54) | 46.10 (3.07) | 56.88 (2.02) | 33.17 (6.48) | 41.92 (3.54) | 13.78 (5.41) |
| Marital status | ||||||
| Married/unmarried couple | 69.80 (0.53) | 41.68 (3.09)a | 53.78 (1.94) | 20.68 (4.85)a | 59.04 (3.43) | 22.64 (7.73)b |
| Single/never married | 6.49 (0.31) | 32.43 (2.84) | 12.92 (1.35) | 38.38 (7.59) | 12.55 (2.01) | 24.45 (9.05) |
| Widowed/separated/divorced | 23.71 (0.49) | 25.89 (2.83) | 33.29 (1.78) | 40.94 (7.82) | 28.41 (3.21) | 52.91 (12.73) |
| Education | ||||||
| High school or less | 35.84 (0.54) | 34.09 (3.15)b | 49.95 (1.95) | 51.04 (7.72) | 60.22 (3.42) | 41.34 (13.93) |
| Some college/technical school | 30.74 (0.57) | 24.59 (2.53) | 32.58 (1.99) | 34.23 (7.91) | 22.73 (2.86) | 31.37 (11.48) |
| College grad/graduate school | 33.42 (0.49) | 41.33 (3.00) | 17.47 (1.36) | 14.73 (4.23) | 17.04 (2.44) | 27.29 (9.68) |
| Employment status Employed (vs not) | 31.30 (0.53) | 37.13 (3.13) | 26.10 (1.86) | 34.53 (7.74) | 37.56 (3.50) | 24.09 (9.79) |
| Without health care coverage | 2.94 (0.23) | 5.40 (1.14)b | 5.07 (0.91) | 3.99 (2.77) | 12.28 (2.70) | 28.15 (15.33) |
| Without a personal physician | 6.19 (0.30) | 7.99 (1.42) | 7.65 (1.02) | 12.83 (3.19) | 22.07 (3.45) | 35.72 (14.82) |
| Could not see MD because of cost | 6.06 (0.30) | 9.81 (1.43)a | 10.62 (1.31) | 10.87 (3.82) | 14.63 (2.61) | 17.34 (6.88) |
| Without routine checkup within past year | 11.82 (0.39) | 8.68 (1.28)b | 7.85 (0.95) | 12.15 (2.50) | 19.35 (3.42) | 22.39 (10.24) |
| Poor access to care | 20.75 (0.49) | 20.58 (2.06) | 22.23 (1.60) | 23.24 (4.80) | 39.59 (3.62) | 59.93 (11.61) |
Abbreviation: SE, standard error.
P < .01.
P < .05.
TABLE 2.
Characteristics of Cisgender Female Cancer Survivors (N = 69,302)
| White Heterosexual, % (SE) | White Sexual Minority, % (SE) | Black Heterosexual, % (SE) | Black Sexual Minority, % (SE) | Hispanic Heterosexual, % (SE) | Hispanic Sexual Minority, % (SE) | |
|---|---|---|---|---|---|---|
| Unweighted N | 60,928 | 1739 | 4259 | 131 | 2118 | 127 |
| Age, mean (SE), y | 63.36 (0.13) | 53.03 (0.85)a | 59.69 (0.56) | 54.87 (3.22) | 54.60 (0.68) | 40.30 (1.94)a |
| Age | ||||||
| 18–44 y | 11.02 (0.32) | 37.08 (2.64)a | 15.29 (1.38) | 31.08 (8.87) | 27.17 (2.17) | 60.74 (7.54)a |
| 45–64 y | 36.55 (0.45) | 33.79 (2.38) | 43.71 (1.79) | 30.02 (9.26) | 41.98 (2.56) | 32.61 (7.12) |
| ≥65 y | 52.43 (0.45) | 29.13 (2.04) | 40.99 (1.78) | 38.89 (11.31) | 30.85 (2.43) | 6.66 (2.40) |
| Marital status | ||||||
| Married/unmarried couple | 54.57 (0.46) | 45.36 (2.53)a | 34.01 (1.78) | 20.31 (7.24) | 53.11 (2.57) | 25.79 (5.95)a |
| Single/never married | 6.09 (0.22) | 18.82 (2.28) | 20.60 (1.30) | 41.75 (10.22) | 12.08 (1.68) | 44.93 (8.61) |
| Widowed/separated/divorced | 39.34 (0.45) | 35.81 (2.41) | 45.39 (1.84) | 37.94 (11.38) | 34.81 (2.43) | 29.28 (7.05) |
| Education | ||||||
| High school or less | 38.49 (0.46) | 35.40 (2.58) | 45.65 (1.78) | 34.89 (8.25) | 54.35 (2.52) | 54.76 (8.08) |
