Cisheteronormativity and its influence on the psychosocial experience of LGBTQ+ people with cancer: A qualitative systematic review

Cancer survivors' health outcomes over the life course: differences by sexual orientation and gender identity

PURPOSE

This study seeks to examine sexual and gender minority (SGM) cancer survivors' quality of life (QoL) by age at diagnosis and time since diagnosis.

METHODS

This secondary data analysis utilized 2014-2023 Behavior Risk Factor Surveillance Survey data. The survey respondents consisted of 1708 SGM cancer survivors and 56,184 heterosexual cisgender cancer survivors. Logistic regression models compared individual SGM cancer survivor groups to heterosexual cisgender survivors' QoL while stratifying by age at diagnosis and time since cancer diagnosis. We adjusted models for sociodemographic characteristics, access to care, and survey year.

RESULTS

Lesbian women's and gay men's QoL was similar to heterosexual men's and women's overall and when stratifying by time since diagnosis. However, after stratifying by age at diagnosis, both lesbian women and gay men had significantly greater odds of difficulty concentrating compared to their peers, when diagnosed at younger ages. Bisexual women and men as well as transgender survivors' QoL, differed from heterosexual cisgender survivors' overall and by both time since diagnosis and age at diagnosis.

CONCLUSIONS

Sexual and gender minority survivors' QoL varied by age at diagnosis and time since diagnosis, indicating a dynamic vulnerability among SGM cancer survivors. Therefore, this study elucidates critical periods for targeted interventions that address the unique needs of SGM cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

We found that sexual and gender minority survivors' QoL differs based on stages of life and time since diagnosis. These findings highlight the need for targeted support for sexual and gender minority survivors at times of their greatest vulnerability.

Prevalence, correlates and solutions to people with HIV in China being refused treatment for diseases not related to HIV: a mixed-methods study

INTRODUCTION

Existing studies on treatment refusal towards people with HIV (PWH) lack focus on the Chinese context and key factors. We aimed to elucidate the prevalence, correlates and solutions to PWH being refused treatment for diseases not related to HIV (DNRH) in China.

METHODS

We conducted a mixed-methods study of PWH and healthcare providers (HCPs) between April 2021 and June 2022. An online survey of PWH assessed the prevalence and correlates of treatment refusal for DNRH during their most recent outpatient or inpatient visit. Semi-structured telephone interviews were conducted with PWH and HCPs to understand their experiences of treatment refusal and to generate potential solutions.

RESULTS

We included 35 PWH and 30 HCPs in the interviews, and 902 PWH in the survey. In the survey, 42.2% and 63.0% of PWH reported treatment refusal for DNHR during their most recent outpatient and inpatient visit, respectively. Among outpatients, PWH who were <30 years old (AOR: 0.43, 95% CI: 0.25-0.73), acquired HIV through male-male sex (0.56, 0.35-0.90) and did not disclose their HIV status to HCPs (0.64, 0.42-0.96) were less likely to report treatment refusal. PWH who were not adherent to antiretroviral therapy (10.66, 1.16-98.20), had their outpatient visit before the COVID-19 pandemic (1.74, 1.00-3.00) and received care at a surgical department (2.10, 1.23-3.60) were more likely to report treatment refusal. Among inpatients, PWH who received care from a male HCP (2.31, 1.27-4.22) and were hospitalized in central provinces of China (2.60, 1.07-6.31) had higher odds of treatment refusal. In semi-structured interviews, we found HCP refusal to treat PWH for DNRH could be influenced by stigma against HIV, concerns about HIV acquisition, limited knowledge of HIV post-exposure prophylaxis and insufficient protection from health authorities against discrimination by HIV status. Participants identified several solutions that may help mitigate treatment refusal, including supporting PWH to achieve virologic suppression, HIV education for HCPs, employment protections and compensation for HCPs who acquire HIV in the workplace, and the establishment of dedicated government offices and laws to address treatment refusal.

CONCLUSIONS

Treatment refusal for DNRH was common among PWH in China. Factors contributing to treatment refusal involve PWH, HCPs and health authorities. Systematic interventions involving all stakeholders, particularly legal protections against discrimination by HIV status, should be implemented to reduce treatment refusal.

