Abstract
Purpose:
A disparity exists in cancer screening rates for the lesbian, gay, bisexual, transgender and queer (LGBTQ+) community. We sought to understand the perceptions and baseline knowledge of cancer screening among LGBTQ+ community members.
Methods:
Survey administered via social media from June 2018 to October 2018. We asked thirty-one questions focused on cancer screening, human papillomavirus, emotional distress, and experience with the healthcare system. Those included were age-eligible for cancer screening. Cancer screening attitudes and knowledge, as well as perceptions of the health care system were investigated.
Results:
There were 422 respondents: 24.6% identified as female, 25.5% as male, 40.1% transgender and 9.6% as other. 65.4% of the LGBTQ+ community is not certain what cancer screening to do for themselves. Only 27.3% and 55.7% knew that HPV was a risk factor associated with head and neck cancer and anal cancer respectively. Half stated their emotional distress prevents them from getting cancer screening. It was identified that process changes in making appointments, comforts during the visit, and formal training for physicians and nurses could increase cancer screening compliance for this community. The transgender population had notably more gaps in knowledge of appropriate cancer screening and excess emotional distress.
Conclusion:
Gaps in cancer screening knowledge, and emotional and financial distress may be responsible for the disparity of lower cancer screening rates for the LGBTQ+ population, and the transgender population may be most at risk. Appreciating the cancer screening concerns of the LGBTQ+ population can help shape future clinical and institutional approaches to improve healthcare delivery.
Introduction
Cancer screening guidelines were initiated in the 1960’s and evidence demonstrates that early detection can decrease the number of cancer related deaths [1–2]. Unfortunately, existing cancer screening guidelines do not consider unique medical scenarios of the LGBTQ+ population which accounts for 4.5% of the US population [3]. In 2011, the LGBTQ+ population was identified as vulnerable after a report demonstrated the community has poor access to healthcare, increased proportion of persons with cancer, HIV, and depression and healthcare needs incompletely understood by medical professionals [4]. In 2015 the NIH established the sexual and gender minority (SGM) research office and by 2016, SGM were designated by the NCI as a health disparity population [5].
The oncology care disparities in the LGBTQ+ community are multifactorial and poorly understood. The 2011 National Transgender Discrimination Survey showed 50% of respondents postponed preventative care services because they could not afford it and 19% were denied health care because of their gender nonconforming status [6–9]. LQBTQ+ patients have a higher proportion of cancer risk factors including HIV, HPV, tobacco use, alcohol use, nulliparity, and a high fat diet [10]. The combination of increased risks of cancer, lack of access to health care, and distrust of providers is thought to translate to poor outcomes in the LGBTQ+ population [11–12].
Despite the critical need for improved health care in the LGBTQ+ community, there are no cancer screening guidelines specific to the LGBTQ+ population which leads to uncertainty for both health care providers and community members [13]. In this study, we sought to understand the unmet and unique needs of the LGBTQ+ population. In a survey of over 400 LGBTQ+ community members, half of the respondents were not certain what cancer screenings should be done, what age they should begin, and half of patients had emotional distress due to cancer screening with 40% concerned about medical insurance. It was also found that respondents agree that cancer screening may improve if the medical infrastructure helped to decrease their emotional distress surrounding cancer screening with additional training for medical professionals, improved scheduling and comfort during exams. We present the first study assessing the knowledge and perceptions of the LGBTQ+ community on cancer screening.
Methods
An IRB approved redcap survey was administered on social media to engage LGBTQ+ community members via Thomas Jefferson University Hospital. The survey was posted 540 times between 6/2–10/10/2018 to online groups including general LGBT, transgender general, female to male, male to female, lesbian, gay, queer, bisexual, and other across the social media platforms Facebook, Reddit, and other blogs. 82% of the postings were on Facebook groups. The anonymous survey included a consent statement for the interviewee to agree to participate and no protected health information was collected as part of the survey. Participants were not compensated for completing the survey.
Inclusion/Exclusion Criteria
The target audience was individuals who self-identified with the LGBTQ+ community. We targeted English-speaking adults over the age of 18 as those would be eligible for cancer screening.
Survey
The survey was developed to better understand the knowledge and needs of the LGBTQ+ community, to increase cancer screening and reduce barriers towards medical care. The survey used words and phrases that were gender and identity neutral and considered inclusivity. The survey asked 31 questions across several topics: 1) awareness of cancer screening exams, 2) knowledge of HPV as a risk factor for certain cancers, 3) emotions experienced when going to the doctor, 4) experience with the healthcare system, and 5) demographic characteristics. (Table 1). The questionnaire ended with an open-ended response section to allow participants to provide suggestions on how to improve patient-provider interactions and the health care experience for LGBTQ+ patients.
Table 1.
Summary Statistics of Entire Survey (n = 422).
| All (n = 422) |
|
|---|---|
| Which of the following do you identify with?, n (%) 1 | |
| Female | 103 (24.6) |
| Male | 107 (25.5) |
| Transgender (FTM) | 94 (22.4) |
| Transgender (MTF) | 75 (17.9) |
| Other | 40 (9.6) |
| What is your age?, n (%) 2 | |
| 30 or Under | 200 (48.0) |
| 31 – 40 | 108 (25.9) |
| 41 – 50 | 43 (10.3) |
| 51 – 60 | 43 (10.3) |
| Over 60 | 23 (5.5) |
| Which of the following best describes your sexual orientation?, n (%) 3 | |
| Lesbian | 79 (18.8) |
| Gay | 106 (25.2) |
| Bisexual | 85 (20.2) |
| Heterosexual | 32 (7.6) |
| Queer | 83 (19.7) |
| Other | 36 (8.6) |
| Which of the following best describe the area in which you reside?, n (%) 2 | |
| Rural | 72 (17.3) |
| Suburban | 185 (44.4) |
| Urban | 160 (38.4) |
| What is the highest level of education you have completed?, n (%) | |
| Less than high school (grade 11 or less) | 12 (2.8) |
| High school diploma (including GED) | 36 (8.5) |
| Some college | 104 (24.6) |
| Bachelor’s or associate’s degree | 155 (36.7) |
| Some graduate training | 24 (5.7) |
| Graduate or professional training | 91 (21.6) |
| I am certain of what cancer screening to do for myself, n (%) | |
| Yes | 146 (34.6) |
| No | 276 (65.4) |
