Phelan, Lynn M.

Background: This qualitative study sought to understand factors related to low rates of screening mammography among transgender and gender-diverse (TGD) individuals and how these rates might be improved. Methods: Individuals who self-reported as TGD were recruited from multiple sites and national patient advocates. Consenting participants completed an individual interview using a semistructured guide informed by the Health Belief Model (HBM). Interview data were analyzed using thematic analysis. Results: A total of 44 individuals completed the interview (median age, 44.9 years; range, 19–77 years); 11% were a racial/ethnic minority; and 52%, 20%, and 25%, respectively, self-identified as a transgender woman, transgender man, or nonbinary. Three themes emerged around constructs in the HBM. First, individuals voiced a hope to be treated equally (“I just want to go to work, pay my taxes, love my family, and go along my day and be a good human”) and described how such equitable treatment during screening guarded against gender dysphoria and favored gender affirmation (“it is affirming…being treated as any other woman”). Second, barriers and facilitators related to mammography were identified, including the need to address cost/low cost (“screenings are a luxury”); prior negative/positive experiences (“they would call my name and look at me but dismiss me”); absence/presence of education (“none of the doctors…ever told me what that process looks like”); and perceived low/high cancer risk (“my mom died pretty young from breast cancer”). Finally, practical recommendations were offered, including individual changing/waiting rooms, hiring gender-diverse staff, and engaging clinicians who provide whole-person, trauma-informed care. Conclusions: Mammographic screening among TGD individuals could be improved by proactively creating safe, affirming spaces; working to lower costs; providing educational materials tailored to the TGD community about cancer risk and the practical aspects of screening; and hiring gender-diverse staff. These recommendations from TGD participants merit implementation as well as further study.

Purpose To assess how comfortable patients with cancer are in responding to intimate questions on sexual orientation and gender identity (SOGI) and to examine whether question sequencing alters patient-reported comfort. Patients and Methods Patients with cancer were asked to respond to one of two surveys that were provided to patients in a randomized manner and that included seven identical SOGI questions but differed in sequence of responses (upfront vs later debated terms, e.g. “genderqueer”). Using a Likert scale (1 = very uncomfortable to 5 = very comfortable), patients rated comfort. The primary endpoint was the percentage of patients comfortable with the question, “Do you consider yourself to be… [12 response options, including genderqueer]”. Secondary endpoints included differences in comfort based on question sequence or demographics. Write-in comments were captured. Results 74% of patients (95% CI: 70%, 78%) were comfortable when reviewing the primary endpoint SOGI question. Similar comfort levels were reported for the other questions. No significant differences in comfort were observed based on question sequence or demographics. Four themes emerged from write in comments 1) emotional reactions to the questions (“uncomfortable because this question is essentially gender binary”) 2) emotional reactions toward SOGI (“bending over backwards to be politically correct”); 3) concern for privacy and relevance to cancer care (“not sure why this information is needed/necessary”); and 4) constructive remarks (“didn’t know what cisgender was - please define”). Conclusions Most patients with cancer are comfortable in answering SOGI questions. However, their comfort might be enhanced with slight question/response modifications.