Minority Stress Clusters and Health and Cancer Care Outcomes of Sexual and Gender Minority Cancer Survivors

Purpose: Structural factors affect the health of sexual and gender minority (SGM) cancer survivors, yet how people experience minority stress within their social and health care systems remains unclear. We explored experiences of minority stress across health care and sociocultural contexts and their impact on health and cancer outcomes. Methods: We conducted a K-medoid cluster analysis (grouping technique) using data from 2519 participants (training subset = 2015, testing subset = 504) from OUT: The National Cancer Survey (2020-2021). Cluster differences in the testing subset were assessed using chi-square, analysis of variance, and nonparametric tests. Regression models examined associations between cluster membership and health (mentally unhealthy days) and cancer outcomes (perceived welcomeness after identity disclosure and treatment satisfaction), adjusting for demographic and clinical factors. Results: Five clusters emerged, differing in demographics, mental and social health outcomes, SGM identity disclosure, and perceived welcomeness after disclosure (0.017 < p < 0.001). Cluster one experienced poorer mental health than cluster five (odds ratio [OR] = 1.182, 95% confidence interval [CI] = 1.003-1.392), lower cancer care satisfaction than all other clusters (1.177 < OR <1.265; 1.091 < 95% CI <1.389), and perceived less welcoming or unchanged environments after SGM identity disclosure than all other clusters (1.278 < OR <1.314; 1.161 < 95% CI <1.431). Conclusion: The study highlights the impact of minority stress across different contexts. The findings emphasize the need for targeted interventions to address the unique vulnerabilities of SGM individuals, particularly in health care contexts, to improve their overall health and cancer care experiences.

An Exploratory Analysis of Contributors to Cognitive Functioning Among Sexual and Gender Minority Individuals Who Had COVID-19

Sexual and gender minority (SGM) individuals face mental health disparities. However, research analyzing SGM people's mental health after a COVID-19 diagnosis is scarce. In this secondary analysis of a remote study, we 1) examined associations between cognitive and psychosocial health and 2) explored differences between these health outcomes among SGM (n = 14) and heterosexual cisgender (n = 64) U.S. adults who had COVID-19. We used the Patient Reported Outcome Measures Information System (PROMIS) v2.0 to assess subjective cognition and the BrainCheck cognitive test to analyze objective cognition. We administered the Perceived Stress Scale and PROMIS 57 Profile V.2.0 to measure psychosocial health. SGM COVID-19 survivors had worse scores in depression, anxiety, sleep disturbance, pain, stress, and objective cognition than heterosexual cisgender participants (p-values < .05). Objective cognition was associated with age, SGM classification, racial or ethnic minority classification, income, comorbidities, COVID-19 severity, number of symptoms, and pain (|0.137| < r < |0.373|, p-values < .05). Subjective cognition was associated with comorbidities, number of symptoms, depression, anxiety, sleep disturbance, pain, and stress (|0.158| < r < |0.537|, p-values < .05). Additional studies are needed to expand what is known about post-COVID-19 health disparities and to guide policies and interventions that promote cognitive functioning.

Disparities in fertility preservation discussions among sexual and gender minority cancer patients and their cancer care providers

BACKGROUND

Cancer providers are advised to inform their reproductive aged patients about fertility preservation given the potential for treatment-related infertility. How consistently fertility preservation discussions (FPDs) occur is understudied in sexual and gender minority (SGM) cancer patients. The effects of bias and heteronormativity may reduce the rate of FPDs. We identified the frequency and correlates of FPD in a sample of SGM cancer patients.

METHODS

Data were from the cross-sectional 2020 OUT National Cancer Survey. The sample was restricted to those diagnosed with cancer between the ages of fifteen and forty-five. FPD was measured with a single item. Multivariable logistic regression was conducted to determine factors significantly associated with FPDs.

