Microaggressions in LGBTQ+ Cancer Care

Battling cancer is already a mentally taxing time, but it is worse for those in the LGBTQ+ community, who will likely experience microaggressions while receiving cancer care and treatment.

There are thousands of ways an LGBTQ+ person may feel unwelcome, says Darryl Mitteldorf, LCSW, founder of the National LGBT Cancer Project. For example, a transgender woman may be addressed as a man by a healthcare provider, says Mitteldorf. Or a doctor may ask a couple with two men, "Are you brothers?" Or there may be a presumption that LGBTQ+ couples don't want children. And typically, the reading material and pictures in facility lobbies and office waiting rooms are heterosexual in orientation.

“Opportunities to connect in a genuine, heartfelt way are screwed up innocently by physicians, nurses, and other healthcare providers because they just haven't taken the time to get clued in on what LGBTQ+ life is,” Mitteldorf says. But this can have grave effects on LGBTQ+ individuals who seek treatment for cancer.

“LGBTQ+ people report higher rates of cancer and higher rates of distress, partially explained by minority stress, the chronic and cumulative stress on those with stigmatized sexual and gender identities,” Ussher says. “This includes stigma, social exclusion, and discrimination commonly associated with LGBTQ+ identities. The internalization of anti-LGBTQ+ sentiments contributes to negative self-views, identity concealment, and expectations of rejection, hostility, and potential future victimization.”

LGBTQ+ people report lower satisfaction with cancer care and greater unmet care needs in comparison with the general population of people with cancer, Ussher says. She adds that LGBTQ+ people may lack adequate information and support, and may be reluctant to come out in healthcare settings because they’re afraid of discrimination.

Ignoring LGBTQ+ Status

Another issue is that some providers don't realize that a patient’s LGBTQ+ status is relevant to their care, says Kelly Haviland, the advanced practice provider manager of professional development at Memorial Sloan Kettering Cancer Center in New York City and cochair of the LGBTQ Clinical Advisory Council.

By not seeing how a patient’s LGBTQ+ identity is relevant to care, healthcare practitioners are forming gaps in care throughout a patient's trajectory, Haviland says. This starts from the moment they try to register for an appointment at a clinic, institution, or hospital all the way through to death.

Lack of acknowledgement can also impact an LGBTQ+ individual’s comfort during treatment. Everything from the photographs on the wall to the magazines in the waiting room could make patients feel less welcomed and less likely to come back, Haviland says.

Microaggressions in Treatment Options

Discussions with healthcare providers about treatments can also be fraught. For some individuals, offering androgen deprivation therapy might be seen as a microaggression, Mitteldorf says. Androgen deprivation therapy may include surgical removal of the testicles or medical castration through drugs to help limit the levels of male hormones in the body, or androgens. Limiting androgens can help stop prostate cancer cell growth.

Many cancer treatments and therapies impact sexual abilities and can involve hormone manipulation, Mitteldorf says. “So being misidentified as a heterosexual and presumed to engage in heterosexual sexual activities means having to come out to the doctor to be able to have a conversation about how those treatments might affect them,” he says.

Heteronormative assumptions can create a divide in the relationship between patient and clinician, Haviland says. “This makes it less likely for patients to come for follow-up visits, to trust their provider to give them care, and to feel safe.”

For LGBTQ+ individuals seeking cancer treatment, it can be helpful to look for inclusive healthcare providers, ask many questions, and speak up about any perceived microaggressions.

Find an Inclusive Healthcare Provider

One thing that patients can do is research. The National LGBT Cancer Network lists many LGBTQ+ affirming providers, plus GLMA: Health Professionals Advancing LGBTQ+ Equality has a provider directory with vetted LGBTQ+ affirming providers. OutCare Health offers provider and patient resources along with a provider database of its own.

There are also resources available at the National LGBT Cancer Project and American Cancer Society.

Talk About Microaggressions Openly

If you do feel misunderstood, you should share your discomfort, anger, and fear — all of the feelings that you experienced, Mitteldorf says.

“Empathize that the provider may not have been aware of how provocative or triggering their treatment suggestions were,” says Mitteldorf, “but be firm in saying that they were indeed triggering. Offer an alternative by saying, ‘I would have felt better and safer had you said this, instead of that.’”

And never hesitate to request a different healthcare provider, whether you need a doctor, nurse, or technician, Mitteldorf says. Though if you live in an isolated or remote area, you may need to stay with the healthcare provider who can treat you first, so you can survive and follow up later, he says.

“Treatment includes feeling safe about the care the provider offers,” Mitteldorf says. “If you don't feel safe, it will be hard to be treated appropriately.”

Report Microaggressions

If you experience a microaggression, Haviland says to report what happened. “It's important to report to our healthcare agencies, whether it be a clinic or an institution. Utilize the patient incident reporting system,” she says.

Ussher says that patients should also take an advocate to clinical meetings, know their legal rights of care, and if needed, ask for a referral to another clinician.

Still, there may be instances in which a provider or institution needs to be held accountable. “Raise the alarm. If a hospital is institutionally promoting and supporting homophobic behavior, then absolutely call your local journalist and your local American Civil Liberties Union, attorneys, and make a stink about it,” Mitteldorf says.

But in times of medical emergency, you have to focus on immediate needs, he says.

“Get the treatment you need right away while making a mental note about the microaggressions you experienced,” Mitteldorf says. “After your medical emergency has stabilized, ask to speak to someone in charge. Sending follow-up emails and letters is critical, as a written record is often the spark that initiates action and change.”

• Microaggressions in LGBTQ+ cancer care are real and can feel isolating and distressing for those seeking treatment.
• If facing a serious health issue, prioritize your immediate medical needs first and follow up later to address any experienced biases with the hospital administration.
• You should document and report microaggressions to healthcare facilities to encourage systemic change. Communicating your experiences will help make treatment environments better and safer for the LGBTQ+ community.
• Databases like those operated by the GLMA: Health Professionals Advancing LGBTQ+ Equality and National LGBT Cancer Network make it easier to find LGBTQ+ affirming cancer care from vetted providers.