V1
Provider Pack
Breaking down barriers to LGBTIQ+
inclusive cancer careAbout this booklet
Live Through This is the UK’s only LGBTIQ+ cancer charity. This means our unique expertisehas been sought nationally across different cancer settings. So we can maximise our reachand deliver on our promise to improve cancer services for all LGBTIQ+ patients, we havecreated this booklet, which combines some of our core training and information, so thateveryone can begin to improve the LGBTIQ+ inclusivity of their local services.
This booklet should be considered as a whole, but we support individual pages being
displayed internally to improve staff awareness. For example, it may benefit your team(s) tohave our glossary to hand or to display our pronoun guide on your notice board. However,
we encourage you to display the Visible Commitments poster in a place where it can be seenby staff and patients. Guidance on how to do this can be found on page 15.
This booklet is intended to improve awareness of LGBTIQ+ issues in cancer and its
treatment, and how we as individuals and organisations can work together to address thebarriers to equitable care.
If you have read anything in this booklet that you would like further training on or would like tocommission a custom programme, resource or talk, please email us with your requirements
at contact@livethroughthis.co.uk
We aim to update this booklet in line with any new information or developments within thefield of LGBTIQ+ cancer health and care. For this reason, we recommend that you keep
regularly updated with our resources to be sure you have the most current version. You are
currently viewing Version 1. You can be notified of the publication of any updates to thisdocument or additional resources by registering for our mailing list which can be found on our
website www.livethroughthis.co.uk
This booklet and its contents are not intended for any form of reissue, reproduction or resale.
Please reference this booklet or Live Through This when promoting its ideas. In APA format,
this would look like: Live Through This. (2021). Provider Pack: Breaking down barriers to
LGBTIQ+ inclusive cancer care, V1.
I hope that you find the contents of this booklet interesting, informative and useful. By
appreciating the fundamentals of LGBTIQ+ affirmative healthcare, I firmly believe that we can
improve the patient experience for all.
I look forward to us making this progress together.

Supporting and advocating for
Stewart O’Callaghan (they/them)
LGBTIQ+ people affected by cancer
Founder & Executive Director

Registered Charity 1190756

Supporting and advocating for
LGBTIQ+ people affected by cancer

The basics
The initialism ‘LGBT’ refers to Lesbian, Gay, Bisexual and Transgender people.
Being lesbian, gay or bisexual is an example of a sexual orientation, whereas beingtransgender is a form of gender identity. You may see ‘LGB’ used when referring only tosexual orientations. ‘LGBT’ is used as a more collective term for all sexual orientations andgender identities, but there are variations of this initialism that make this more apparent.
Sometimes you may see a plus to refer to ‘others’ (LGBT+), sometimes a ‘Q’ is added forqueer (LGBTQ), at times you may see culturally specific versions with third gender
representation such as Two Spirit (LGBT2S). At Live Through This we opt for LGBTIQ+ to
include intersex people. All forms are valid.
Sexual Orientation (SO) is how a person feels sexually about different genders. Sexual
activity does not always indicate sexual orientation. Because of this, we at times will see theterms women who sleep with women (WSW) and men who sleep with men (MSM) as
inclusive labels of sexual activity.
Sex refers to the biological characteristics that define humans as female, male or intersex,
the latter also being known as variations of sex characteristics (VSC).
Gender is the social construct that we use to label our characteristics, social norms,
behaviours and social roles as masculine, feminine or third gender. Our gender identity (GI)is where we see ourselves in this social coding.
This interplay between our sex, which is commonly assigned to us at birth by a medical
professional, and our gender identity is what gives us the labels cisgender and transgender(trans). A person who is cisgender will have a sex that aligns with their gender, whereas aperson who is trans will have a sex assigned at birth that does not align with their gender.
Non-binary people may also identify as trans if they experience this lack of alignment, but it isimportant to note that they do not identify their gender within the binary constructs of ‘male’and ‘female’.
This lack of alignment, referred to as gender incongruence, can lead to feelings of discomfort
or distress that may be experienced physically, mentally and socially. We call these feelings
gender dysphoria.
Based on their identity, LGBTIQ+ patients have:••••

Been refused care or treatment
Feared poorer levels of care or treatment
Been unable to access or attend screening in the same way as others
Reported lower satisfaction scores in numerous health surveys

It is important that providers of healthcare or support are able to help their LGBTIQ+ patientsnavigate the barriers they face when accessing care. We hope that this booklet will provide
an introduction to the area of LGBTIQ+ affirmative care and assist you in creating positivechange for the improvement of patient experience.