| I am certain of what age to begin my cancer screening, n (%) 4 | |
| TRUE | 120 (28.6) |
| FAULSE | 300 (71.4) |
| Within the LGBTQ+ community, each sub-population has very different health concerns, n (%) 4 | |
| Strongly agree | 116 (27.6) |
| Agree | 219 (52.1) |
| Neutral | 59 (14.1) |
| Disagree | 15 (3.6) |
| Strongly disagree | 11 (2.6) |
| Lesbian women (Checked), n (%) | |
| Mammograms | 400 (94.8) |
| Pap Smears | 391 (92.7) |
| Oral Screening Exams | 352 (83.4) |
| Gay men (Checked), n (%) | |
| Mammograms | 70 (16.6) |
| Pap Smears | 45 (10.7) |
| Oral Screening Exams | 383 (90.8) |
| Transgender men (Checked), n (%) | |
| Mammograms | 359 (85.1) |
| Pap Smears | 344 (81.5) |
| Oral Screening Exams | 361 (85.6) |
| Transgender men after mastectomy (Checked), n (%) | |
| Mammograms | 132 (31.3) |
| Pap Smears | 334 (79.2) |
| Oral Screening Exams | 362 (85.8) |
| Transgender women (Checked), n (%) | |
| Mammograms | 208 (49.3) |
| Pap Smears | 99 (23.5) |
| Oral Screening Exams | 372 (88.2) |
| Transgender women taking hormone supplements (Checked), n (%) | |
| Mammograms | 335 (79.4) |
| Pap Smears | 107 (25.4) |
| Oral Screening Exams | 362 (85.8) |
| Transgender men are at risk for breast cancer, n (%) 4 | |
| TRUE | 391 (93.1) |
| FAULSE | 29 (6.9) |
| Transgender women who are taking supplemental hormones are at risk for breast cancer, n (%) 1 | |
| TRUE | 390 (93.1) |
| FAULSE | 29 (6.9) |
| All sexually active people are at risk for HPV infections, n (%) 5 | |
| TRUE | 388 (92.8) |
| FAULSE | 30 (7.2) |
| A HPV infection is a risk factor for which cancers? (Checked), n (%) | |
| Anal cancer | 235 (55.7) |
| Cervical cancer | 378 (89.6) |
| Head and Neck cancer | 115 (27.3) |
| None | 11 (2.6) |
| Nervous, anxious or on edge, n (%) 4 | |
| Never | 19 (4.5) |
| Rarely | 50 (11.9) |
| Sometimes | 144 (34.3) |
| Often | 101 (24.1) |
| Always | 106 (25.2) |
| Excessively worried, cannot think about anything else, n (%) 1 | |
| Never | 69 (16.5) |
| Rarely | 116 (27.7) |
| Sometimes | 105 (25.1) |
| Often | 76 (18.1) |
| Always | 53 (12.7) |
| Depressed or helpless, n (%) 1 | |
| Never | 107 (25.5) |
| Rarely | 121 (28.9) |
| Sometimes | 120 (28.6) |
| Often | 41 (9.8) |
| Always | 30 (7.2) |
| Overwhelmed, n (%) 6 | |
| Never | 68 (16.4) |
| Rarely | 68 (16.4) |
| Sometimes | 105 (25.3) |
| Often | 101 (24.3) |
| Always | 73 (17.6) |
| My concern about emotional distress prevents me from getting regular cancer screenings. (e.g. mammograms, pap smears, colonoscopies, etc...), n (%) 7 | |
| Strongly agree | 86 (21.1) |
| Agree | 116 (28.4) |
| Neutral | 60 (14.7) |
| Disagree | 93 (22.8) |
| Strongly disagree | 53 (13.0) |
| I am concerned about medical insurance not paying for my screening services due to misgendering, n (%) 8 | |
| Strongly agree | 66 (20.0) |
| Agree | 77 (23.3) |
| Neutral | 43 (13.0) |
| Disagree | 65 (19.7) |
| Strongly disagree | 79 (23.9) |
| Scheduling appointments online would be an effective method of avoiding confusion to figure out the screening appropriate for me, n (%) 9 | |
| Strongly agree | 11 (2.7) |
| Agree | 186 (45.9) |
| Neutral | 80 (19.8) |
| Disagree | 28 (6.9) |
| Strongly disagree | 11 (2.7) |
| If staff did not use personal pronouns (Mr. / Mrs. / Miss. / Ms.) and instead called patients by their last name only, it would lessen misgendering and discomfort, n (%) 10 | |
| Strongly agree | 143 (36.4) |
| Agree | 132 (33.6) |
| Neutral | 62 (15.8) |
| Disagree | 33 (8.4) |
| Strongly disagree | 23 (5.9) |
| I think it is important for __________ to have formal training to prevent misgendering / confusion when I present for my cancer screening (Checked), n (%) | |
| Physicians | 385 (91.2) |
| Nurses | 382 (90.5) |
| Clerical staff | 351 (83.2) |
| Technicians | 343 (81.3) |
| Others | 108 (25.6) |
| In order to make waiting areas more comfortable for all patients, I believe it is important to _______. (Checked), n (%) | |
| Offer separate, private waiting areas for patents who request | 209 (49.5) |
| Give patients the option to change immediately before imaging, to avoid waiting in gowns/robes | 272 (64.5) |
| Use gender neutral decor (including patient garments) | 291 (69.0) |
| None of these | 50 (11.9) |
| Other | 22 (5.2) |
There were 3 missing data for this question
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There were 1 missing data for this question
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There were 14 missing data for this question
There were 92 missing data for this question
There were 17 missing data for this question
There were 29 missing data for this question.
Statistical Analysis
Subgroup analysis was performed to determine if a patient’s identification, age, residence area, and education status might influence their views on cancer screening. The subpopulations included: a) Trans (MTF, FTM, other) vs. Non-Trans (female, male), b) Age ≤ 30 vs. Age >30, c) Urban vs. Non-Urban (suburban and rural) and d) education: Non-Degree (Less than high school, high school diploma, some college) vs. Degree (Bachelor’s or associate’s degree, Some graduate training, graduate or professional training). Chi-square or Fisher’s exact test were conducted to investigate significant differences in subgroups. The significance level was set a priori to the 0.05 level. All analyses were performed with SAS 9.4 (SAS Institute Inc., Cary, NC).
Results
The survey was completed by 428 individuals with a complete data set from 422 individuals. Demographic data is summarized in Table 1 but briefly, 24.6% identified as female, 25.5% as male, 40.1% transgender (22.4% as transgender female to male, 17.7% as transgender male to female), and 9.6% as other. 52% of the respondents were over 30 years old, with most living in urban or suburban areas, and 64% with a college degree or greater.
Understanding and Beliefs of Screening
Overall, members of LGBTQ+ community are uncertain which cancer screening exams are appropriate. 276 respondents (65.4%) not certain what cancer screening to do for themselves and 300 (71.4%) uncertain what age to begin screening. It was clearly recognized by 79.7% of respondents, that each sub-population within the LGBTQ+ community has unique health concerns. While most respondents understood that the lesbian community should have breast (94.8% suggest mammograms) and cervical cancer (92.7% suggest pap smears) screening, the response was less overwhelming for the gay population. It was believed that mammogram screening should be done in 85.1% of transgender men, 31.3% of transgender men after mastectomy, 49.3% of transgender women, and 79.4% for transgender women who are taking hormone supplements. Interestingly, 390 (93.1%) answered it was true that transgender women who are taking supplemental hormones are at risk for breast cancer though not all believed screening should be done. The respondents views on the importance of pap smears for the transgender populations included 81.5% for transgender men, 79.3% for transgender men after mastectomy, 23.5% for transgender women, and 25.4% for transgender women taking hormone supplements.