| Some college/technical school | 35.14 (0.45) | 35.33 (2.49) | 35.96 (1.94) | 50.22 (10.73) | 27.74 (2.40) | 32.34 (7.79) |
| College grad/graduate school | 26.36 (0.36) | 29.27 (2.04) | 18.39 (1.10) | 14.88 (6.65) | 17.91 (1.67) | 12.90 (3.51) |
| Employment status | ||||||
| Employed (vs not) | 31.02 (0.43) | 45.39 (2.61)a | 32.05 (1.78) | 39.52 (10.40) | 35.41 (2.38) | 37.03 (8.47) |
| Without health care coverage | 3.69 (0.18) | 9.11 (1.52)a | 5.59 (0.78) | 13.35 (5.26) | 12.50 (1.52) | 16.18 (4.95) |
| Without a personal physician | 5.33 (0.21) | 12.59 (1.88)a | 6.24 (0.91) | 9.30 (3.70) | 13.45 (1.70) | 14.19 (4.60) |
| Could not see MD because of cost | 10.90 (0.30) | 26.24 (2.60)a | 15.71 (1.21) | 19.51 (6.16) | 22.68 (2.12) | 40.10 (8.07)b |
| Without routine checkup within past year | 13.20 (0.32) | 16.59 (1.71) | 9.77 (1.17) | 17.63 (7.43) | 16.27 (1.81) | 23.93 (7.45) |
| Poor access to care | 24.15 (0.40) | 39.91 (2.62)a | 26.53 (1.57) | 33.60 (8.93) | 40.59 (2.53) | 55.28 (8.40) |
Abbreviation: SE, standard error.
P < .01.
P < .05.
TABLE 3.
Logistic Regression of White, Black, and Hispanic Sexual Minority Cancer Survivors’ Physical and Mental Health With Heterosexuals as the Reference Group
| White Sexual Minority, OR (95% CI) | White Sexual Minority, AOR (95% CI) | Black Sexual Minority, OR (95% CI) | Black Sexual Minority, AOR (95% CI) | Hispanic Sexual Minority, OR (95% CI) | Hispanic Sexual Minority, AOR (95% CI) | |
|---|---|---|---|---|---|---|
| Men | ||||||
| Fair or poor health | 1.29 (1.00–1.67) | 1.28 (0.95–1.73) | 0.88 (0.49–1.57) | 0.87 (0.48–1.57) | 0.99 (0.33–2.95) | 0.73 (0.27–2.02) |
| Depression | 2.35a (1.82–3.03) | 1.99a (1.53–2.57) | 3.28a (1.72–6.28) | 2.44b (1.24–4.82) | 3.78b (1.21–11.84) | 2.64 (0.96–7.22) |
| 14 or more poor mental health days | 2.13a (1.54–2.93) | 1.87a (1.35–2.59) | 1.83 (0.76–4.42) | 1.66 (0.71–3.88) | 4.16b (1.20–14.42) | 3.81b (1.24–11.74) |
| 14 or more poor physical health days | 1.22 (0.92–1.62) | 1.20 (0.87–1.68) | 0.96 (0.44–2.10) | 0.93 (0.46–1.87) | 1.61 (0.43–6.09) | 1.04 (0.31–3.46) |
| 14 or more days on which physical or mental health interfered with daily activities | 1.27 (0.92–1.76) | 1.15 (0.77–1.72) | 1.29 (0.52–3.18) | 1.19 (0.51–2.74) | 4.12b (1.32–12.82) | 2.71 (0.84–8.77) |
| Women | ||||||
| Fair or poor health | 1.41a (1.14–1.73) | 1.30b (1.03–1. 65) | 0.65 (0.31–1.35) | 0.63 (0.30–1.33) | 1.39 (0.71–2.70) | 1.45 (0.68–3.08) |
| Depression | 2.56a (2.09–3.13) | 1.75a (1.40–2.18) | 1.49 (0.68–3.27) | 1.36 (0.59–3.15) | 3.23a (1.62–6.42) | 2.43b (1.12–5.26) |
| 14 or more poor mental health days | 2.24a (1.77–2.83) | 1.36b (1.04–1.78) | 2.67b (1.26–5.65) | 2.27 (0.98–5.25) | 2.55b (1.22–5.33) | 1.52 (0.67–3.46) |
| 14 or more poor physical health days | 1.59a (1.26–1.99) | 1.50a (1.14–1.97) | 1.14 (0.52–2.49) | 1.26 (0.52–3.01) | 1.81 (0.87–3.76) | 1.89 (0.76–4.71) |
| 14 or more days on which physical or mental health interfered with daily activities | 1.74a (1.35–2.25) | 1.48b (1.09–2.02) | 0.88 (0.42–1.84) | 0.88 (0.42–1.86) | 1.80 (0.86–3.73) | 1.37 (0.61–3.09) |
