Providing Trauma-Informed Oncologic Care to Sexual and Gender Minority Patients

Experts have noted the critical need to provide trauma-informed care (TIC) to sexual and gender minority (SGM) patients with cancer.

“Cancer and its treatments can be traumatizing and may create traumatic experiences that require a TIC approach to help promote the physical and emotional safety of patients,” said Christina M. Wilson, PhD, CRNP, WHNP-BC, assistant professor at the University of Alabama (UAB) at Birmingham and nurse practitioner in the Division of Gynecologic Oncology at UAB.

Various efforts are underway to improve oncology care for SGM patients. ASCO released a position statement in 2017 outlining strategies to reduce cancer health disparities among SGM populations, and ASCO and several other national organizations have taken steps to create more SGM-inclusive research and treatment guidelines pertaining to oncology patients.¹ 

“Many SGM patients report discrimination in healthcare facilities, and using a TIC approach can ensure that they feel safe during their visits,” said Dr Wilson.

Using a TIC approach, “basically means that the provider is paying attention to what the patient is bringing to the situation — and how the past might inform their ability to hear information and act on it,” explained Mandi L. Pratt-Chapman, MA, PhD, associate center director for Community Outreach, Engagement and Equity; associate professor of Medicine; and associate professor of Prevention and Community Health at The George Washington University in Washington, DC. 

“A patient with a trauma history may have a fear of being treated poorly and may need more signals of safety from their health care team because life has shown them that people are not to be trusted,” Dr Pratt-Chapman continued.

“[Traumatic experiences can make a patient] more fearful and less likely to be able to hear what their provider is saying and more likely to perceive a threat or even experience pain, as trauma makes it harder to think, process, respond, or act in one’s best interest,” said Dr Pratt-Chapman. A new traumatic experience — such as a cancer diagnosis — can also exacerbate the effects of previous or concurrent traumas.^2,3 

Fears of mistreatment may stem from adverse childhood experiences, social stigma, or a history of sexual trauma or past healthcare discrimination. “Some queer people have experienced all of these things,” noted Dr Pratt-Chapman. 

According to a 2023 review article, SGM individuals are at higher risk of poverty, stigma, marginalization, hypersexualization, and hate‐motivated violence, and are disproportionately more likely to experience traumatic events than their cisgender, heterosexual counterparts.⁴ 

SGM patients facing intersectional forms of oppression (ie, discrimination based on intersecting social identities, such as race, gender, sexuality, disability, class, and other factors) are particularly vulnerable to trauma, the authors of the review reported.⁴

Dr Pratt-Chapman noted that basic civil rights have recently come under threat by the record number of anti-LGBTQI bills that have been introduced at the state level. “[This can] make queer people afraid of just being themselves — much less getting health care when needed,” she commented.¹

Along with specific TIC strategies, Dr Pratt-Chapman highlighted the importance of several aspects of patient-centered care. “Our systems do not really support providers in doing these things, but we should try anyway,” she said. 

Dr Pratt-Chapman suggests that providers aim to do the following: 

• Embrace interprofessional team-based care to more adequately identify patient needs and maximize safety and trust.

• Speak more slowly, clearly explain details before and during procedures, and check in on understanding to see if you need to repeat anything.

• Ask patients what is most important to them, what they are worried about, what they care about, and who should be in the room.

• Encourage patients to bring anyone they feel is supportive to their appointment.

• Encourage the supportive person to take notes for the patient.

Dr Pratt-Chapman also recommends that clinicians provide their patients with essential information written in a language the patient can read and understand and that is within their level of literacy (having the information available in a range of literacy levels may be beneficial); at the very least, she recommends providing the information in the most common native languages used by the clinic’s patient population. An interpreter and/or written translation of the information should also be made available, when needed, even when the patient speaks a less commonly encountered language. 

“This is so important for patient and family understanding — it really isn’t an extra or optional,” Dr Pratt-Chapman emphasized. “Conveying information in a culturally appropriate, accessible way is a pillar for basic quality care,” she notes.