RESULTS

Average age at cancer diagnosis was 34.97 (SD = 8.34). Respondents were mostly non-Hispanic white (77.6%) and college-educated (63.4%), and 32.6% reported FPDs. In the multivariable model, identifying as lesbian (Adjusted odds ratio [aOR] = 0.49; 95% CI: 0.24-0.99), pansexual (aOR = 0.34; 95% CI:0.12-0.94), or queer (aOR = 0.24; 95% CI: 0.08-0.70) was negatively associated with FPDs compared to bisexuals. Being treated more than ten years ago (aOR = 0.47; 95% CI:0.26-0.85) was also negatively associated with FPDs.

CONCLUSION

Findings suggest potential bias against some SGM patients based on sexual orientation identity in FPDs, though changes over the past decade may have increased the frequency of FPD with patients more broadly. More research is needed to investigate why some SGM patients of reproductive age are not being counseled about fertility preservation.

Theory of health promotion for sexual and gender minority populations with cancer

BACKGROUND

Structural factors (e.g., cisheteronormativity) promote minority stressors, which generate healthcare disparities among sexual and gender minority (SGM) populations (also known as lesbian, gay, bisexual, transgender, queer, intersexual, asexual, and other sexual and gender-expansive persons--LGBTQIA+) with cancer. The individual's biological, behavioral, social, and psychological response to minority stressors will vary throughout their life course. However, there is a lack of empirical and theoretical guidance for conceptualizing health outcomes among SGM subgroups.

PURPOSE

To propose a nursing theory for the health promotion of SGM populations with cancer.

METHODS

Walker and Avant's strategies for theoretical derivation were followed.

RESULTS

I present the definition, theoretical assumptions, concepts, propositions, and implications for practice, education, research, and policy of the derived theory.

DISCUSSION AND CONCLUSION

The theory provides a nursing framework to understand and address the multilevel impact of minority stress on the health of SGM individuals throughout their cancer care continuum.

Advancing Equity in Cancer Care: The Critical Role of Sexual Orientation and Gender Identity Data Collection

New study highlights critical gaps and opportunities to enhance equitable cancer care for sexual and gender minority patients.

Care Needs, Challenges, and Experiences of Sexual and Gender Minority Cancer Survivors in Taiwan: Findings from a Qualitative Study

OBJECTIVES

This study aimed to explore the care needs, challenges, and experiences of cancer care among sexual and gender minority (SGM) cancer survivors in Taiwan.

METHODS

Semi-structured interviews were conducted face-to-face or telephonically with 30 SGM cancer survivors in Taiwan. Data were analyzed using the socio-ecological model and the constant comparative technique. The study used the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

RESULTS

The needs, challenges, and experiences of cancer care among SGM cancer survivors were categorized and presented according to the level of the social-ecological model: (1) intrapersonal level: physical and psychological impacts and changes in outlook on life after cancer diagnosis and treatment; (2) interpersonal level: informal social support resources and challenges for developing intimate relationships; (3) community level: formal social support resources and lack of SGM support groups; and (4) societal and policy level: positive and negative experiences with oncology healthcare providers (HCPs), sexual orientation disclosure, and lack of an SGM-friendly environment.

CONCLUSIONS

Multilevel care needs and challenges in cancer care among SGM cancer survivors were identified. Oncology HCPs should be aware of and assess SGM cancer survivors' psychosexual issues and psychological status and provide suitable care resources to individuals. Moreover, training courses on culturally competent cancer care and information on SGM-related health policies (including same-sex marriage) should be provided to oncology HCPs to improve their sensitivity, knowledge, and skills to provide suitable care for SGM cancer survivors.

IMPLICATIONS FOR NURSING PRACTICE

The study findings can be used to design and develop training courses for culturally competent cancer care for oncology HCPs to improve the quality of care and reduce cancer care disparities among SGM cancer patients.