Knowledge of Human Papilloma Virus Association with Cancer
It was universally understood by 92.8% of respondents that all sexually active people are at risk for HPV infections. To also gauge the knowledge of how HPV can affect cancer risk in the LGBTQ+ population, respondents were queried for their understanding of which cancer types were associated with HPV. While 89.6% appreciated that HPV was associated with cervical cancer, only 27.3% and 55.7% understood that HPV was associated with head and neck cancer and anal cancer respectively.
Personal Emotional Response to Cancer Screening
Several survey questions were designed to determine if members of the LGBTQ+ community have emotional distress associated with cancer screening. Most community members (83.6%) were nervous or anxious at least some of the time when thinking about cancer screening with 49.3% of individuals responding that they were often or always nervous/anxious with a smaller proportion (30.8%) feeling that they were excessively worried about cancer screening and unable to think of anything else. While 41.9% stated they were often or always overwhelmed by the thought on cancer screening, only 17% felt depressed or helpless. Almost 50% of LGBTQ+ community members either agreed or strongly agreed that their emotional distress prevents them from getting regular cancer screenings such as mammograms, pap smears and colonoscopies.
Health Care Infrastructure Perceptions
Questions were also designed to understand the intricacies of LGBTQ+ community members concerns with the healthcare infrastructure that may prevent comfort with appropriate cancer screening. Unfortunately, 43% either agreed or strongly agreed that they were concerned about their medical insurance not paying for screening services due to misgendering however 92 subjects did not answer this particular question. With regards to interacting with medical staff, 48.6% of people surveyed agreed or strongly agreed that scheduling appointments online would be an effective way of avoiding confusion regarding determining appropriate screening. Seventy percent agreed or strongly agreed that medical staff using last name alone instead of personal pronouns (Mr./Mrs.) would lessen misgendering and discomfort. Over 90% responded that they think it is important for physicians and nurses to have formal training to prevent misgendering and confusion when they have appointments for cancer screening. In order to make health care office waiting areas more comfortable for all patients, 49.5% believed offered a private waiting area is important, with 64.5% believing allowing patients to change just before imaging is important, and 69% believe that using gender neutral décor including garments is important.
Subgroup Analyses
Subgroup Analysis for Transgender vs. Non-Transgender Community Members (Subgroup A), Table 2.
Table 2.
Subgroup Analysis for Subgroup A (Trans vs. Non-Trans), n=419.
| Non-Trans (n=210, 50%) |
Trans (n=209, 50%) |
p-value | |
|---|---|---|---|
| I am certain of what cancer screening to do for myself (Yes), n (%) | 81 (38.6) | 63 (30.1) | 0.07 |
| A HPV infection is a risk factor for which cancers? (Checked), n (%) | |||
| Anal cancer | 126 (60.0) | 108 (51.7) | 0.09 |
| Cervical cancer | 194 (92.4) | 182 (87.1) | 0.07 |
| Head and Neck cancer | 72 (34.3) | 42 (20.1) | <0.01 |
| None | 3 (1.4) | 8 (3.8) | 0.14 |
| Nervous, anxious or on edge, n (%) 1 | |||
| Never | 14 (6.7) | 5 (2.4) | <0.01 |
| Rarely | 37 (17.7) | 13 (6.3) | |
| Sometimes | 70 (33.5) | 72 (34.6) | |
| Often | 49 (23.4) | 52 (25.0) | |
| Always | 39 (18.7) | 66 (25.2) | |
| Excessively worried, cannot think about anything else, n (%) 2 | |||
| Never | 48 (23.1) | 21 (10.1) | <0.01 |
| Rarely | 64 (30.8) | 50 (24.0) | |
| Sometimes | 43 (20.7) | 61 (29.3) | |
| Often | 32 (15.4) | 44 (21.2) | |
| Always | 21 (10.1) | 32 (15.4) | |
| Depressed or helpless, n (%) 2 | |||
| Never | 78 (37.5) | 29 (13.9) | <0.01 |
| Rarely | 62 (29.8) | 57 (27.4) | |
| Sometimes | 47 (22.6) | 72 (34.6) | |
| Often | 14 (6.7) | 27 (13.0) | |
| Always | 7 (3.4) | 23 (11.1) | |
| Overwhelmed, n (%) 3 | |||
| Never | 49 (23.8) | 19 (9.2) | <0.01 |
| Rarely | 38 (18.5) | 29 (14.1) | |
| Sometimes | 56 (27.2) | 48 (23.3) | |
| Often | 38 (18.5) | 62 (30.1) | |
| Always | 25 (12.1) | 48 (23.3) | |
| My concern about emotional distress prevents me from getting regular cancer screenings. (e.g. mammograms, pap smears, colonoscopies, etc...), n (%) 4 | |||
| Strongly agree | 25 (12.3) | 61 (30.4) | <0.01 |
| Agree | 44 (21.6) | 70 (34.8) | |
| Neutral | 37 (18.1) | 22 (11.0) | |
| Disagree | 63 (30.9) | 30 (14.9) | |
| Strongly disagree | 35 (17.2) | 18 (9.0) | |
| I am concerned about medical insurance not paying for my screening services due to misgendering, n (%) 5 | |||
| Strongly agree | 6 (4.3) | 58 (31.0) | <0.01 |
| Agree | 11 (7.9) | 66 (35.3) | |
| Neutral | 18 (12.9) | 25 (13.4) | |
| Disagree | 38 (27.1) | 26 (13.9) | |
| Strongly disagree | 67 (47.9) | 12 (6.4) | |
| Scheduling appointments online would be an effective method of avoiding confusion to figure out the screening appropriate for me, n (%) 6 | |||
| Strongly agree | 50 (25.4) | 49 (23.9) | 0.31 |
| Agree | 94 (47.7) | 91 (44.4) | |
| Neutral | 34 (17.3) | 46 (22.4) | |
| Disagree | 11 (5.6) | 16 (7.8) | |
| Strongly disagree | 8 (4.1) | 3 (1.5) | |
| If staff did not use personal pronouns (Mr. / Mrs. / Miss. / Ms.) and instead called patients by their last name only, it would lessen misgendering and discomfort, n (%) 7 | |||
| Strongly agree | 52 (28.3) | 91 (44.2) | <0.01 |
| Agree | 64 (34.8) | 68 (33.0) | |
| Neutral | 35 (19.0) | 25 (12.1) | |
| Disagree | 16 (8.7) | 16 (7.8) | |
| Strongly disagree | 17 (9.2) | 6 (5.9) | |
| I think it is important for __________ to have formal training to prevent misgendering / confusion when I present for my cancer screening (Checked), n (%) | |||
| Physicians | 183 (87.1) | 200 (95.7) | <0.01 |
| Nurses | 184 (87.6) | 196 (93.8) | 0.03 |
| Clerical staff | 169 (80.5) | 182 (87.1) | 0.07 |
| Technicians | 161 (76.7) | 182 (87.1) | 0.01 |
| Others | 44 (21.0) | 64 (30.6) | 0.02 |
There were 2 missing data for this question (1 in Non-Trans and 1 in Trans)
There were 3 missing data for this question (2 in Non-Trans and 1 in Trans)
There were 7 missing data for this question (4 in Non-Trans and 3 in Trans)
There were 14 missing data for this question (6 in Non-Trans and 8 in Trans)
There were 92 missing data for this question (70 in Non-Trans and 22 in Trans)
There were 17 missing data for this question (13 in Non-Trans and 4 in Trans)
There were 29 missing data for this question (23 in Non-Trans and 3 in Trans).