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio.
Adjusted for age, education, employment, marital status, and access to care.
P < .01.
P < .05.
RESULTS
Among cisgender male cancer survivors (Table 1), within each race/ethnicity group, sexual minority men were significantly younger and less likely to be married in comparison with their heterosexual counterparts. Among White men, sexual minority survivors were more educated than their heterosexual counterparts, whereas among Blacks and Hispanics, men of either sexual orientation had similar education. There were no differences in employment by sexual orientation among any of the 3 race/ethnicity groups. Although White sexual minority men were more likely to be uninsured and unable to see a physician because of costs in comparison with their heterosexual counterparts, White, Black, and Hispanic men of either sexual orientation reported similar access.
Among cisgender female survivors (Table 2), Black women were the only racial group that was similar on all sociodemographic and access-to-care characteristics, regardless of sexual orientation. White women showed the most differences by sexual orientation, in that sexual minority women were significantly younger, less likely to be married, and more likely to be employed but had similar education in comparison with their heterosexual counterparts. There were also significant differences in access among White women, with sexual minority women more likely to be uninsured, to be without a personal physician, to have had no routine care in the past year, to avoid care because of costs, and to have overall poorer access to care in comparison with their White heterosexual counterparts. Among Hispanic women, sexual minority survivors were significantly younger, were less likely to be married, and were more likely to avoid medical care because of costs; although their overall access to medical care was poorer, this difference was not statistically significant.
Survivors’ ages varied widely, with White heterosexual men and women being the oldest in comparison with all other groups (P < .01). We further assessed access to care by race/ethnic identity and sexual identity (Supporting Table 1). Compared with White heterosexual men, Hispanic heterosexual men had significantly greater odds of poor access to care, whereas Black heterosexual men’s access to care was overall similar to White heterosexual men’s access. Similarly, among sexual minorities, Black and White men had similar access to care, whereas Hispanic sexual minority men had significantly worse access to care than White sexual minority men. Similarly, Hispanic heterosexual women had significantly worse access to care than White heterosexual women, whereas Black heterosexual women’s access to care did not significantly differ from White heterosexual women’s access. Among sexual minority women, access to care did not significantly differ by race/ethnicity.