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A brief glossary
LGBTIQ+ community language is as rich and nuanced as its community members. Here is abrief list of common terms currently in use. This list is by no means exhaustive and we
encourage all people to engage with their local community in order to appreciate local andcultural variations.
Ace
An umbrella term to include variations in an
absence of sexual or romantic interest, including
the experiences of asexual, aromantic,
demisexual, demiromantics and grey-As.

Gay / Homosexual
A general label for same sex attraction. Most
commonly used with men who are exclusively or
preferentially attracted to other men in an
emotional, sexual and/or physical manner.

Agender
A lived experience that does not relate to gender.

Gender
A social construct informed by the norms, roles
and behaviours that we attribute to being
masculine, feminine or third gender.

Ally
A person who supports and advocates for
LGBTIQ+ people.
Assigned Female at Birth (AFAB)
Any person whose sex assignment at birth
resulted in a declaration of "female”.
Assigned Male at Birth (AMAB)
Any person whose sex assignment at birth
resulted in a declaration of "male”.
Biphobia
Prejudice, discrimination, fear or dislike towards
someone that is bisexual based on their identity.

Gender confirmation / affirmation
Replacing the term ‘Gender Reassignment’.
Gender dysphoria
The discomfort felt between one’s gender andtheir sex assigned at birth. This may be mental,
physical or social.
Gender fluid
A form of gender and expression that is not fixed.
Gender identity
An individual's personal sense of having aparticular gender.

Bisexual
An individual who is attracted to more than one
gender. One should not assume this is always anequally weighted attraction to different genders.

Heterosexism / Heteronormative assumptions
A system of attitudes or beliefs that assumes orfavours opposite sex relationships and attraction.

Cisgender
A person whose gender identity aligns with thesex they were assigned at birth.

Heterosexual
A person who is romantically or sexually attracted
to someone of a different gender.

Deadname
A trans person’s previous or birth name. It isconsidered offensive to use this name.
‘Deadname’ can be used as a noun and a verb.

Homophobia
Prejudice, discrimination, fear or dislike towards
someone that is homosexual based on theiridentity.

Demisexual
A person who only experiences sexual attraction
once they have an emotional bond with a person.

Intersectionality
Theory introduced by Prof. Kimberlé Crenshaw todescribe how multiple facets of a person’s identity
can combine to make unique forms of oppression
and discrimination.

Enby
Colloquialism for non-binary.
FTM / MTF
Referring to Female-to-Male / Male-to-Femaletransition.

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Intersex
A general term used for a variety of instances inwhich a person is born with reproductive or
sexual characteristics that do not fit the typicaldefinitions of female or male. They may express
their gender as male, female or non-binary.
Clinically known as Variations in Sex
Characteristics (VSC).

Lesbian
A woman who is exclusively or preferentiallyattracted to other women in an emotional, sexual
and/or physical manner.
LGBT
Initialisation of Lesbian, Gay, Bisexual andTransgender. Used to refer to the broader sexualand gender minority community.
LGBTQIA+A variant of LGBT that includes Lesbian, Gay,
Bisexual, Transgender, Queer, Intersex, Asexualand others.
LGBT-phobia
Prejudice, discrimination, fear or dislike towards
someone that is LGBT based on their identity.
Men who have sex with men (MSM)
A term for any man who has sex with men to
include homosexual, bisexual, pansexual andthose who do not identify as a sexual minority.
Non-binary
A term for people who do not identify with thediscrete categories of male and female. This term
includes a variety of gender expressions.
Outing someone
Identifying someone as LGBTIQ+ without theirconsent. This is considered extremely harmful as
there may be social factors or issues of safety
involved in a person’s choice to be discreet.
Pansexual
A person whose attraction to others is notconstrained by sex or gender.
PronounA word that takes the place of a noun in a
sentence. The most common third-person
pronouns we encounter are he, she and they.
Correct pronoun use corresponding to a person’s
gender is important.
Queer
An umbrella term for LGBTIQ+ people. Also
refers to a mode of critical theory and political
discourse. It is a reclamation of a slur.
Sex
The underlying biological profile of a person. It
influences a range of bodily responses that areimportant in tackling infection or disease.
Sexual minority
Individuals who do not identify as heterosexual.
Gender minority may also be used for individuals
who do not identify as cisgender.