This univariate analysis was done on 419 respondents and showed that 50% of respondents were transgender. There was a trend for transgender patients to be slightly less aware of what cancer screening should be done (30.1% vs 38.6%, p=0.07). In addition, the transgender population did not fully understand the link between HPV and various cancer types with a statistically significant difference in knowing the link between HPV and head and neck cancer (p < 0.01). Transgender community members were significantly more likely to be nervous/anxious, excessively worried, depressed/helpless and overwhelmed by thoughts of cancer screening (p <0.01 for all questions). In addition, transgender patients were more likely to have emotional distress regarding misgendering and insurance payments (p < 0.01 for all questions). Formal training for healthcare providers was thought to be more significantly prudent by transgender patients.
Subgroup Analysis for Age ≤ 30 vs. Age > 30 (Subgroup B), Table 3.
Table 3.
Subgroup Analysis for Subgroup B (Age ≤ 30 vs. Age > 30), n=417.
| Age ≤ 30 (n=200, 48%) | Age > 30 (n=217, 52%) | p-value | |
|---|---|---|---|
| I am certain of what cancer screening to do for myself (Yes), n (%) | 61 (30.5) | 83 (38.3) | 0.10 |
| A HPV infection is a risk factor for which cancers? (Checked), n (%) | |||
| Anal cancer | 99 (49.5) | 134 (61.8) | 0.01 |
| Cervical cancer | 191 (95.5) | 184 (84.8) | < 0.01 |
| Head and Neck cancer | 52 (26.0) | 62 (28.6) | 0.56 |
| None | 3 (1.5) | 8 (3.7) | 0.22 |
| Nervous, anxious or on edge, n (%) 1 | |||
| Never | 7 (3.5) | 12 (5.6) | 0.07 |
| Rarely | 20 (10.0) | 29 (13.4) | |
| Sometimes | 61 (30.5) | 82 (38.0) | |
| Often | 50 (25.0) | 49 (22.7) | |
| Always | 62 (31.0) | 44 (20.4) | |
| Excessively worried, cannot think about anything else, n (%) 2 | |||
| Never | 29 (14.6) | 39 (18.1) | 0.08 |
| Rarely | 46 (23.1) | 69 (31.9) | |
| Sometimes | 50 (25.1) | 53 (24.5) | |
| Often | 43 (21.6) | 33 (15.3) | |
| Always | 31 (15.6) | 22 (10.2) | |
| Depressed or helpless, n (%) 2 | |||
| Never | 47 (23.6) | 58 (26.9) | 0.84 |
| Rarely | 58 (29.2) | 61 (28.2) | |
| Sometimes | 56 (28.1) | 64 (29.6) | |
| Often | 22 (11.1) | 19 (8.8) | |
| Always | 16 (8.0) | 14 (7.2) | |
| Overwhelmed, n (%) 3 | |||
| Never | 22 (11.2) | 45 (21.0) | 0.01 |
| Rarely | 30 (15.2) | 38 (17.8) | |
| Sometimes | 46 (23.4) | 57 (26.6) | |
| Often | 61 (31.0) | 39 (18.2) | |
| Always | 38 (19.3) | 35 (16.4) | |
| My concern about emotional distress prevents me from getting regular cancer screenings. (e.g. mammograms, pap smears, colonoscopies, etc...), n (%) 4 | |||
| Strongly agree | 48 (25.3) | 38 (17.8) | 0.37 |
| Agree | 50 (26.3) | 64 (29.9) | |
| Neutral | 30 (15.8) | 30 (14.0) | |
| Disagree | 40 (21.1) | 53 (24.8) | |
| Strongly disagree | 22 (11.6) | 29 (13.6) | |
| I am concerned about medical insurance not paying for my screening services due to misgendering, n (%) 5 | |||
| Strongly agree | 31 (20.5) | 35 (19.9) | 0.70 |
| Agree | 30 (19.9) | 46 (26.1) | |
| Neutral | 20 (13.3) | 23 (13.1) | |
| Disagree | 33 (21.9) | 31 (17.6) | |
| Strongly disagree | 37 (24.5) | 41 (23.3) | |
| Scheduling appointments online would be an effective method of avoiding confusion to figure out the screening appropriate for me, n (%) 6 | |||
| Strongly agree | 49 (25.8) | 50 (23.7) | 0.14 |
| Agree | 92 (48.4) | 93 (44.1) | |
| Neutral | 38 (20.0) | 40 (19.0) | |
| Disagree | 9 (4.7) | 19 (9.0) | |
| Strongly disagree | 2 (1.1) | 9 (4.3) | |
| If staff did not use personal pronouns (Mr. / Mrs. / Miss. / Ms.) and instead called patients by their last name only, it would lessen misgendering and discomfort, n (%) 7 | |||
| Strongly agree | 72 (38.7) | 69 (33.8) | 0.18 |
| Agree | 69 (37.1) | 62 (30.4) | |
| Neutral | 24 (12.9) | 38 (18.6) | |
| Disagree | 12 (6.5) | 21 (10.3) | |
| Strongly disagree | 9 (4.8) | 14 (6.9) | |
| I think it is important for __________ to have formal training to prevent misgendering / confusion when I present for my cancer screening (Checked), n (%) | |||
| Physicians | 183 (91.5) | 199 (91.7) | 0.94 |
| Nurses | 189 (94.5) | 190 (87.6) | 0.01 |
| Clerical staff | 170 (85.0) | 178 (82.0) | 0.41 |
| Technicians | 165 (82.5) | 175 (80.7) | 0.63 |
| Others | 47 (23.5) | 61 (28.1) | 0.28 |
There were 1 missing data for this question (1 in Age > 30)
There were 2 missing data for this question (1 in Age ≤ 30 and 1 in Age > 30)
There were 6 missing data for this question (3 in Age ≤ 30 and 3 in Age > 30)
There were 13 missing data for this question (10 in Age ≤ 30 and 3 in Age > 30)
There were 90 missing data for this question (49 in Age ≤ 30 and 41 in Age > 30),
There were 16 missing data for this question (10 in Age ≤ 30 and 6 in Age > 30)
There were 27 missing data for this question (14 in Age ≤ 30 and 13 in Age > 30).
