Ensuring nurses feel confident providing LGBT cancer care
Our series on how cancer affects different patient demographics focuses on lesbian, gay, bisexual and trans people
Disparities still remain for lesbian, gay, bisexual and trans (LGBT) people with cancer in terms of their access to assessment, diagnosis and treatment compared with heterosexual communities.
Furthermore, there is a lack of information about how many people with cancer in the UK are from the LGBT community.
The most recent data for this patient group, covering only England, aligns with NHS England's 2013 National Cancer Patient Experience Survey. Of 68,737 respondents 0.7% (425) identified as gay or lesbian, 0.2% (143) identified as bisexual and 0.5% (288) stated other, the report shows.
Common cancers among LGBT communities
Premenopausal lesbian and bisexual women have a higher risk of the following cancers compared with heterosexual women:
- Breast cancer
- Cervical cancer
- Ovarian cancer
- Lung cancer
Gay men are at an increased risk of anal cancer compared with heterosexual men. Overall, gay men are reported to be 1.9 times more likely to have cancer in their lifetime compared with heterosexual men. This increase is likely because of lifestyle and health behaviour factors, such as alcohol and smoking.
(Hulbert-Williams et al 2017)
A 2015 report by equality charity Stonewall on the treatment of LGBT people in health and social care revealed that 6% of nurses feel they ‘are not confident in their ability to understand and meet the specific needs of LGBT patients and service users’.
The report also found that 21% of nurses ‘are not confident in their ability to respond to the specific care needs of trans patients and service users’.
Reflecting on this current landscape, what can be done to give nurses working in cancer care greater confidence when caring for LGBT people and helping them to manage the challenges presented by the disease?
Address specific needs
Macmillan Cancer Support policy manager, health inequalities, Chris Thomas says that learning more about the LGBT community and basing ‘care on each person’s specific needs’ is one way to help nurses working with LGBT cancer patients.
He adds that keeping up to date on the latest guidelines advising cancer professionals on how to support the lesbian, gay, bisexual, trans, queer and others (LGBTQ+) community will help improve care.
The healthcare environment where patients are treated is another element that needs change. Mr Thomas says that ‘professionals should consider if members of the LGBTQ+ community would feel welcome in their trust or facility. For example, is there provision for same-sex couples? Research has shown that LGBTQ+ people often look for, and feel reassured by, commitments to equality in healthcare settings.’
The health challenges and outcomes that LGBTQ+ people face compared with heterosexual people can vary widely, however these different needs are not always taken into account by healthcare professionals, explains Mr Thomas.
He cites Macmillan’s 2014 report showing that an estimated 33% of gay men are smokers compared with 21% of heterosexual men, and 25% of lesbians are smokers compared with 15% of heterosexual women.
Misinformation is another aspect affecting the care LGBTQ+ people receive, and can cause delays in presentation to a healthcare professional. A 2012 survey by Macmillan showed that 41% of lesbian and bisexual women had been told by someone that they did not need a cervical cancer screening.
Cervical screenings – available to all?
Ben Heyworth, Macmillan survivorship network manager at The Christie NHS Foundation Trust, says many trans people are not invited for cervical cancer screenings, which can lead to avoidable delays in diagnosis.
He explains that an additional problem is that often people from the LGBT community have bad experiences with health services and therefore do not trust healthcare professionals.
of lesbian and bisexual women had been told they did not need cervical cancer screening
‘There is a general reluctance to engage with services in the LGBT community and that’s because of the potential perception of homophobia and transphobia,’ he says.
‘Not necessarily because they have encountered it. It’s because of the historical, cultural and social discrimination.’
For this trust to be regained, Mr Heyworth says it’s important to document an individual’s sexual identity or what gender pronoun they want to be referred to as, in a similar way to how ethnicity is recorded.
‘What you don’t want to do is forget and then ask again. People don’t want to be coming out every five minutes to a healthcare professional,’ he says.
Mr Heyworth also recommends changing the way nurses present themselves, such as wearing the rainbow flag badge, adding that these changes can be made by all staff, even those in care homes.
Tips on supporting LGBT people with cancer
- Ask a patient their sexual identity, and document this so other members of staff can access this information
- Ask what gender pronoun a patient would like to be referred to as, such as he, she, they or them
- Wear LGBT rainbow badges
- Put LGBT posters up to make the environment more LGBT friendly
of nurses are not confident in their ability to understand and meet the specific needs of LGBT patients
The 2015 Stonewall report revealed that 72% of patient-facing staff have not had training on the health needs of the lesbian, gay or bisexual (LGB) community, or on the use of language and practices that are inclusive of the LGB population. Patient-centred care must be applied to an LGBT patient in the same way as it would for a heterosexual patient.
Mr Heyworth notes how cancer clinics are often set up for a particular type of patient, adding: ‘A prostate cancer clinic is likely to have mainly male patients in the waiting room and this could be a daunting and off-putting experience for a trans woman.
‘Why not give the trans woman the first appointment of the day, so they don’t have to sit in a waiting room with the majority of men,’ he says.
The fact that a number of nurses reported a lack of training in supporting the LGBT community could also prevent sensitive topics from being discussed. Mr Heyworth says nurses could refer to Macmillan’s Recovery Package and use it as a tool to help them begin these difficult conversations.
‘For example, how long should a person abstain from anal sex following radiotherapy through colorectal cancer?’ he says.
‘LGBT patients don’t want to be the ones to instigate the conversation around sex; that’s what professionals need to do. But when it gets mentioned they are happy to converse.’
If treatment is no longer a possibility and palliative care becomes the next step, Mr Heyworth says that end of life care options are similar for the LGBT community and heterosexuals.
of patient-facing staff have not had training on the health needs of the lesbian, gay or bisexual community
However, a survey revealed that 93% of LGBT specialists and service-users consider that more work needed to be done to ensure end of life services are improved for LGBT people (Macmillan Cancer Support 2014).
The overarching factor that Mr Heyworth and Mr Thomas believe is necessary to help LGBTQ+ people with cancer throughout their journey of care – and at the end of life − is improved training.
‘Training is vital so that the NHS’s hard-working and dedicated professionals feel confident communicating with and supporting everyone in their care,’ says Mr Thomas.
Useful tools for nurses
How cancer affects different patient demographics – other articles in this Cancer Nursing Practice series
- Hulbert-Williams N, Plumpton C, Flowers P et al (2017) The cancer care experiences of gay lesbian and bisexual patients: a secondary analysis of data from the UK Cancer Patient Experience Survey. European Journal of Cancer Care. doi: 10.1111/ecc.12670