Sexual orientation
A person’s sexual feelings towards certain
genders. Activity does not equate orientation assome people will have same-gender sexual
activity for various reasons and not classify
themselves as LGB+.
Sexuality
A term referring to someone’s sexual attractions,behaviours, kinks and desires. Sexuality is a term
broader than sexual orientation to encompass asense of what a person enjoys and with whom.
SOGI
Shorthand for sexual orientation and gender
identity.
StealthCommunity term describing the ability to live as
your gender without disclosing your transition.
Third Gender
A distinct form of gender from that of male orfemale. Often culturally informed with a richhistory such as the Hĳra, Māhū, Fa’afafine,Two-Spirit and Muxe.
Top surgery
Common term for bilateral mastectomy and malechest reconstruction.
Trans(gender) man
A man who was assigned female at birth.
Trans(gender) woman
A woman who was assigned male at birth.
Transfeminine
A person who was assigned male at birth but
whose gender identity is more female than male.
TransgenderAn umbrella term for a person whose gender
identity differs from the sex they were assigned atbirth.
Transmasculine
A person who was assigned female at birth but
whose gender identity is more male than female.
Transphobia
Prejudice, discrimination, fear or dislike towards
someone that is transgender based on theiridentity.
Women who have sex with women (WSW)
A term for any woman who has sex with womento include homosexual, bisexual, pansexual andthose who do not identify as a sexual minority.