Regarding an explicitly trauma-informed approach, Dr Wilson explained, “TIC consists of 5 core principles: safety, choice, collaboration, trustworthiness, and empowerment. While each patient’s needs will vary, clinicians can incorporate a TIC perspective in all care they provide by embracing these principles and promoting a patient-first perspective.”⁵

As described by the Substance Abuse and Mental Health Services Administration (SAMHSA), the basic assumptions of TIC are conceptualized in the 4-Rs approach: Programs, organizations, and systems should Realize the widespread impact of trauma and potential paths to recovery, Recognize the signs of trauma, Respond by applying the principles of TIC, and actively Resist re-traumatization.⁶ 

“Importantly, what alleviates trauma is strong social support, inclusion, stress reduction, and basic safety,” Dr Pratt-Chapman said. “The idea is to give as much power and control as possible to the patient — how can we do that better?” 

For clinicians interested in implementing TIC in their practices, she suggested the following strategies.

• Assess Incorporate questions about past trauma. Ask patients if they have fears or concerns or past negative experiences. Ask what you can do to ensure their comfort to optimize their health and healthcare experience. An important tenet to consider: Do not make assumptions, and allow space for what you may not immediately expect.

• Address Connect people who have experienced trauma to resources to which they are open, such as social work, peer support, and/or counseling. Familiarize yourself and stay up to date with reputable resources and use them, particularly those that might alleviate hypervigilance, anxiety, and avoidance.
• Introduce Make sure patients know their medical team and staff before a medical procedure.
• Adapt and Respond Some screening procedures, such as cervical cancer screening, for example, can put people in an extremely vulnerable situation. For someone who has been abused or has gender dysphoria or both, basic examinations can feel extremely traumatic and invasive. Consider the following:
  • Clearly communicate with the patient. Always tell the patient exactly what you are going to do next and why. 
  • Give the patient options to adapt. For example, can the patient insert the speculum initially so they can have some control over what is going into their body? Can you use a smaller speculum, such as a Pederson or pediatric speculum?
  • Allow patients to remain clothed as much as possible or in a robe or clothing of their choice.
  • Give patients options. For example, “Do you want to do X first or Y first?” and “Do you want to do this lying down or sitting up?”
  • Let patients stop if they want or need to. This might mean a pause or a total stop.

• Include Go out of your way to create an inclusive, welcoming environment. Queer people like to see the whole range of queerness — every race, ethnicity, SES, geography, nationality, sexual orientation, and gender identity.
• Listen If the patient tells you they are extremely anxious or fearful, do not dismiss that. You could offer some anti-anxiety medication and ask if they want someone with them in the room. You could ask if they need to pause for more time, if they need to ask questions, or if there are things you can do to make them more comfortable. Reinforce why the procedure is important and that you are committed to making the experience as comfortable as possible for them to get a good result and take care of their health.
• Echo Use the patient’s words, particularly regarding their name, pronouns, and body parts. 
• Reflect Consider your immediate responses and whether they are in the best interest of the patient. Does your instinctual response ensure respect, compassion, and quality care for the patient? If not, seek out training and pause to listen and re-orient the patient’s needs at the center of the healthcare encounter.
• Ensure Nondiscrimination policies should name sexual orientation and gender identity as protected categories with a clear point of contact if discrimination is experienced.
• Be safe and Trustworthy Reinforce trustworthiness in health care by being clear, honest, transparent, affirming, and nondiscriminatory. Be a safe person, create a safe space, and do not minimize experiences of fear or past discrimination. 
• Support training Ensure basic requirements for training in cultural humility and basic understanding of queer identities and healthcare risks.
• Advocacy Whenever and wherever you can, advocate for enforced nondiscrimination and quality care that is patient-centered.

Along with these provider-level strategies, ongoing broader needs to improve inclusive and TIC for SGM include training requirements for basic cultural competency in working with these populations,⁷ judicial and institutional nondiscrimination protections to improve SGM health equity,¹ and “representation of intersectional queer people in leadership and healthcare practice,” according to Dr Pratt-Chapman.