Discrimination, and the chronic stress it causes, have been identified as key drivers of heightened cancer risks among LGBTQ+ communities in a pioneering new report from the American Cancer Society. The first-of-its-kind study found LGBTQ+ people face a disproportionate burden of the disease, with a higher incidence of certain cancers and later-stage diagnoses. The ACS has begun a campaign to increase early detection screening and is now calling on U.S. clinicians to step up their level of care by acknowledging — and fixing — discriminatory medical practices which leave marginalized groups behind.
The ACS report, published in the journal Cancer, arrived the same day as a Pride Month proclamation from the White House. In his May 31 speech, President Joe Biden laid out a series of health-focused initiatives aimed at LGBTQ+ communities — including new anti-discrimination rules for health care providers, expanded mental health resources, and new training programs through the Department of Health and Human Services.
“One of the biggest take-aways from our report is that LGBTQ+ people are probably at higher risk for cancer, yet experience multiple barriers to high-quality healthcare access like discrimination and shortfalls in provider knowledge of their unique medical needs,” said ACS' Rebecca Siegel in a release.
Siegel is the study's lead author and the ACS' senior scientific director of cancer surveillance. Using data gathered from the Centers for Disease Control, her team examined the prevalence of cancer risk factors across the U.S., based on the National Health Interview Survey (for information on sexual orientation) and the Behavioral Risk Factor Surveillance System (for gender identity).
“Everyone deserves an equal opportunity to prevent and detect cancer early," she said, "which is why it’s so important to remove these roadblocks for this population."
The ACS reports that 40% of all cancers among the general population are attributable to "modifiable risk factors" — including tobacco and alcohol use, along with unhealthy diets and excess body weight. These risk factors are driven by stress. Along with a number of sexuality-distinct health variables, the vast majority of sexual and gender minorities (SGM) experience each factor more frequently than straight and cisgender counterparts, creating an overall rate disparity through the accumulation of smaller, categorical ones.
Among the range of categorical cancer risks, here are five major factors currently driving disproportionately high disease rates among LGBTQ+ populations — and the changes that medical experts are calling for in the fight for nationwide health justice.
In its new report and research summary, the ACS goes through the main cancer-risk factors, one after the next — tobacco, alcohol, excess body weight, and unhealthy diet. For each one of these factors, the report notes its rates of discovery can be linked to "minority stress" — the term for stress arising from systemic discrimination of marginalized groups. Much like health disparities other researchers found in 2023, ACS linked this psychological burden to the greater-than-average use of cancer-causing substances like tobacco and alcohol. The disparity is made worse by a lack of access to treatment for substance use disorder and by economic disparity preventing healthy nutritional access.
"Reducing minority stressors by implementing interventions at the structural, interpersonal, and individual level is a crucial component of mitigating cancer disparities in LGBTQ+ communities," the ACS wrote. "These interventions include establishing institutional safe spaces for LGBTQ+ individuals and programs designed to increase knowledge and empathy among providers."
The biggest risk-factor among the gay and stressed is a familiar foe. Cigarettes, accounting for 80% of all lung cancers globally, continue to be far more popular among LGBTQ populations than among heterosexuals. 23% of bisexual women smoke compared to just 10% of straight women. Meanwhile, the National LGBT Cancer Network holds that smoking rates among gay men are nearly double those of the general population. The ACS also found bisexual women were more than twice as likely as straight women to have more than seven alcoholic drinks per week.
What one study calls stress, however, many others describe as a painful part of a national mental health epidemic heavily impacting SGM groups and contributing to earlier-in-life use of cancer-causing substances.
Last year, a systematic review and meta-analysis of 27 studies — featuring 31,903 LGBTQ study subjects, 273,842 controls, and a 95% confidence interval — delivered resounding confirmation that SGM groups are far more likely than others to suffer from post-traumatic stress disorder. Additional research from the Department of Veterans Affairs found that, while the average prevalence of PTSD among the general U.S. population is about 4.7%, the rate among LGBTQ groups is as high as 48%.