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An introduction to LGBTIQ+
experiences of cancer support
It is estimated that 5-7% of the UK population identify as lesbian, gay or bisexual1 (LGB) andcancer has higher rates of incidence and risk in these communities. The government does
not currently collect any robust data for transgender (trans) people. We know that lesbians
are less prevention oriented in their health care behaviour and avoid routine screening tests
such as Pap smears and mammograms,2 gay men can show up to a twofold increase indiagnosis of cancer with HIV being a risk factor3,4 and have a higher risk of anal cancer5,6,7
and trans people report poorer health8 and a higher incidence of late stage diagnoses due tohealthcare access issues or avoidance.4,6,9
An intersectional approach is key in appreciating the lifestyle factors and socioeconomic
disparities associated with increased risk of cancer in LGBT+ (lesbian, gay, bisexual, transand others) people.9,10,11 Therefore, there needs to be a complimentary focus in care toaddress these stressors and their subsequent risk behaviours in this population.9,12,13
Smoking is an area that has received some attention12 however research into the LGBT+
experience of cancer is largely underexplored.10 Other socioeconomic factors for LGBT+
people include barriers to education, gainful employment and access to healthcare.3,4,9,14
Research is so sparse that in order to comment, inferences must be taken from around theglobe and thus we must be mindful of cultural variations of accessing healthcare for LGBT+
patients, such as barriers to acquiring health insurance for private healthcare.8,10
It is important for a patient’s wellbeing for them to be their authentic selves,15,16 however, due
to the difficulty in coming out and the fear of other people’s responses.3,10,17 This is especiallythe case for bisexual patients.15 Patients may go ‘back into the closet’ in order to avoid
anticipated complications in their clinical interactions.7,15,17,18 Sensitivity is required toappreciate the compound stress and the social stigma from being both LGBT+ and a cancer
patient.17 One must note that whilst a healthcare provider may not be overtly prejudiced,
microaggressions, heterosexist assumptions and behavioural cues can often give rise to this
discordance.3,4,7,10,17,19,20,21,22,23 Providers tend to report confidence regarding LGBT+affirmative care24 despite gaps in their knowledge.24,25 Of these respondents, around only aquarter spoke to their patients about gender or sexual orientation, contesting that their care
was sufficient without including this consideration.4,24 Recording gender identity or sexual
orientation is often avoided out of fear of offence, despite only 10% of patients respondingthat they would feel this way.26 Likewise, attempts at inclusion must take into account the
aforementioned social stigmas and barriers faced by this population that leads topsychosocial stress posing further risk to their health9 in addition to the intersectional natureof race.3,4,11 Without these considerations, patient adherence begins to wane as they lose
confidence in their care and their agency in the decisions being made.3,17,23,27 While ourpolitical and social climate moves towards acceptance, we must note that it was not until the
Equality Act of 2010 that it was made illegal for organisations to discriminate against
characteristics such as sexual orientation. Therefore, due to the typically higher age range ofcancer patients, this is a lived memory for some in addition to the AIDS epidemic and theillegality of homosexuality.21
Both LGB and trans patients report poorer quality of life and mood markers when comparedto their cisgender and heterosexual peers.4,9,29 This self reported outcome is in part due tonegative healthcare interactions but also the lack of additional support available. LGB
patients are significantly less satisfied with the written information provided around diagnosis
and subsequent care.27 In order to improve the uptake of information it is important torepresent LGBT+ people in supporting media and divert from the current over-representationof heterosexual imagery.17,30 This is key for trans patients and the assumptions made inprovided information about the body at screening, during treatment and in remission.10,17,31,32
An example of this is the overt gendering of breast and gynaecological cancers as women’sLive Through This
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cancers, which becomes a barrier for trans patients seeking care and may be an attributing
factor to later stage diagnoses.10,32 Also to consider is the outcome of potential mastectomy
and the different nuances to be appreciated with non-binary or trans patients when
discussing their chests.23,31,32 Likewise the conversation surrounding wigs is often gendered toovert femininity or relating to an assumed male partner, which leaves some patients avoiding
the service all together.7
LGBT+ patients are more likely to report that no family or friends are involved in theircare.17,22,27 Family and friends are key to both emotional and social support respectively,3,28
but one patient interviewed suggested that “An LGBTI person who has to live with theirheterosexual family is more socially isolated than a heterosexual person in the same
situation.”22 Therefore it is important to find ways to support the psychosocial needs of
LGBT+ patients as a lack of adequate support leads to fatalistic attitudes and social
isolation.3,17,21,27,28,29 Patients emphasised the importance of support groups,9,17,21 especiallythose with a targeted focus reflecting their identity.22,25 Patients report being more satisfied
with support when it comes from someone who is aware of their orientation.26,28 This reflects
the importance of queer agency31 in the patient’s experience of support and care as theyoften demonstrate a better understanding of the impact of how their LGBT+ identity
intersects with other factors in their lives, such as illness.17,32 The use of peer support throughLGBT+ specific support groups is a key source of information for trans patients32 as opposedto the heavily gendered presentation of other support groups that may be discussing specificcancers.32 To give another example, the discussion of anal cancer in gay men can be better
facilitated by social initiatives where sex and intimacy are discussed with greater ease than in
the standard healthcare setting.7,17 Community is a key factor for LGBT+ people and building
a supportive framework to compliment this through cancer therapy is a goal that benefits
professionals, patients and future research.9,17
The hesitation of individuals to discuss gender and sexual orientation is often rooted in a lackof information or confidence with these sensitive topics. Whilst accessing and supporting thispatient demographic is vital it is also important not to ‘out’ an individual who has chosen not
to disclose their sexual orientation or gender history. Instead, a more appropriate goal is tomake the service suitable to every individual on the gender identity and sexual orientation
spectrums so that patients may find a knowledgeable, accessible and supportive
environment in which they might feel that they can share themselves fully. Ultimately,engaging with patients about how their health intersects with their life is crucial in supporting
their psychosocial needs, treatment adherence and also demonstrating sensitivity andcompassion to a population who may otherwise fall into social isolation and additional
detriment if not properly supported.
Document Published: May 2019Live Through This
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— References —1. The Department of Business, Enterprise and Regulatory Reform [Internet]. Final
Regulatory Impact Assessment: Civil Partnership Act 2004. https://webarchive.nationalarchives.gov.uk/20090609004826/http://www.berr. gov.uk/files/
file23829.pdf (accessed on 7.03.2019)
2. Fish J. & Anthony D. (2005). UK national Lesbians and Health Care Survey. Women
Health, 41(3), 27-45. doi: 10.1300/J013v41n03_02. PMID: 15970574.
3. Boehmer, U. (2018). LGBT Populations’ Barriers to Cancer Care. Seminars in Oncology
Nursing, 34(1), 21-29.
4. Ceres, M., Quinn, G.P., Loscalzo, M. & Rise, D. (2018). Cancer Screening Considerations
and Cancer Screening Uptake for Lesbian, Gay, Bisexual and Transgender Persons.
Seminars in Oncology Nursing, 34(1), 37-51.
5. Goldstone, S., Palefsky, J.M., Giuliano, A.R., Moreira, E.D., Aranda, C., Jessen, H.,
Hillman, R.J., Ferris, D.G, Coutlee, F., Liaw, K.L., Marshall, J.B., Zhang, X., Vuocolo, S., Barr,E., Haupt, R.M., Guris, D & Garner, E.I. (2011) Prevalence of and risk factors for humanpapillomavirus (HPV) infection among HIV-seronegative men who have sex with men.
Journal of Infectious Diseases, 203(1), 66-74.
6. Institute of Medicine. The health of Lesbian, Gay, Bisexual and Transgender People:
Building a foundation for better understanding. Washington DC: National Academy of
Sciences; 2011.
7. Fish, J. & Williamson, I. (2018). Exploring lesbian, gay and bisexual patients’ accounts of
their experiences of cancer care in the UK. European Journal of Cancer Care, 27.
8. Jennings, L., Barcelos, C., McWilliams, C., Malecki, K. (2019). Inequalities in lesbian, gay,bisexual and transgender (LGBT) health and health care access and utilization in Wisconsin.
Preventive Medicine Reports, 14, 100864.
9. Matthews, A.K., Breen, E. & Kittiteerasack P. (2018). Social Determinants of LGBT Cancer
Health Inequities. Seminars in Oncology Nursing, 34(1), 12-20.
10. Quinn, G.P., Schabath, M.B., Sanchez, J.A., Sutton, S.K. & Green, B.L. (2015). The
importance of disclosure: Lesbian, Gay, Bisexual, Transgender/ Transsexual, Queer/
Questioning and Intersex Individuals and the Cancer Continuum. Cancer, 121(*), 1160-1163.
11. Damaskos, P., Amaya, B., Gordon, R.A. & Burrows Walters, C. (2018). Intersectionality
and the LGBT Cancer Patient. Seminars in Oncology Nursing, 34(1), 30-36.
12. Kamen, C., Blosnich, J.R., Lytle, M., Janelsins, M.C., Peppone, L.J. & Mustian, K.M.
(2015). Cigarette smoking disparities among sexual minority cancer survivors. Preventive
Medicine Reports, 2, 283-286.
13. Baskerville, N.B., Dash, D., Shuh, A., Wong, K., Abramowicz, A., Yessis, J. & Kennedy,
R.D. (2017). Tobacco use cessation interventions for lesbian, gay, bisexual, transgender andqueer youth and young adults: A scoping review. Preventive Medicine Reports, 6, 53-62.
14. Ravishankar, Mathura (January 18, 2013). "The Story About Robert Eads". The Journalof Global Health. Archived from the original on September 14, 2013. Accessed May 26,
2019.
15. Durso, L.E., Meyer, I.H. (2013). Patterns and Predictors of Disclosure of Sexual
Orientation to Healthcare Providers Among Lesbians, Gay Men and Bisexuals. Sex Res
Social Policy, 10, 35-42.

