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In a recent article from Oncology Issues, authors conducted a systematic literature review and found that two main drivers of care disparities exist for transgender and nonbinary individuals with cancer: rigid binary gender frameworks and gaps in mental health care.
Approximately 2.8 million people in the US identify as transgender or nonbinary, meaning their gender identity is different from their sex assigned at birth or they do not identify with any gender at all. Despite having a population larger than the state of New Mexico, this group is understudied and underdiscussed in health care. In oncology settings, this means that questions remain about cancer risk, providers lack knowledge about how treatments interact with gender-affirming care, and patients face significant disparities in outcomes.
In the latest issue of ACCC’s journal, Oncology Issues, authors from the Weitzman Institute and Wesleyan University examined the current state of cancer care for transgender and nonbinary individuals through a systematic literature review. Their analysis revealed two main drivers of care disparities: rigid binary gender frameworks and gaps in mental health care within oncology. While the research centered on one population group, the authors suggest interventions that use a patient-centered approach focused on mental health, which has wide-reaching benefits for all patients.
The importance of mental health has been gaining recognition in oncology, and this factor is uniquely linked to gender-affirming care for transgender and nonbinary patients. In this systematic review, gender-affirming care primarily referred to hormone replacement therapy, but social factors, like using the correct name and pronouns for the patient, can also be included under this umbrella.
In an interview with ACCCBuzz, Maximillian Morris, MSPH, research and evaluation associate at the Weitzman Institute, explained that access to this type of care has profound psychological impacts on patients, improving mental health and quality of life. However, case studies reveal that transgender and nonbinary patients are often pressured to prioritize cancer treatments over gender-affirming care goals. “You’re already going through the stress of having a cancer diagnosis and then being told by multiple providers that you have to stop this treatment that makes you feel like your most authentic self....It has a huge impact,” Morris said.
Several factors may drive a provider to deprioritize gender-affirming care. The relatively small body of research—along with limited awareness of that research—on interactions between cancer treatments and hormone therapies leads many oncology professionals to assume it is unsafe or ineffective to provide both treatments concurrently. Providers may also be unaware of the connection between gender-affirming care and mental health, or they may be concerned that supporting these treatments will jeopardize federal funding for their institution. However, neglecting the needs of this patient population leads to significant disparities in health outcomes.
Patient-centered care, which respects each individual’s preferences and values, is widely recognized as an effective model for improving treatment adherence, perceived treatment quality, and trust in the care team. For transgender and nonbinary patients, those preferences often include prioritizing gender-affirming care. While this may seem like a novel factor to weigh into treatment planning, it fits neatly into many existing frameworks of care and shared decision-making.
The Oncology Issues article maps out actionable solutions to improve patient-centered care and better integrate mental health at individual, interpersonal, and structural levels. Many of the strategies are broadly applicable across patient groups and are already widely enacted in cancer programs. For example, the authors recommend evaluating each individual’s unique circumstances, engaging in collaborative decision-making, and implementing trauma-informed care practices.
Other interventions are more targeted to transgender and nonbinary patients. Cancer programs can document patient preferences regarding gender-affirming care, recommend gender-affirming training for oncology staff, and include gender-affirming care specialists on the oncology team. While these strategies vary in cost, staffing needs, and infrastructure requirements, many can be integrated into existing training and mental health programs.
By focusing on enhancing patient-centered care and mental health, which apply to all patients, many of these strategies may also be compliant with restrictive state policies and federal funding requirements that create barriers to explicitly addressing gender identity in cancer care. When systems are truly designed to support everyone, transgender and nonbinary individuals will be included.
Beyond implementing the suggested strategies to improve quality care, Morris explained that further research on transgender and nonbinary patient experiences is key to improving outcomes. Existing data are limited by small sample sizes and a lack of diversity. In addition to race and ethnicity, he emphasized that capturing data across a wide age range is especially important, as many cancers are trending towards younger patient populations.
Prioritizing mental health and gender-affirming care in oncology is not merely an act of inclusion. It is a step toward ensuring that all individuals have access to patient-centered care. While there are real and significant barriers to improving outcomes for transgender and nonbinary individuals, Morris and colleagues demonstrate accessible strategies with tangible benefits. “I know it’s a smaller patient population, but everyone deserves to be heard, especially [when they’re] going through one of the biggest challenges of their life,” said Morris.
To learn more about actionable strategies for improving cancer care in this patient population, read A Patient-Centered Framework for Transgender and Nonbinary Health in Oncology Issues.