To determine if age affected beliefs of cancer screening, analysis was done for 417 respondents less than (48%) and greater than age 30 (52%). Patients >30 trended to be more aware of what cancer screening should be done. While significantly more respondents >30 years old were aware that anal cancer was associated with HPV (p=0.01), they were significantly less likely to associate HPV with cervical cancer (p < 0.01). The >30 year old population had a trend toward having less nervousness/anxiety, excessive worrying, depression/helplessness, and were significantly less likely to feel overwhelmed (p=0.01).
Subgroup Analysis for Urban vs. Non-Urban (Subgroup C), Table 4.
Table 4.
Subgroup Analysis for Subgroup C (Urban vs. Non-Urban), n=417.
| Non-Urban (n=257, 62%) | Urban (n=160, 38%) | p-value | |
|---|---|---|---|
| I am certain of what cancer screening to do for myself (Yes), n (%) | 87 (33.9) | 57 (35.6) | 0.71 |
| A HPV infection is a risk factor for which cancers? (Checked), n (%) | |||
| Anal cancer | 134 (52.1) | 98 (61.3) | 0.07 |
| Cervical cancer | 230 (89.5) | 143 (89.4) | 0.97 |
| Head and Neck cancer | 64 (24.9) | 50 (31.3) | 0.16 |
| None | 8 (3.1) | 3 (1.9) | 0.54 |
| Nervous, anxious or on edge, n (%) 1 | |||
| Never | 12 (4.7) | 7 (4.4) | 0.20 |
| Rarely | 33 (12.9) | 17 (10.7) | |
| Sometimes | 78 (30.5) | 66 (41.5) | |
| Often | 68 (26.6) | 31 (19.5) | |
| Always | 65 (15.4) | 38 (23.9) | |
| Excessively worried, cannot think about anything else, n (%) 2 | |||
| Never | 43 (16.9) | 26 (16.4) | 0.93 |
| Rarely | 70 (27.5) | 45 (28.3) | |
| Sometimes | 61 (23.9) | 43 (27.0) | |
| Often | 48 (18.8) | 26 (16.4) | |
| Always | 33 (12.9) | 19 (12.0) | |
| Depressed or helpless, n (%) 2 | |||
| Never | 69 (27.1) | 38 (23.9) | 0.32 |
| Rarely | 69 (27.1) | 50 (31.5) | |
| Sometimes | 69 (27.1) | 50 (31.5) | |
| Often | 30 (11.8) | 10 (6.3) | |
| Always | 18 (7.1) | 11 (6.9) | |
| Overwhelmed, n (%) 3 | |||
| Never | 44 (18.6) | 25 (15.9) | 0.39 |
| Rarely | 39 (15.4) | 28 (17.8) | |
| Sometimes | 57 (22.5) | 47 (29.9) | |
| Often | 66 (26.1) | 33 (21.0) | |
| Always | 47 (18.6) | 25 (15.9) | |
| My concern about emotional distress prevents me from getting regular cancer screenings. (e.g. mammograms, pap smears, colonoscopies, etc...), n (%) 4 | |||
| Strongly agree | 54 (22.0) | 30 (19.1) | 0.94 |
| Agree | 66 (26.8) | 47 (29.9) | |
| Neutral | 36 (14.6) | 24 (15.3) | |
| Disagree | 58 (23.6) | 35 (22.3) | |
| Strongly disagree | 32 (13.0) | 21 (13.4) | |
| I am concerned about medical insurance not paying for my screening services due to misgendering, n (%) 5 | |||
| Strongly agree | 38 (19.1) | 26 (20.5) | 0.57 |
| Agree | 45 (22.6) | 32 (25.2) | |
| Neutral | 30 (15.1) | 13 (10.2) | |
| Disagree | 42 (21.1) | 22 (17.3) | |
| Strongly disagree | 44 (22.1) | 34 (26.8) | |
| Scheduling appointments online would be an effective method of avoiding confusion to figure out the screening appropriate for me, n (%) 6 | |||
| Strongly agree | 52 (20.9) | 44 (29.1) | 0.06 |
| Agree | 111 (44.6) | 75 (49.7) | |
| Neutral | 58 (23.3) | 21 (13.9) | |
| Disagree | 20 (8.0) | 8 (5.3) | |
| Strongly disagree | 8 (3.2) | 3 (2.0) | |
| If staff did not use personal pronouns (Mr. / Mrs. / Miss. / Ms.) and instead called patients by their last name only, it would lessen misgendering and discomfort, n (%) 7 | |||
| Strongly agree | 89 (37.1) | 53 (35.8) | 0.88 |
| Agree | 78 (32.5) | 52 (35.1) | |
| Neutral | 36 (15.0) | 25 (16.9) | |
| Disagree | 22 (9.2) | 10 (6.8) | |
| Strongly disagree | 15 (6.3) | 8 (5.4) | |
| I think it is important for __________ to have formal training to prevent misgendering / confusion when I present for my cancer screening (Checked), n (%) | |||
| Physicians | 232 (90.3) | 148 (92.5) | 0.44 |
| Nurses | 232 (90.3) | 145 (90.6) | 0.91 |
| Clerical staff | 214 (83.3) | 133 (83.1) | 0.97 |
| Technicians | 206 (80.2) | 133 (83.1) | 0.45 |
| Others | 72 (28.0) | 34 (25.4) | 0.12 |
There were 2 missing data for this question (1 in Non-Urban and 1 in Urban).
There were 3 missing data for this question (2 in Non-Urban and 1 in Urban).
There were 7 missing data for this question (4 in Non-Urban and 3 in Urban).
There were 14 missing data for this question (11 in Non-Urban and 3 in Urban).
There were 91 missing data for this question (58 in Non-Urban and 33 in Urban).
There were 17 missing data for this question (8 in Non-Urban and 9 in Urban).
There were 29 missing data for this question (17 in Non-Urban and 12 in Urban).
Of the 417 respondents, no statistically significant differences were observed.
Subgroup Analysis for Degree vs. Non-Degree (Subgroup D), Table 5.
Table 5.