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16. Axtell, S. (1999). Disability and chronic illness Identity: Interviews with Lesbians andBisexual Women and their Partners. Journal of Gay, Lesbian and Bisexual Identity, 4(1),53-72.
17. Kamen, C. (2018). Lesbian, Gay, Bisexual and Transgender (LGBT) Survivorship.
Seminars in Oncology Nursing, 34(1), 52-59.
18. St Pierre, M. (2012). Under what conditions do Lesbians disclose their sexual orientation
to primary healthcare providers? A review of the literature. Journal of Lesbian Studies, 16(2),199-219.
19. Sabin, J.A., Riskind, R.G. & Nosek, B.A. (2015). Health Care Providers’ Implicit andExplicit Attitudes toward Lesbian Women and Gay Men. American Journal of Public Health,105, 1831-1841.
20. Irwin, L. (2007). Homophobia and heterosexism: Implications for nursing and nursing
practice. Australian Journal of Advanced Nursing, 25(1), 70-76.
21. Hill, G. & Holborn, C. (2015). Sexual minority experiences of cancer care: a systematic
review. Journal of Cancer Policy, 6, 11-22.
22. Jowett, A. & Peel, E. (2009). Chronic illness in non-heterosexual contexts: An online
survey of experiences. Feminism & Psychology, 19(4), 454-474.
23. Carr, E. (2018). The Personal Experience of LGBT Patients with Cancer. Seminars in
Oncology Nursing, 34(1), 72-79.
24. Shetty, G., Sanchez, J.A., Lancaster, J.M., Wilson, L.E., Quinn, G.P. & Schabath, M.B.
(2016). Oncology Healthcare Providers’ Knowledge, Attitudes and Practice Behaviors
Regarding LGBT Health. Patient Educ Counsel, 99, 1676-1684.
25. Griggs, J., Maingi, S., Blinder, V., Denduluri, N., Khorana, A.A., Norton, L., Francisco, M.,
Wollins, D.S. & Rowland, J.H. (2017). American Society of Clinical Oncology Position
Statement: Strategies fr reducing Cancer Health Disparities among Sexual and Gender
Minority Populations. Journal of Clinical Oncology, 35(19), 2203-2208.
26. Maragh-Bass, A.C., Torain, M., Adler, R., Schnieder, E., Ranjit, A., Kodadek, L.M.,
Shields, R., German, D., Snyder, C., Peterson, S., Schuur, J., Lau, B. & Haider, A. (2017).
Risks, Benefits and Importance of Collecting Sexual Orientation and Gender Identity Data in
Healthcare Settings: A Multi-Method Analysis of Patient and Provider Perspectives. LGBT
Health, 4(2), 141-152.
27. Hulbert-Williams, N.J., Plumpton, C.O., Flowers, P., McHugh, R., Neal, R.D. & Semleyn,
J. (2017). The cancer care experiences of gay, lesbian and bisexual patients: A secondary
analysis of data from the UK Cancer Patient Experience Survey. European Journal of Cancer
Care, 26, e12670.
28. Grossman, A.H, D’Augelli, A.R. & Hershberger, S.L. (2000). Social support networks oflesbian, gay and bisexual adults 60 years of age and older. Journals of Gerotology, 55(3),171-179.
29. Boehmer, U., Glickman, M. & Winter, M. (2012). Anxiety and depression in breast cancer
survivors of different sexual orientations. Journal of Consulting and Clinical Psychology,
80(3), 382-395.
30. Blank, T.O. (2005). Gay men and prostate cancer: Invisible diversity. Journal of ClinicalOncology, 23, 2593-2596.
31. Horncastle, J. (2018). Practicing care: queer vulnerability in the hospital. Social Identities,
24(3), 383-394.
32. Taylor, E.T., Bryson, M.K. (2016). Cancer’s margins: Trans* and gender nonconforming
people’s access to knowledge, experiences of cancer health and decision making. LGBT
Health, 3(1), 79-89.