In Supporting Table 2, we present frequencies and 95% confidence intervals of the 4 outcomes among White, Black, and Hispanic men and women by sexual orientation. Among men, White heterosexual survivors consistently had the lowest rates of fair or poor health (32%), depression (16%), poor mental health (9%), poor physical health (22%), and poor activity (14%). Hispanic heterosexual men had the highest rate of fair or poor health (47%), whereas all other outcomes were highest among Hispanic sexual minority men, in that 45% had depression, 43% had poor mental health, 34% had poor physical health, and 46% had poor activity.
Among women, Hispanic sexual minority women had the highest prevalence of all outcomes; 60% had fair or poor health, 59% had depression, 40% had poor mental health, 41% had poor physical health, and 31% had poor activity. Black sexual minority women had the lowest rates of fair or poor health (30%) and poor activity (16%). White heterosexual women had the lowest rates of poor mental health (16%) and poor mental health (25%), whereas Black heterosexual women had the lowest rate of depression (25%).
Within each racial/ethnic group, men’s likelihood of fair or poor health was similar, regardless of sexual orientation (Table 3). However, within each race or ethnicity group, sexual minority men had significantly greater odds of depression in comparison with their heterosexual counterparts, and after adjustments for confounders, these differences remained for White and Black sexual minority men but not for Hispanic sexual minority men. White and Hispanic sexual minority men had significantly greater odds of poor mental health in comparison with their heterosexual counterparts, even after adjustments. Although Hispanic sexual minority men had more than 4 times the odds of poor activity in comparison with their heterosexual counterparts, after adjustments, the likelihood was no longer significantly different.
Among women, White sexual minority women showed the most consistent results; sexual minority women had greater odds of poor or fair health, poor physical health, depression, poor mental health, and physical and mental health interfering with daily activities in comparison with their heterosexual peers, even after adjustments. Hispanic sexual minority women had greater odds of depression and poor mental health, although after adjustments, only depression remained significantly different from heterosexual women’s odds. Black sexual minority women were mostly similar to their heterosexual peers except for greater odds of poor mental health days, although after adjustments, this difference was no longer significant.
DISCUSSION
To our knowledge, this is the first representative study from a geographically diverse sample that examined cancer survivors’ physical and mental health in relation to both sexual orientation and race/ethnicity among cisgender men and women in the United States. This study is novel because of its focus on multiple intersecting social positions of cancer survivors. A previous review of cancer survivor studies did not consider intersectionality and reported that sexual minorities and heterosexual survivors have mostly similar psychological health.6 This is inconsistent with studies of the US population, which have indicated that sexual minority men and women report significantly worse psychological health than heterosexual individuals.20–22 Our study findings differed for cancer survivors’ physical health versus mental health. Concerning mental health, our findings consistently showed that sexual minority cancer survivors had 2 to 3 times greater odds of depression and/or poor mental health in comparison with their heterosexual counterparts among White, Black, and Hispanic male and female survivors. Although some of these findings were not significant at the P < .05 level, this was likely due to the smaller sample sizes for Black and Hispanic individuals, which resulted in large confidence intervals. The adjusted odds of mental health were still substantially greater for Black sexual minority men and women in comparison with their heterosexual peers. This is consistent with recent intersectional studies of the general population showing that Hispanic and Black sexual minorities have worse psychological health in comparison with their heterosexual peers of the same race/ethnicity.23,24
Other findings showed more variance. Among White, Black, and Hispanic men, the odds of fair or poor health were similar, regardless of sexual orientation, and White and Black men’s poor physical days and poor activity days were similar, regardless of sexual orientation. Among women, only White sexual minority women presented with greater odds of fair or poor health, poor physical health, and physical and mental health interfering with daily activities in comparison with their heterosexual counterparts. This confirms earlier findings among cancer survivors showing that sexual minority women have significantly greater odds of fair or poor health, whereas sexual minority men’s poor health is similar to that of their heterosexual counterparts.3 Hispanic survivors were an exception to this pattern, with both sexual minority men and women having greater odds of poor physical health and activity in comparison with their heterosexual counterparts; however, the results were not significant at the .05 level.