Subgroup Analysis for Subgroup D (Degree vs. Non-degree), n=422.
| Non-Degree (n=152, 36%) | Degree (n=270, 64%) | p-value | |
|---|---|---|---|
| I am certain of what cancer screening to do for myself (Yes), n (%) | 43 (28.3) | 103 (38.2) | 0.04 |
| A HPV infection is a risk factor for which cancers? (Checked), n (%) | |||
| Anal cancer | 81 (53.3) | 154 (57.0) | 0.46 |
| Cervical cancer | 132 (86.8) | 246 (91.1) | 0.17 |
| Head and Neck cancer | 32 (21.1) | 83 (30.7) | 0.03 |
| None | 6 (4.0) | 5 (1.9) | 0.21 |
| Nervous, anxious or on edge, n (%) 1 | |||
| Never | 6 (4.5) | 13 (4.8) | 0.01 |
| Rarely | 12 (8.0) | 38 (14.1) | |
| Sometimes | 45 (29.8) | 99 (36.8) | |
| Often | 35 (23.2) | 66 (24.5) | |
| Always | 53 (35.1) | 53 (19.7) | |
| Excessively worried, cannot think about anything else, n (%) 2 | |||
| Never | 16 (10.6) | 53 (19.8) | < 0.01 |
| Rarely | 39 (25.8) | 77 (28.7) | |
| Sometimes | 31 (20.5) | 74 (27.6) | |
| Often | 36 (23.8) | 40 (14.9) | |
| Always | 29 (19.2) | 24 (9.0) | |
| Depressed or helpless, n (%) 2 | |||
| Never | 28 (18.5) | 79 (29.5) | < 0.01 |
| Rarely | 44 (29.1) | 77 (28.7) | |
| Sometimes | 39 (25.8) | 81 (30.2) | |
| Often | 24 (15.9) | 17 (6.3) | |
| Always | 16 (10.6) | 14 (5.2) | |
| Overwhelmed, n (%) 3 | |||
| Never | 15 (10.0) | 53 (20.0) | 0.01 |
| Rarely | 27 (18.0) | 41 (15.5) | |
| Sometimes | 31 (20.7) | 74 (27.9) | |
| Often | 45 (30.0) | 56 (21.1) | |
| Always | 32 (21.3) | 41 (15.5) | |
| My concern about emotional distress prevents me from getting regular cancer screenings. (e.g. mammograms, pap smears, colonoscopies, etc...), n (%) 4 | |||
| Strongly agree | 38 (26.6) | 48 (18.1) | 0.05 |
| Agree | 44 (30.8) | 72 (27.2) | |
| Neutral | 22 (15.4) | 38 (14.3) | |
| Disagree | 28 (19.6) | 65 (24.5) | |
| Strongly disagree | 11 (7.7) | 42 (15.9) | |
| I am concerned about medical insurance not paying for my screening services due to misgendering, n (%) 5 | |||
| Strongly agree | 32 (26.2) | 34 (16.4) | 0.12 |
| Agree | 32 (26.2) | 45 (21.6) | |
| Neutral | 14 (11.5) | 29 (13.9) | |
| Disagree | 20 (16.4) | 45 (21.6) | |
| Strongly disagree | 24 (19.7) | 55 (26.4) | |
| Scheduling appointments online would be an effective method of avoiding confusion to figure out the screening appropriate for me, n (%) 6 | |||
| Strongly agree | 37 (25.3) | 63 (24.3) | 0.96 |
| Agree | 67 (45.9) | 119 (46.0) | |
| Neutral | 27 (18.5) | 53 (20.5) | |
| Disagree | 10 (6.9) | 18 (7.0) | |
| Strongly disagree | 5 (3.4) | 6 (2.3) | |
| If staff did not use personal pronouns (Mr. / Mrs. / Miss. / Ms.) and instead called patients by their last name only, it would lessen misgendering and discomfort, n (%) 7 | |||
| Strongly agree | 55 (38.5) | 88 (35.2) | 0.43 |
| Agree | 52 (36.4) | 80 (32.0) | |
| Neutral | 19 (13.3) | 43 (17.2) | |
| Disagree | 8 (5.6) | 25 (10.0) | |
| Strongly disagree | 9 (6.3) | 14 (5.6) | |
| I think it is important for __________ to have formal training to prevent misgendering / confusion when I present for my cancer screening (Checked), n (%) | |||
| Physicians | 135 (88.8) | 250 (92.6) | 0.19 |
| Nurses | 133 (87.5) | 249 (92.2) | 0.11 |
| Clerical staff | 122 (80.3) | 229 (84.8) | 0.23 |
| Technicians | 116 (76.3) | 227 (84.1) | 0.05 |
| Others | 38 (25.0) | 70 (25.9) | 0.83 |
There were 2 missing data for this question (1 in Non-Degree and 1 in Degree).
There were 3 missing data for this question (1 in Non-Degree and 2 in Degree).
There were 7 missing data for this question (2 in Non-Degree and 5 in Degree).
There were 14 missing data for this question (9 in Non-Degree and 5 in Degree).
There were 92 missing data for this question (30 in Non-Degree and 62 in Degree).
There were 17 missing data for this question (6 in Non-Degree and 11 in Degree).
There were 29 missing data for this question (9 in Non-Degree and 20 in Degree).
Subgroup analysis was done to determine if those with a degree (64% with a Bachelor’s or Associate’s degree, some graduate training, graduate or professional training) were more comfortable with cancer screening. All 422 respondents were included and those with a degree had a significantly increased proportion of respondents understanding what screening to (p=0.04) with a trend towards improved awareness of the HPV association with various cancers, especially head and neck cancer (p=0.03). Respondents without a degree were significantly more likely to have any distress such as nervousness/anxiety (p=0.01), excessively worried (p<0.01), depressed/helpless (p<0.01) and were less likely to be overwhelmed (p=0.01) when thinking about cancer screening.
Discussion
The results of this survey include the baseline knowledge of cancer screening in the LGBTQ+ patient population and reveals barriers and unmet needs in the health care system as identified by this diverse group of individuals. Overall, the LGBTQ+ community we surveyed were unsure of the appropriately indicated cancer screening and, when coupled with emotional and financial concerns, negatively impacted the desire for members of the SGM community to adhere to cancer screening. The survey input from the community provides ideas for interventions that may decrease emotional distress when visiting a health care professional including an option for online scheduling, not using personal pronouns, providing gender neutral gowns and office décor, and providing all staff with basic education about the LGBTQ+ community.
To decrease health disparities in cancer outcomes for the LGBTQ+ population, it is essential that community members understand the cancer screening that should be undertaken but it was found that approximately two-thirds of those surveyed were not certain what cancer screenings should be done for themselves and almost three-quarters were unsure what age screening should begin. Cancer screening is especially important since it has been established that the LGBTQ+ population have increased risk factors for cancer including increased rates of tobacco and alcohol consumption [14–16].