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The Gender Triangle
Gender is often described as a spectrum to convey our
variations in personal experience, but what is the best
way to represent this idea visually?
The Gender Triangle, also referred to as the
Triangular Model of Gender, depicts thisspectrum between three commonly encounteredand socially defined genders: ‘female’, ‘male’and ‘third gender’. Introduced by Live ThroughThis’ founder Stewart O’Callaghan in 2020, thismodel allows us to think in new ways about
gender identity and how we might describe
ourselves to others if labels feel limiting.
Away from the binary
The Triangular Model moves us away from the idea that gender isbinary. Current popular models of gender identity in circulation often
rely on a single line that places ‘male’ and ‘female’ at polar opposite
points. This one-dimensional approach makes the assumption thatmale and female are absolute values of gender and that any othergender we encounter must exist somewhere between them on thisline. This view is too simplistic and fails to represent the breadth andnuance of the transgender and non-binary experience.
Third gender
By using a third value when modelling gender we are able to not only represent people who
identify as a third gender, but we also are able to broaden our understanding of the gender
spectrum. There are many third genders in the world such as the Fa’afafine of Samoa, theHĳra of India, the Muxe of Latin America, the Two Spirit of North America and the Burrnesha
of Balkan tradition to name a few. These are distinct forms of socially upheld gender identitywith varied histories and cultural importance attached.
Non-binary
By using the Gender Triangle we are able to more accurately
represent the variation in non-binary and gender-variant
experience. Assuming that all non-binary people are somewhere
on a fixed line between ‘male’ and ‘female’ has the potential toincorrectly infer some level of androgynous gender expression.
By using The Gender Triangle, we can appreciate that people
identifying as non-binary might include people with no feeling ofgender (agender), a partial feeling of gender (demigender),people who are third gender and any other identity that may exist beyond being either
exclusively male or female. By using this visual model, we present an opportunity todescribe one’s own gender identity without the need for labels which may support those
who do not wish to use or identify with them.

