Beyond Black and White: race and sexual identity as contributors to healthcare system distrust after breast cancer screening among US women

Abstract

Objective Healthcare system distrust (HCSD) has been linked to poor breast cancer outcomes. Previous HSCD analyses have focused on Black‐White disparities; however, focusing only on race ignores the complex set of factors that form identity. We quantified the contributions of race and sexual minority (SM) identity to HCSD among US women who had received breast cancer screening. Methods This cross‐sectional study used intersectionality decomposition methods to assess the degree to which racial and SM identity contributed to disparate responses to the validated 9‐item HCSD Scale. The sample included online survey participants identifying as a Black or White woman living in the US, with a self‐reported abnormal breast cancer screening result in the past 24 months and/or breast cancer diagnosis since 2011. Results Of 649 participants, 49.4% of Black SM women (n = 85) were in the highest HCSD tertile, followed by 37.4% of White SM women (n = 123), 24.4% of Black heterosexual women (n = 156), and 19% of White heterosexual women. Controlling for age, 72% of the disparity in HCSD between Black SM women and White heterosexual women was due to SM status, 23% was due to racial identity, and 3% was due to both racial and SM identity. Conclusions SM identity emerged as the largest driver of HCSD disparities; however, the combined racial and SM disparity persisted. Excluding sexual identity in HCSD studies may miss an important contributor. Interventions designed to increase the HCS's trustworthiness at the provider and system levels should address both racism and homophobia.

Intersectionality in cancer care: A systematic review of current research and future directions

“…Among studies that included SOGI as their intersection of focus ( n = 4), sexual minority women were less likely to engage in cancer prevention behaviors than heterosexual women 22,30‐32 . In several studies, these disparities were impacted by the intersection of the individual's other marginalized identity.…”

“…21,23,28,29 Among studies that included SOGI as their intersection of focus (n = 4), sexual minority women were less likely to engage in cancer prevention behaviors than heterosexual women. 22,[30][31][32] In several studies, these disparities were impacted by the intersection of the individual's other marginalized identity. For example, in a study examining rates of mammography among women at the intersection of marginalized SOGI and racial identities, Agénor and colleagues reported that bisexual women had lower rates of mammography compared with heterosexual White women; however, the opposite pattern was noted among Black women.…”

“…32 Dean et al described intersectional identities and "marginalization within healthcare due to being at the intersection of racism and homophobia" as underlying root causes related to disparities in prostate cancer diagnosis. 32 Specifically, disparities were noted at the intersection of race/ethnicity minorities among self-identified Black or White patients and SOGI minority individuals, especially among persons who self-identified as "lesbian, gay, queer, bisexual, or same-gender loving." 32 Of note, patients with intersecting identities had particular distrust of the healthcare system.…”

“…32 The higher levels of distrust among sexual minority women, especially sexual minority Black women, placed these patients at higher risk of not seeking a definitive diagnosis after an abnormal screening finding. 32 In turn, patients with an intersectional identity tended to be at the highest risk for worse outcomes due later presentation/stage of disease and lack of seeking indicated cancer care.…”

Patient engagement and advocacy considerations in development and implementation of a multicancer early detection program

“…Population adoption of cancer screening tests 24‐27 is driven by several factors, many of which speak to the critical need to engage the population of potential users to understand their relevant attitudes and beliefs about the potential advantages of the innovation; the compatibility of the innovation with their experiences, values, and needs; the perceived complexity or challenges related to adoption of the innovation; and the visibility of the innovation among potential adopters 28,29 . It is critical to acknowledge and explore perceptions among patients about perceived harms from screening, such as overdiagnosis, false negatives, false positives, and invasive confirmatory tests, 30 especially for populations that may have had negative experiences or a lack of trust in the health care system 31 . Cancer advocacy organizations can serve as liaisons between screening test producers, researchers, and potential users to ensure the alignment of testing characteristics and processes with patients' needs and preferences.…”