And while mental health gaps exist across all SGM age groups, Black gay kids suffer the heaviest burden. John Hopkins University has been ringing the alarm for years on a growing national crisis of suicide among Black LGBTQ youth, who have the sharpest rate increase compared to their peers — among ages 10-17 that rate increased by 144% between 2007 and 2020. In the first such move of its kind, the Human Rights Campaign last year declared a national state of emergency for LGBTQ Americans — a response to the flood of discriminatory legislation offered at statehouses across the country.
Transgender and nonbinary youth also continue to struggle for mental health care access with fewer than average specialist providers, according to a 2023 poll from the Trevor Project — and 86% of them are straining under the psychological burden of anti-trans legislation debates. Half or more of the trans youth respondents said anti-trans policies caused feelings of anger, fear, sadness and even hopelessness.
Cause for optimism has been mounting since 2019, however, when LGBTQ youth took the lead to become the most politically active demographic group in the U.S. And despite persistent backlash from far-right groups over LBGTQ activism, clinical studies show that the choice to stand up to discrimination through protest actually improves mental health.
Access needs: More cancer-screening, health worker education
While financial and insurance limitations remain the biggest obstacle to SGM health care access, the ACS found that fear of discrimination and prior negative medical experiences continue to drive down the number of SGM seeking preventative treatment and early detection scans — the two best ways to stay ahead of of cancer. One in six LGBTQ adults report avoiding taking health care action due to previous experiences of discrimination.
Continuing education and training among health workers remain key strategies for driving down gaps in SGM cancer detection, per the report. The ACS found that only 25% of medical students are confident in the healthcare needs of transgender patients. The organization's analysis also notes a separate study which found 30% of medical students reported being uncomfortable treating transgender patients.
Findings from a Harvard-led survey this year encouraged increased training on LGBTQ needs among health workers in oncology. The survey found that while most health workers in oncology are philosophically comfortable treating sexual and gender minorities in their care, only 50% are confident in their knowledge of LGBTQ-specific needs during treatment.
These disparities are far more likely to impact trans patients, according to the ACS — especially when it comes to getting preventive screenings. In one promising development, however, researchers observed that "prevalence of cancer screening and risk reducing vaccinations in LGBTQ+ individuals is similar to or higher than their heterosexual/cisgender counterparts except for lower cervical and colorectal cancer screening among transgender men."
The ACS is currently on a mission to increase screening for colorectal cancer across LGBTQ populations. Despite being the second-leading cause of U.S. cancer deaths, patients who detect the cancer early have a 91% five-year survival rate compared to advanced cases caught later. The ACS also offered another reason for optimism.
"Regardless of their sexual orientation, people whose health care providers knew their sexual orientation were more likely to have been encouraged to get cancer screenings compared to people whose providers didn’t know their sexual orientations," the organization reports.
Breast, cervical cancer rates higher for lesbians, bisexuals
When compared to heterosexual women, lesbians and bisexual women are at higher risk for both breast and cervical cancer. Like other SGM groups in the ACS' study, the women's stress-driven substance use was collectively higher on average than that of most straight counterparts. Discrimination-driven threats to economic security are long-standing chronic stressors for women encountering sexism and racism. When combined with prolonged SGM-specific stress those stressors intensify, though other factors continue to spur health disparity rates.
"Lesbian women were the only subgroup that was less likely than heterosexual women to be encouraged to receive cancer-preventive care, such as HPV vaccinations and Pap tests," the ACS said, adding that "when they are tested, the result is more likely to be abnormal."
This ACS's findings follow a historical trend noted across more than 20 years of data — and largely concur with the findings of a scoping review published in March in the Journal of Psychosocial Oncology, pointing to the series of discrimination-based obstacles lesbian and bisexual female breast cancer survivors face across the care continuum, including unique post-treatment challenges.
