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Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual (2SLGBTQIA+) (Table 1) individuals face multiple barriers to accessing oncology care and have poorer clinical outcomes.1-3 They are more likely to develop certain cancers, yet often remain underrepresented in research and underserved in clinical practice.3,4 Patient, provider, and systemic barriers limit access to timely prevention, screening, treatment, survivorship care, and end-of-life care. Recognizing these issues and addressing these challenges is essential to delivering equitable cancer care.
This module will examine the experiences of and challenges faced by 2SLGBTQIA+ individuals across the cancer care continuum and discuss strategies to help reduce these inequities.
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The health of 2SLGBTQIA+ individuals has often been compromised by stigmatization, discrimination, lack of visibility, and limited cultural competency within the healthcare system. These challenges are compounded by intersectionality, which describes how overlapping aspects of a person’s social identity, such as race, gender, ethnicity, age, religion, and sexual orientation, interact to shape experiences of both discrimination and privilege. For 2SLGBTQIA+ individuals, this means that cis-heteronormativity, ageism, ableism, racism, denial of gender-affirming care, lower socioeconomic status, and lack of insurance may intersect to magnify barriers to care.1 Together, these factors increase vulnerability to health inequities and poorer cancer outcomes.
As a result, many patients are hesitant to discuss their sexual orientation or gender identity (SOGI) with healthcare providers (HCP). Reasons include limited opportunities for disclosure, the perception that SOGI is irrelevant to cancer care, and fears of discrimination, microaggressions, or negative reactions from providers. Although providers intend to deliver equitable care, implicit bias can create barriers to open communication. This hesitancy decreases participation in early detection and cancer screening programs, contributing to delayed diagnoses and more advanced disease at presentation. In fact, despite an increased cancer risk among the 2SLGBTQIA+ community, approximately 25% are less likely to undergo cancer screening.3 Patients may also experience higher rates of depression, anxiety, and maladaptive coping behaviours such as smoking, alcohol use, or risky sexual behaviours, all of which can further increase cancer risk.1,3,7
Alongside these disparities in access and care, certain biological risks contribute to cancer outcomes. Nulliparity may increase the risk of breast cancer, human papillomavirus (HPV) is linked to higher rates of cervical and anal cancers, and immunosuppression from human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) contributes to cancers such as Kaposi sarcoma, non-Hodgkin lymphoma, and testicular cancer.8,9 Although research in this area remains limited, current evidence suggests that gender-affirming hormone therapy does not carry the same cancer risks for transgender patients as hormone therapies do for cisgender individuals. For example, transgender women on estrogen therapy have a slightly higher risk of breast cancer compared to cisgender men, but their overall risk remains lower than that of cisgender women.
Many HCPs lack the knowledge and training necessary to meet the needs of 2SLGBTQIA+ patients. For instance, less than one-third of medical schools in Canada and the United States provide education on hormone therapy or surgical transition, and only 10% of medical students feel prepared to care for transgender patients.1 In oncology, HCPs often express limited confidence in caring for 2SLGBTQIA+ patients, especially when it comes to inclusive communication, understanding transgender patients’ medical and psychosocial needs, and discussing SOGI.1,2,10
These gaps can create misalignments between a patient’s lived experience and an oncologist’s medical approach, making effective communication essential for ensuring clinical accuracy and culturally competent care. When patients feel safe and respected, they are more likely to share information about their SOGI, allowing providers to deliver appropriate care. Conversely, when providers are unaware of a patient’s SOGI or make assumptions about sex assigned at birth, they may omit recommended cancer screenings or fail to tailor care to the patient’s actual risk profile.2,3
At the systems level, the absence of standardized cancer screening guidelines for transgender and gender diverse individuals contributes to low screening rates. Transgender patients may be excluded from organized screening programs if their legal sex or gender markers do not align with eligibility criteria, as many screening systems rely on legal sex rather than clinical anatomy or risk. The lack of clear, evidence-based protocols also creates uncertainty for providers, leading to inconsistent recommendations and limited proactive engagement in preventive care.2-4
In addition, the lack of structured data collection on sexual orientation and gender identity in clinical records and national databases limits data on cancer prevalence and clinical outcomes, research progress, and hinders the development of tailored healthcare policies. Without this information, it is difficult to track disparities, design inclusive cancer prevention programs, or ensure that health systems meet the needs of 2SLGBTQIA+ communities.2,4
The 2SLGBTQIA+ community comprises a diverse and multicultural range of community members. It includes all races, ethnic and religious backgrounds, and socioeconomic status. Cultural competence involves understanding, respecting, and responding appropriately to patients’ health needs, including those shaped by gender identity, sexual orientation, and prior healthcare experiences.1,4,5 In oncology, this impacts cancer screening, treatment adherence, and patient outcomes. To reduce barriers faced by 2SLGBTQIA+ individuals, clinicians must adopt an inclusive approach across the cancer care continuum. This involves being familiar with accurate terminology (Table 1), practicing inclusive communication, and creating a welcoming clinical environment.
Using language and behaviours that affirm identity fosters trust, reduces stigma, and improves disclosure of relevant health information.6,11 Here are some examples of how clinicians can demonstrate this:
A safe and affirming clinical space signals inclusivity and encourages engagement in cancer care.1,6,11 Some strategies include:
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