Most individuals surveyed agreed each LGBTQ+ sub-population has different health concerns, however the respondents had no consensus about which specific screenings are recommended, especially in transgender patients. For example, community members were unified in their perspective on screening recommendations for the lesbian population but not the transgender population. This is congruent with studies showing transgender women were less likely to have screening mammograms [17]. Based on the present survey, 93% of respondents agreed that transgender women taking hormones are at increased risk for breast cancer. It is known that 71% of MTF take exogenous hormones which allows breast tissue to transition to Tanner stage IV and create biological changes, but the malignant potential is unknown and warrants further investigation to create definitive recommendations [18]. Population based studies from the Dutch (2,307 patients) and the U.S. Veterans Administration Healthcare System (3,566 patients) demonstrate a reduced risk of breast cancer for transgender compared to cis-gender women [19–20]. Although the incidence may be slightly lower in transgender women, the Dutch found that 60% of MTF have dense or extremely dense breasts indicating possible false negative mammogram results with recommendations for a second method of breast screening [13,21]. In addition, depending on the type of mastectomy performed, patients may still need screening depending on how much breast tissue was removed [22]. UCSF has developed screening recommendations suggesting mammogram every two years starting at age 50 or 10 years after starting hormone therapy which may be controversial since some patients will begin exogenous hormones as young as 10–12 years old [23]. Community members with advanced degrees had a more accurate assessment of cancer screening needed. The confusion surrounding cancer screening is multifactorial, stemming in part from the lack of trust in the health care community, lack of physician education, and lack of consensus guidelines. Standardized and national guidelines need to be established by governing bodies such as NCCN and ASCO that consider the type of gender reassigning surgeries a patient may have had and the duration of exogenous hormone therapy.
Overall the risks associated with HPV infection were not well understood, with the least awareness from the transgender population. Most understood infection was related to sexual activity and cervical cancer, however only half of those surveyed knew that HPV is a risk for anal cancer and less than a third knew it was a risk for head and neck cancer. Since the LGBTQ+ population has increased risk for HPV infection and lower rates of vaccination, this survey suggests additional education of the risks of HPV infection and benefits of vaccination is crucial and could have a significant impact on this population, especially now that the CDC has expanded the vaccine recommended ages up to age 45 [24–29].
Evaluating potential reasons community members may decline or avoid cancer screenings, it was found that emotional and financial concerns contribute to the cancer screening disparity in the LGBTQ+ population. Seeking healthcare can be an emotional burden, but the LGBTQ+ population may be more vulnerable [30–31]. This study found that 83.6% of community members were nervous or anxious at least some of the time, 41.9% often/always overwhelmed and 17% felt depressed/helpless. This notion is supported since anxiety and depression are more prevalent in SGM youth [32–33]. Half of our respondents stated emotional distress prevented them from getting cancer screening which is a public health concern. In particular, the transgender population is most prone to anxiety, worry and depression making this population vulnerable. Respondents with advanced education or older age had less overall emotional distress suggesting improved education on cancer screening may improve concerns. Lastly, 43% of all respondents and 66% of transgender respondents were concerned that insurance would not cover cancer screening due to misgendering. This is complex because patients in same-sex relationships are less likely to have health insurance coverage [35].
Implementing change in cancer screening perspectives will require a multidisciplinary approach and the survey results demonstrate that online scheduling of appointments, education and training for healthcare professionals to include sensitivity and creation of comfortable space in waiting and changing rooms with neutral décor may improve screening rates. Survey respondents believed changes to the process of making appointments and comfort with the actual visit could make a difference in their perceptions of cancer screening. For instance, 48% wanted the ability to schedule appointments online to avoid using pronouns (70%) and confusion regarding which screening should be done, 70% wanted gender neutral décor including garments and 50–65% wanted alternate waiting and changing rooms. Prior studies suggest that equality signs and gender-neutral language were perceived as safer [36]. Over 90% responded it is important for health care providers to have formal training to prevent misgendering and confusion during cancer screening appointments which has been shown in other studies [37]. The SGM population is known to use word of mouth and social media to find providers who are LGBTQ+ “friendly” [38]. The Association of Professors of Gynecology is designing curricula for medical students but education about unique medical concerns of the LGBTQ+ population for all health care providers is needed to establish increased comfort of our patients and increased rates of cancer screening [39].
These findings suggest that gaps in cancer screening knowledge and emotional and financial distress for the LGBTQ+ population may be at the root of the disparity that exists in lower cancer screening rates. The medical community must establish cancer screening guidelines nuanced on specific health care issues related to SGM patients that must be coupled with education for the LGBTQ+ population about what cancer screening should be done when. In addition, while some may be reticent to undergo cancer screening, many SGM patients may reconsider if they believed healthcare professionals had more education on the topic and the environment was more sensitive to specific needs. This study has shown that the transgender population is most at risk due to gaps in knowledge of appropriate cancer screening and excess emotional distress. Appreciating the cancer screening concerns of the LGBTQ+ population and nuances of each subpopulation can help shape future clinical and institutional approaches to improve healthcare delivery. There should be continued research on sexual and gender minority cancer screening disparities so that plans for implementing optimal health care delivery can ensue.
Supplementary Material
Funding
This work was supported by the NCI Cancer Center Grant P30CA056036 for supporting the Biostatistics Core.
Footnotes
Conflict of interest
The authors declare no conflict of interest.
Declarations
Ethics Approval
IRB: The Institutional Review Board approved this study prior to data collection.
Consent to participate
Informed consent was obtained from all individual participants included in the study
Consent for publication
Informed consent was obtained from all individual participants included in the study
Code Availability
Not applicable
Availability of data and material
All data generated or analysed during this study are included in this published article and its supplementary information files
References
- 1.History of Cancer Screening and Early Detection. American Cancer Society. https://www.cancer.org/cancer/cancer-basics/history-of-cancer/cancer-causes-theories-throughout-history11.html. Accessed December 9, 2019.
- 2.Cancer Screening Overview (PDQ®)–Patient Version. National Cancer Institute. https://www.cancer.gov/about-cancer/screening/patient-screening-overview-pdq. Accessed December 9, 2019.
- 3.LGBT Proportion of Population: United States. The Williams Institute. https://williamsinstitute.law.ucla.edu/visualization/lgbt-stats/?topic=LGBT. Accessed December 9, 2019.
- 4.The Health of Lesbian, Gay, Bisexual, and Transgender People. Institute of Medicine. 2011. doi: 10.17226/13128. [DOI] [Google Scholar]
- 5.HHS Office, Assistant Secretary for Health. Advancing LGBT Health and Well-being: 2016 Report. HHS.gov. https://www.hhs.gov/programs/topic-sites/lgbt/reports/health-objectives-2016.html. Published December 6, 2016. Accessed December 9, 2019.
- 6.Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, Populations, Board on the Health of Select, Medicine Iof. Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington: National Academies Press; 2014. [PubMed] [Google Scholar]
- 7.Healthcare Equality Index 2013 - Human Rights Campaign. https://www.hrc.org/files/assets/resources/HEI_2013_final.pdf. Accessed December 9, 2019.
- 8.Griffin JA, Casanova TN, Eldridge-Smith ED, Stepleman LM. Gender Minority Stress and Health Perceptions Among Transgender Individuals in a Small Metropolitan Southeastern Region of the United States. Transgender Health. 2019;4(1):247–253. doi: 10.1089/trgh.2019.0028. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.THE REPORT OF THE - National Center for Transgender Equality. https://www.transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf. Accessed December 9, 2019.