"Starting before diagnosis, disparities for SMW (sexual minority women) have been identified in breast cancer risk and screening. Lesbian and bisexual women have a higher prevalence of breast cancer risk factors including nulliparity (having no history of giving birth), obesity, alcohol use, and smoking. SMW are also less likely to have health insurance coverage, a recent pelvic examination, or mammogram. Studies show Black SMW have even higher delays in breast care than white SMW, reporting intersectional stigma (i.e. stigma for Black and sexual minority identities) and lower social support," researchers wrote.
"SMW breast cancer survivors may experience distress in clinical settings through discrimination, discomfort disclosing sexual orientation or relationship with their support person, and lack of culturally appropriate support services.
Double impact: Cancer-causing infections threaten gay, bisexual men
Overall, about one in eight American men will get prostate cancer, representing 'the second-leading cause of cancer deaths after lung cancer. And the odds of developing it increase with age, disproportionately impacting Black men. The third most common type is colorectal cancer. Increased screening rates and drug use changes can have a dramatic impact on rates for these types of cancers. But detecting, treating and preventing cancer-causing infections may be among the most critical factors in reducing cancer rate disparities among gay and bisexual men.
"The prevalence of cancer-causing infections, such as human immunodeficiency virus (HIV), human papillomavirus (HPV), and hepatitis C virus (HCV) are considerably higher in some LGBTQ+ population groups," the ACS said. "According to the CDC, for example, 70% of HIV infections are attributed to male-to-male sexual contact (versus 22% to heterosexual contact and 7% to injection drug use). HIV-infected individuals are at a higher risk for at least 10 cancers."
While a lack of awareness among providers is currently an obstacle to bringing those rates down, the National LGBT Cancer Network has advocated for faster infection treatment through the wider use of anal Pap tests which are now more available than ever.
Before Pap smear tests became routine in the 1940s, women faced sky-high rates of cervical cancer. And according to the advocacy organization, rates of anal cancer among gay men are now just as high in 2024. The organization specifically points to high-risk strains of HPV which still cause most cervical cancers in women, noting that these strains are also responsible for the development of anal cancers in men. The organization said HPV is present in 65% of gay men without HIV and 95% of those who are HIV positive.
After prostate cancer, skin cancer is the most common form of the disease in men — and UV radiation exposure is still a significant risk factor for cancer among bisexual and gay men, according to the ACS. The groups were also found to face higher odds of developing skin cancer than straight men, according to a 2020 study in JAMA Dermatology, largely attributed to tanning bed use.
Representation is survival: LGBTQ data needed
The ACA's report is one of several to emerge in recent years offering a partial look at the cancer disparities suffered by non-heterosexual groups. But ACS researchers are loudly calling for more data — including more surveys, studies and collaborative reporting efforts — specific to the marginalized communities most at risk.
“All people should have a fair and just opportunity to live a longer, healthier life free from cancer,” wrote Lisa A. Lacasse, the head of ACS' advocacy arm. "The ACS Cancer Action Network urges policymakers and lawmakers to prioritize policies that address the serious challenges and barriers to comprehensive access to health care that LGBTQ+ people experience. Importantly, passing laws that facilitate and increase the appropriate collection of sexual orientation and gender identity data is crucial to better understanding cancer disparities and to ultimately improving health outcomes."
The ACS isn't the only one. Health research outfits across the U.S. are calling for better reporting and more LGBTQ representation in the data. In its 2024 annual disparity report, the American Association for Cancer Research also called on providers and scientists to open the floodgates.
"Population-level cancer data on members of SGM communities are lacking," the report reads, "making it difficult to understand the true burden of cancer in this population."
The organizations echo the concerns of a 2022 executive order from the White House, outlining a full slate of data types notably missing in LGBTQ health studies. Followed by additional directives in the past two years, the 2022 order saw the Biden administration directing federal agencies to rally around the administration's LGBTQ number-crunching office — the Sexual Orientation and Gender Identity (SOGI) Research Group — just as ACS has.
