An Ecological Approach to Understanding Correlates of Breast Health Among a Sample of Gender Non-Conforming Lesbian, Gay, Bisexual, Transgender and/or Queer Women in Toronto, Canada

Background and Purpose: Lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) women often experience significant and pervasive mental and physical health disparities associated with stigma and discrimination related to their sexual minority status.  For example, a recent systematic review indicated that LGBTQ women experience higher rates of breast cancer compared to heterosexual women.  A number of biological and behavioral risk factors have been posited to contribute to this disparity, including higher rates of nulliparity, alcohol consumption, smoking, and obesity among LGBTQ women.  Given the increasing attention to biological and behavioral risk factors for breast cancer among this population, understanding multi-level (individual, social, structural) factors correlated with clinical breast exams (CBE) may inform a deeper understanding of factors associated with breast health for LGBTQ women and may inform social work intervention.  The purpose of this cross-sectional study was to assess individual, social, and structural correlates of having had a CBE in the past two years.  A social ecological approach was utilized, as it allows for exploration of the complex associations between health disparities and social and structural environments.

Methods: A cross-sectional internet-based survey was conducted with 160 women in December 2011.  Inclusion criteria were adults aged 18 and over, capable of providing online informed consent, who self-identified as 1) a women; 2) a sexual minority and/or a woman who has sex with women, including lesbian, gay, bisexual, queer, or other; 3) identifying as gender-nonconforming based the question “Do people consider you masculine by looking at you, your mannerisms, and your appearance?”; and 4) residing in the Greater Toronto Area.  The 105-item survey assessed socio-demographic variables, health outcomes, and individual, social and structural factors.  We conducted descriptive analyses followed by logistic regression analyses based on the social ecological framework to assess correlates of having a CBE in the past 2 years.

Results:  Women were a mean age of 31.1 years (SD:8.0); most were white (64.4%), had at least some post-secondary education (87.5%) and identified as queer (53.1%).  In multivariate logistic regression, significant predictors of having a CBE within the past two years included higher age, higher mean scores of depression and self-esteem, and their healthcare provider (HCP) knowing their sexual orientation.  Higher mean gender non-conformity stigma and overall sexual risk practices scores were associated with reduced likelihood of having a CBE within the past two years.  

Conclusions and Implications:  These findings enhance our understanding of intrapersonal (self-esteem, depression), social (gender non-conformity stigma) and structural (HCP assessment of sexual orientation/sexual orientation disclosure to HCP) factors correlated with breast health among LGBTQ women.  A social ecological approach to understanding health disparities can inform multi-level social work intervention.  Social workers can play a role in promoting CBE and reducing breast health disparities among LGBTQ women through individual mental health interventions to address self-esteem and depression and structural interventions to reduce stigma and enhance healthcare provider knowledge of LGBTQ health.  More research is needed to understand the complex interplay of these factors to inform multi-level interventions to address health disparities, enhance HCP competence and challenge stigma.