Our comparisons within sexual orientation groups identified Hispanic survivors as a particular risk group on account of their age and poor access to care. This cancer survivorship study used the age at interview because the age at diagnosis was not available. Nevertheless, the significant age differences are important to note, in that White heterosexual men and women were the oldest (significantly older than every other race/ethnicity and sexual identity group), with Hispanic sexual minority men and women being the youngest. This is consistent with other studies showing that sexual minority individuals are diagnosed at a younger age in comparison with heterosexual survivors.3,25
However, several limitations of this study are also worth noting. First, the small sample sizes of sexual minority individuals among Black and Hispanic survivors prevented us from assessing sexual minority subgroups (eg, gay and bisexual individuals) separately and considering other marginalized racial or ethnic groups in this analysis. Second, as noted earlier, this study focuses on cisgender adults because of the small sample of transgender and gender-nonconforming cancer survivors. Dedicated research efforts will be needed to better characterize the experience of gender minority cancer survivors with intersecting marginalized identities.26 Third, this study lacked further detail on various important cancer characteristics, including the type of cancer, stage, treatments, and time since diagnosis. Fourth, additional information about these cancer survivors’ environment, including their social support resources and the characteristics of the health care settings in which they were treated, was unavailable. Fifth, we considered marital status with data from 2014 to 2019, although we recognize that same-sex marriage became available nationally only in 2015. Sixth, the study data are cross-sectional, and this prevents us from inferring any directionality or causality; rather, we were able only to identify associations. Lastly, an intersectional analysis would require examining how multiple forms of discrimination at both the interpersonal and structural levels relate to the outcomes of interest across and within racial/ethnic and sexual orientation groups.27 However, because of limited sources of relevant data, we were able to examine only the distribution of outcomes in relation to individual-level measures of social position, which nonetheless reflect macro-level social inequities and power relations.
This study has considerable strengths, in that we were able to assess the physical and mental health of cancer survivors across multiple intersecting social positions, namely gender, race/ethnicity, and sexual orientation. This is an important departure from existing research and an important next step in identifying, describing, and addressing health disparities among cancer survivors. This study meets a call from the National Academies to expand the study of sexual minority health to account for the unique experiences of multiply marginalized individuals and groups, such as Black and Hispanic sexual minority women and men, which is necessary to advance health equity among cancer survivors.2 Furthermore, highlighting cancer survivorship disparities allows for the development of interventions that take into account the unique experiences of individuals across multiple intersecting social positions. The development of such interventions will require health care professionals, including oncology providers, to be trained to meet the needs of sexual and gender minority patients28,29 and to acknowledge the past and present racism of the health care system.30,31 As our study notes, data collection that better reflects multiple intersecting social positions must be prioritized and standardized across various data sources, including the Surveillance, Epidemiology, and End Results program.29,32 Ultimately, creating a more equitable cancer care continuum that accounts for the unique experiences of multiply marginalized communities requires advances in training, data collection, and political will to prioritize health equity across multiple intersecting axes of social inequality.
Supplementary Material
FUNDING SUPPORT
No specific funding was disclosed.
CONFLICT OF INTEREST DISCLOSURES
Ulrike Boehmer reports a grant from the National Cancer Institute (1R01CA181392-01A1). Carl G. Streed reports grants from the National Heart, Lung, and Blood Institute (1K01HL151902-01A1) and the American Heart Association (20CDA35320148), a Career Investment Award from the Boston University School of Medicine, and a leadership or fiduciary role in the US Professional Association for Transgender Health. The other authors made no disclosures.
Footnotes
Additional supporting information may be found in the online version of this article.
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