The intersection of racism, discrimination, bias, and homophobia toward African American sexual minority patients with cancer within the health care system

Abstract

INTRODUCTION Cancer health disparities exist all across the cancer continuum, from prevention to survivorship and endoflife care. For so many years, we have known this, we have tracked and documented it, and we have created graphs showing the vivid parting lines between Whites and Blacks. Our book on cancer in lesbian, gay, bisexual, and transgender (LGBT) populations and more recent data have continued to demonstrate these disparities among LGBT groups. Now imagine how much bigger the disparity is for those who are both LGBT and African American. In a recent scoping review of African American lesbian/bisexual women across the cancer continuum, Malone et al found only 15 articles that focused on this group, and most of the studies included too few African Americans to be able to reach conclusions. This led the researchers to aptly conclude that “[this] indicates the invisibility of a group that experiences multiple marginalized identities.” This same group of researchers conducted a survey of sexual minority women examining delays in cancer care and focusing on the intersection between race (Black vs White) and sexual orientation (heterosexual women vs sexual minority women). The results should give us all cause for concern. Not only did the Black sexual minority group have the highest rate of delay in seeking care (29%), this delay was more than 5 times that in White heterosexual women (5%.) An examination of factors that contributed to the delays also showed differences between racial and sexual orientation groups, with Black sexual minority women reporting more stigma than other groups. The researchers concluded that intersectional stigma played a key role in these disparities. The theoretical model of intersectionality is not one that has been widely considered among cancer researchers or those examining sexual minorities (Fig. 1). More commonly used is minority stress theory, a model that explains how stigma, prejudice, and discrimination create a hostile and stressful social environment that results in physical and mental problems. Yet if we are to achieve health equity, we must examine the concept of intersectionality; it is most often groups that are disempowered and marginalized on multiple levels of society that suffer the most. This theoretical framework suggests that multiple social categories (eg, race, sexual orientation, gender, and socioeconomic status) intersect within a person’s experience (micro level) to reflect multiple interlocking systems of privilege and oppression at the socialstructural level (macro level) such as racism, sexism, and heterosexism. If we are to truly understand health disparities in groups that have been oppressed on multiple levels, such as LGBT African Americans, we have to begin by recognizing and acknowledging the existence of multiple intersecting identities. In a phenomenological study of African American women with breast cancer, ArmourBurton and Etland examined the intersection of race, gender, and class in women’s wellbeing. The 4 themes that emerged from the interviews with the women included 1) selfless caring for others, 2) strength in silence while living on the margins of society, 3) existential invisibility, and 4) marginalization. The last took 1 of 2 forms: either feeling that they did not belong (passive) or being forced to the margins by the dominant group (active.) Their findings lend support to the idea that there are other upstream psychosocial and societal risks for the development of cancer in African American women. It is clear that the interaction of at least 2 societal factors of oppression (racism and prejudice), bias stigma, and discrimination intersect in African American sexual minority women.