Toward diverse SOGIESC-transformative theorizing in nursing: A revisitation and expansion of Im and Meleis' guidelines for gender-sensitive theorizing

Over two decades have passed since Im and Meleis proposed "gender-sensitive theories" as a category of nursing theories in 2001. Since then, the global conditions of women and minoritized identities across the various spectra of sexual orientation, gender identity and expression, and sexual characteristics (SOGIESC) have changed. Moreover, feminist theorizing has evolved, prompting the need to update how nurses theorize and research the interactions of gender and health in their practice. This discursive essay aims to (1) provide a summary of Im and Meleis' characterization and guidelines in the development of gender-sensitive theories in nursing and present exemplars that use these guidelines; (2) assess the gender-sensitive nursing theory guidelines in terms of gender-responsiveness; and (3) expand the transformative potential of gender-sensitive theorizing in nursing by proposing Diverse SOGIESC-Transformative Theories. Diverse SOGIESC-Transformative Theories include three additional aspects to enhance the transformative potential of gender-responsive theorizing in nursing: inclusion of diverse SOGIESC, elaboration of intersectionality, and consideration of men and masculinities.

It takes more than rainbows: Supporting sexual and gender minority patients with trauma-informed cancer care

BACKGROUND/PURPOSE

The American Society of Clinical Oncology has called for an increased priority to improve cancer care for sexual and gender minority (SGM) populations because of heightened risk of receiving disparate treatment and having suboptimal experiences, including perceived discrimination. We demonstrate how integrating trauma-informed care (TIC) principles across the cancer continuum is a key strategy to improving care delivery and outcomes among SGM populations.

METHOD

This empirically informed perspective expands on the concepts generated through the American Society of Clinical Oncology position statement and uses the Substance Abuse and Mental Health Services Association's "Four Rs" Toward Trauma Informed Care: Realize, Recognize, Response, and Resist Traumatization.

RESULTS

Recommendations for each component of TIC include: (1) Realize: Implement SGM cultural humility training, including modules on SGM-specific trauma, discrimination, harassment, and violence; (2) Recognize: Routinely screen for emotional distress using methods to ensure privacy, and/or normalize mental health screenings to cancer patients; (3) Respond: Create and widely disseminate policies and patients' rights that prohibit discrimination and ensure access to gender-neutral clinical environments; and (4) Resist Traumatization: Establish and respond to quality metrics (e.g., standardized patients, patient satisfaction surveys) that are informed by a community advisory board with the purpose of ensuring and maintaining quality care.

CONCLUSIONS AND IMPLICATIONS

Integrating TIC principles into cancer care for SGM populations is crucial to address disparities in treatment and clinical outcomes. Our recommendations offer practical approaches for oncology teams to implement TIC care and ensure equitable and inclusive cancer care for patients and their families.

Cancer-related cognitive impairment in racial and ethnic minority groups: a scoping review

PURPOSE

Disparities in cognitive function among racial and ethnic groups have been reported in non-cancer conditions, but cancer-related cognitive impairment (CRCI) in racial and ethnic minority groups is poorly understood. We aimed to synthesize and characterize the available literature about CRCI in racial and ethnic minority populations.

METHODS

We conducted a scoping review in the PubMed, PsycInfo, and Cumulative Index to Nursing and Allied Health Literature databases. Articles were included if they were published in English or Spanish, reported cognitive functioning in adults diagnosed with cancer, and characterized the race or ethnicity of the participants. Literature reviews, commentaries, letters to the editor, and gray literature were excluded.

RESULTS

Seventy-four articles met the inclusion criteria, but only 33.8% differentiated the CRCI findings by racial or ethnic subgroups. There were associations between cognitive outcomes and the participants' race or ethnicity. Additionally, some studies found that Black and non-white individuals with cancer were more likely to experience CRCI than their white counterparts. Biological, sociocultural, and instrumentation factors were associated with CRCI differences between racial and ethnic groups.

CONCLUSIONS

Our findings indicate that racial and ethnic minoritized individuals  may be disparately affected by CRCI. Future research should use standardized guidelines for measuring and reporting the self-identified racial and ethnic composition of the sample; differentiate CRCI findings by racial and ethnic subgroups; consider the influence of structural racism in health outcomes; and develop strategies to promote the participation of members of racial and ethnic minority groups.

"I don't just say, Hi! I'm gay": Sexual Orientation Disclosures in Oncology Clinic Settings Among Sexual Minority Women Treated for Breast Cancer in the U.S. South

OBJECTIVES

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

DATA SOURCES

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

CONCLUSION

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

IMPLICATIONS FOR NURSING PRACTICE

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