- 10.Ceres M, Quinn GP, Loscalzo M, Rice D. Cancer Screening Considerations and Cancer Screening Uptake for Lesbian, Gay, Bisexual, and Transgender Persons. Seminars in Oncology Nursing. 2018;34(1):37–51. doi: 10.1016/j.soncn.2017.12.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Buchmueller T, Carpenter CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000–2007. Am J Public Health. 2010. Mar;100(3):489–495 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Quinn GP, Sanchez JA, Sutton SK, et al. : Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. CA Cancer J Clin 65:384–400, 2015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Weyers S, Villeirs G, Vanherreweghe E, Verstraelen H, Monstrey S, Van den Broecke R, et al. Mammography and breast sonography in transsexual women. Eur J Radiol 2010;74(3):508–513. doi: 10.1016/j.ejrad.2009.03.018. [DOI] [PubMed] [Google Scholar]
- 14.Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults- United States, 2005–2015. Morbidity and Mortalilty Weekly Report. 2016;65(44):1205–1211 [DOI] [PubMed] [Google Scholar]
- 15.Buchting FO, Emory KT, Scout, et al. Transgender Use of Cigarettes, Cigars, and E-Cigarettes in a National Study. Am J Prev Med 2017;53(1):e1–e7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Project SCUM. Industry Documents Library. https://www.industrydocuments.ucsf.edu/tobacco/docs/#id=sfck0098. Accessed January 2, 2020.
- 17.Bazzi AR, Whorms DS, King DS, Potter J. Adherence to Mammography Screening Guidelines Among Transgender Persons and Sexual Minority Women. American Journal of Public Health. 2015;105(11):2356–2358. doi: 10.2105/ajph.2015.302851. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Grant JM, Mottet LA, Tanis J, Herman JL, Harrison J, Keisling M. National transgender discrimination survey report on health and health care. National LGBTQ Task Force; 2010.https://cancernetwork.org/wpcontent/uploads/2017/02/National_Transgender_Discrimination_Survey_Report_on_health_and_health_care.pdf. Accessed January 2, 2020. [Google Scholar]
- 19.Asscheman H, Giltay EJ, Megens JAJ, de Ronde W, van Trotsenburg MAA, Gooren LJG. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2011. Jan 25;164(4):635–42 [DOI] [PubMed] [Google Scholar]
- 20.Brown GR, Jones KT. Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Res Treat. 2015. Jan;149(1):191–8 [DOI] [PubMed] [Google Scholar]
- 21.Screening for breast cancer in transgender women. Screening for breast cancer in transgender women | Transgender Care. https://transcare.ucsf.edu/guidelines/breast-cancer-women. Published June 17, 2016. Accessed December 12, 2019.
- 22.Sonnenblick EB, Shah AD, Goldstein Z, Reisman T. Breast Imaging of Transgender Individuals: A Review. Current Radiology Reports. 2018;6(1). doi: 10.1007/s40134-018-0260-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Gooren LJ. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med. 2013. [DOI] [PubMed] [Google Scholar]
- 24.Glick SN, Feng Q, Popov V, et al. : High rates of incident and prevalent anal human papillomavirus infection among young men who have sex with men. J Infect Dis 2014;209:369–376 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Kasymova S, Harrison SE, Pascal C. Knowledge and Awareness of Human Papillomavirus Among College Students in South Carolina. Infect Dis (Auckl). 2019;12:1178633718825077. Published 2019 Jan 28. doi: 10.1177/1178633718825077 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Singh V, Gratzer B, Gorbach PM, et al. Transgender Women Have Higher Human Papillomavirus Prevalence Than Men Who Have Sex With Men—Two U.S. Cities, 2012–2014. Sexually Transmitted Diseases. 2019;46(10):657–662. doi: 10.1097/olq.0000000000001051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Cancer Screening Overview (PDQ®)–Patient Version. National Cancer Institute. https://www.cancer.gov/about-cancer/screening/patient-screening-overview-pdq. [PubMed]
- 28.Mcree A-L, Gower AL, Reiter PL. Preventive healthcare services use among transgender young adults. International Journal of Transgenderism. 2018;19(4):417–423. doi: 10.1080/15532739.2018.1470593. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory Committee on Immunization Practices. Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/68/wr/mm6832a3.htm. Published August 15, 2019. Accessed January 19, 2020.
- 30.Gordon JR, Baik SH, Schwartz KT, Wells KJ. Comparing the Mental Health of Sexual Minority and Heterosexual Cancer Survivors: A Systematic Review. LGBT Health. 2019;6(6):271–288. doi: 10.1089/lgbt.2018.0204. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Valentine SE, Shipherd JC. A systematic review of social stress and mental health among transgender and gender non-conforming people in the United States. Clinical Psychology Review. 2018;66:24–38. doi: 10.1016/j.cpr.2018.03.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Marshal MP, Dietz LJ, Friedman MS, et al. Suicidality and Depression Disparities Between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review. Journal of Adolescent Health. 2011;49(2):115–123. doi: 10.1016/j.jadohealth.2011.02.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Becerra-Culqui TA, Liu Y, Nash R, et al. Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers. American Academy of Pediatrics. https://pediatrics.aappublications.org/content/141/5/e20173845. Published May 1, 2018. Accessed January 5, 2020. [DOI] [PMC free article] [PubMed]
- 34.Carter SP, Cowan T, Snow A, Cerel J, Tucker R. Health Insurance and Mental Health Care Utilization Among Adults Who Identify as Transgender and Gender Diverse. Psychiatric Services. 2019. doi: 10.1176/appi.ps.201900289. [DOI] [PubMed] [Google Scholar]
- 35.Buchmueller T, Carpenter CS. Disparities in Health Insurance Coverage, Access, and Outcomes for Individuals in Same-Sex Versus Different-Sex Relationships, 2000–2007. American Journal of Public Health. 2010;100(3):489–495. doi: 10.2105/ajph.2009.160804. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Quinn GP, Sutton SK, Winfield B, et al. Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ) Perceptions and Health Care Experiences. Journal of Gay & Lesbian Social Services. 2015;27(2):246–261. doi: 10.1080/10538720.2015.1022273. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Hunt R, Bates C, Walker S, Grierson J, Redsell S, Meads C. A Systematic Review of UK Educational and Training Materials Aimed at Health and Social Care Staff about Providing Appropriate Services for LGBT People. International Journal of Environmental Research and Public Health. 2019;16(24):4976. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Find a Provider. GLMA. http://www.glma.org/index.cfm?fuseaction=Page.ViewPage&PageID=939. Accessed December 12, 2019.
- 39.Women’s Health Care Physicians. ACOG. https://www.acog.org/About-ACOG/ACOG-Departments/CREOG/CREOG-Search/Transgender-Healthcare-Curriculum. Accessed December 12, 2019.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data generated or analysed during this study are included in this published article and its supplementary information files