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AgenderThe Gender Triangle allows for a meaningful inclusion of agender people, those who do notexperience gender or identify with any of its labels. Other models tend to over-simplify or
exclude the agender experience from their models which can negatively affect our implicit
bias towards agender people. It is also important to note that being agender is not always
absolute and there can be multiple levels of intensity for gender identity. In the TriangularModel, a scale of agender experience is demonstrated by placing ‘agender’ centrally in the
broader gender spectrum. The further from the centre the person identifies, the stronger theexperience of their gender is in that direction, whether that be towards ‘male’, ‘female’, ‘third
gender’ or elsewhere in the spectrum.
Gender fluid
For some people, their gender identity may be fixed andinflexible. In the Triangular Model, this may be shown as a small
circle or point on the spectrum where the person identifies
their gender. For others, their gender may be more fluid. To
visualise this, a person might draw a larger circle, or any shapefor that matter, across the area of the spectrum that they feel
their gender moves between.
Fluid

A note on colours
The colours used in the Gender Triangle are merely arbitrary
placeholders to represent the differences between genders andhow they may overlap. Of course, this model is informed bywestern coding of gendered colours, but we appreciate thatparticular colour-coding of cancers and resources can alienate
some. We therefore encourage people to not only draw theirown personal shape on the Gender Triangle but also to assign
themselves the colours that feel are most correct to them.

Fixed

The Gender Triangle and you
Gender is a social construct and a spectrum of
personal experience. We hope that this model
helps to convey this idea and foster a greater
understanding of the trans and non-binary
experience. This model can also help us toappreciate these nuances in cisgender people
too, which may in turn support a greater
understanding of others.
We encourage you to think about how the The
Gender Triangle might represent your own
gender identity and what shape and colour you
might use to express yourself. Here we have a
blank diagram, so why not try it out for yourself?

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Pronouns
Correct pronoun use is important for everybody but especially for trans, non-binary andgender diverse people. Although pronouns are nothing new, some people may be unfamiliar
with discussing how they are used. This poster provides information and examples to help
everyone comfortably talk about pronouns in their own daily conversations. By normalising
the discussion around pronouns we can help to create an inclusive environment foreveryone.
The most commonly encountered pronouns are:Subjective

Objective

Possessive

Reflexive

ExampleShe

Her

Her(s)

Herself

She is a good boss. Her team appreciates her.

He

Him

His

Himself

He is a good listener. People like him.

They

Them

Their(s)Themself

We appreciate their skills. They are valuable.

Ze

Hir/Zir

Hir(s)/Zir(s)Hirself/Zirself

Ze works for zirself. Ze loves zir career.

Pronunciation guide: Ze; