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Dr. Sands:
Welcome to Project Oncology on ReachMD. I’m Dr. Jacob Sands. And joining me to talk about how we can provide better care for our lesbian, gay, bisexual, transgender, queer and questioning patients, or LGBTQ+ for short, is Dr. Maya Leiva, who’s a board certified hematology and oncology clinical pharmacy specialist at Inova Schar Cancer Institute and Associate Professor of Pharmacy Practice at West Coast University.

Dr. Leiva, thanks so much for being here today to discuss this important subject.

Dr. Leiva:
Thank you for having me.

Dr. Sands:
So let’s begin with some groundwork. Can you share with some of the disparities patients in the LGBTQ+ community face when it comes to accessing healthcare?

Dr. Leiva:
Absolutely. And, you know, this is a really loaded question because we know that the LGBTQ+ community is not a homogeneous community. Right? And there’s also a lot of intersectionality with race, ethnicity, and of course all the other social determinants of health that have become such a prominent focus in discussion of healthcare equity in this country. So some of the disparities just kind of on a high level, we know that members of this community often delay seeking care for a variety of reasons, including many have had negative experiences with healthcare providers and systems. Unfortunately, you know, within this community we also see high rates of poverty. We also see high rates of, lack of general access to preventive care and screening, and so, unfortunately, you know, a number of patients in this historically marginalized and vulnerable community end up being diagnosed, particularly with respect to cancers, diagnosed later, with, of course, higher rates of morbidity and mortality. So, again, they are multifactorial.

One of the terms that we use quite a bit when we talk about these healthcare disparities is around the term situated vulnerabilities, and that model was actually kind of created by our substance use disorder colleagues in talking about, again, you know, all the kind of facets behind substance use disorders. And when it’s applied to the LGBTQ+ community, it really does give us a much better understanding of, again, the difficulties in a medical care journey that many of these patients face.

Dr. Sands:
Now, you mentioned cancer screening and prevention in particular, and that seems to be an important topic, specifically within the LGBTQ+ community. Are you able to speak a little bit more to that specifically?

Dr. Leiva:
Absolutely. It depends on kind of who you are in this LGBTQ+ community, right? So, when it comes to persons who are transgender or gender nonconforming or nonbinary, we know that cancer screening especially is complicated by some of the potential gender-affirming hormone therapies and gender-affirming surgeries that these persons may undergo, and that sometimes can complicate conversations with providers around what patient-specific risks are. And so, you know, one of the things that the WPATH and UCSF transgender care recommendations suggest is, of course, focusing a lot on organ inventory for patients. You know, what organs do they have currently, and where do those organs fall in terms of, need for screening based on a number of different guidelines that we have available that are, I might add, not necessarily concordant for cisgender heteronormative persons as well? So, there’s a lot of controversy at this point just in terms of when do we start screening for certain diseases and then also just considering sex hormones to be carcinogens and that really kind of complicates the conversation around, how do we screen for patients who identify as transgender, nonbinary and gender nonconforming. And, of course, even though there is a dearth of data out there, we do have some data to suggest that particularly for trans women, there are much higher rates of breast cancer, particularly after prolonged exposure to hormonal therapy.

Dr. Sands:
For those just tuning in, you’re listening to Project Oncology on ReachMD. I’m Dr. Jacob Sands, and I’m speaking with Dr. Maya Leiva about the health disparities faced by the LGBTQ+ community.

So, Dr. Leiva, I want to make sure that we as healthcare providers are doing right by our patients. Can you talk about the importance of capturing sexual orientation and gender identity, or SOGI for short?

Dr. Leiva:
Yes. And, you know, it’s one of the kind of entry points for a healthcare system to address some of these inequities because we won’t know necessarily how to treat our patients and what kinds of services they need, if we’re not able to at least get a snapshot—right? of the communities that we’re serving. We won’t know how to make cogent recommendations for patients, and also get them involved in their own care if we’re not collecting sexual orientation and gender identity. So, you know, these components of collection are important both for serving individual patients but also for healthcare systems to really take a more population-based health approach. And this also helps for advocacy too, and it gives health systems and opportunity to, again, work with the community that they’re serving.

Dr. Sands:
Now, another tool that healthcare facilities can use is the Healthcare Equality Index, also known as HEI. Can you give us a brief overview of this resource?

Dr. Leiva:
Yes, definitely. So the Health Equality Index is a survey that’s actually administered by the Human Rights Campaign, and one of the really great things about this survey is it gives a healthcare system an opportunity to do a deep dive into all other practices. Right? And this isn’t just about serving patients. It’s also about recognizing and supporting LGBTQ+ employees. And, you know, what that involves is looking at everything from, you know, do we have nongendered bathrooms for patients? do we have a visitor policy that is inclusive of all the kinds of configurations of relationships that persons in this community may have? also, things like patient registration. Are we making sure that we’re—again—capturing back to that SOGI data, are we capturing it correctly so we’re not misgendering patients, or, you know, potentially not recommending certain types of care? And then things as kind of separated from patient care like, does a system provide gender-affirming coverage and treatment for its employees, and then also for its patients? So, what’s really nice about this, again, it’s a multifaceted survey that enables an institution to take a really hard look, and if they’re doing things that are right, be essentially recognized for that. Right?

Inova Health System just recently, we participated for the first time in the Health Equality Index, and one of our hospitals actually earned a top performer within the HEI, which meant that we scored 90 points or higher. And, you know, of course we still have a lot of room to grow and improve, but this is a starting point, and it also helps us engage in a lot of very important conversations with leadership about, are we serving our LGBTQ+ community appropriately? do we have, you know, LGBTQ+-friendly providers? do we have resources available within the system to support these patients? And then also, when it comes to recruitment—right?—if you want to serve the community, you also want to have providers, clinicians across the entire healthcare system that reflect the population they’re serving. So this is another opportunity to increase diversity, equity and inclusion.

Dr. Sands:
So to add to that now, on top of SOGI and participating in HEI, what are some other actionable steps that we can take to provide equitable care?

Dr. Leiva:
Absolutely. So, you know, when we think about even just simple things like partnering with local community-facing groups having a diversity, equity and inclusion council, or some other committee body that is working toward supporting the community and liaising with particular vulnerable communities is a really great start, and it also enables feedback, you know, from the community to say, “Hey, these are the things you’re doing well, and these are some of the gaps that would be great for us to face together.”

In addition to that, I mean, and again, this is a pretty simple thing to do, incorporating questions that are directed at LGBTQ+ patients in, for example, you know, a number of people use the Press Ganey surveys. That is a great way to capture data and also acknowledge to your LGBTQ+ patients that this is important that essentially a system is paying attention. And then also surveys of employees and staff because it’s important to make sure, that, you know, we are providing support for employees so that they can also in turn hopefully provide the best care to their patients.

Dr. Sands:
Now, a lot of this comes down to awareness it seems. So, can you share your thoughts on how we can improve the training and curriculum for healthcare professionals?

Dr. Leiva:
We can start by considering it absolutely necessary to do it from a longitudinal perspective. You know, I hear a lot of people like Oh, yeah, I took a, a DEI certificate, or, I, you know, took a course or a webinar. And, and those are really important things. This is obviously someplace to start, and that’s progress too. You know, even 5 years ago these things were not, were not necessarily being discussed as openly, and as urgently as they are now. But we have to start from the beginning of a person’s medical, pharmacy, nursing, you know, other clinical programs. We have to incorporate this into learning outcomes. We have to kind of move beyond this term cultural competence, which is kind of a loaded term and definitely controversial, to things like cultural humility. You know, you’re never necessarily going to be an expert in another person’s culture, but you can certainly develop humility and have that kind of agency to advocate where your patient’s grow. We can’t do this without training.

One other additional thing that I would really want to kind of harp on also is this need for trauma-informed care, and if we can integrate the principles of trauma-informed care into training and also the way that we treat patients, we are going to be able to address a number of health disparities among historically marginalized and vulnerable communities, you know, kind of beyond just the consideration of sexual orientation and gender identity.

So, emphasis on training that occurs from the beginning of a clinician’s life so to speak to the end of their career, requiring CE, CMEs, you know, all of those things that again can help augment, a provider’s learning and a number of persons, practice with great intention but don’t necessarily have the tools for harm reduction. Right? And some of this training can help providers learn how to deal with accidentally misgendering a patient, and can help affect change among their staff. I mean, you can be the most you know, culturally sensitive and humble, provider, but if the members of your staff serve as a barrier to patients coming in and they don’t have a positive experience, then all of your efforts are going to be for naught, so I would say the emphasis is we really need to make sure that every person who’s interacting with a patient, is getting that training consistently and held to that standard.

Dr. Sands:
Well, you’ve given us a lot of good information to think about. And as we come to the end of today’s program, what are some final takeaways that we can take from this?

Dr. Leiva:
Patient experience drives decision-making for patients, and again, as clinicians, if we can incorporate a number of opportunities to change systems and to make systems more equitable, we’re going to have better outcomes for patients, and in turn that’s going to hopefully help healthcare become a much more sustainable entity, you know, especially even from a cost perspective—right?—because, unfortunately, we do have—we tend to have poor medical outcomes in a lot of these historically marginalized and vulnerable communities. So we can do better, and we have all the opportunities to do so.

Dr. Sands:
Well, that’s a great note to end on as we come to the end of today’s program. I want to thank my guest, Dr. Maya Leiva, for sharing her expertise on how we can address healthcare inequity and disparities in the LGBTQ+ community. Dr. Leiva, pleasure talking with you today.

Dr. Leiva:
Thank you so much for having me.

Dr. Sands:
I’m Dr. Jacob Sands. To access this and other episodes in our series, visit reachmd.com/projectoncology where you can be Part of the Knowledge. Thanks for listening.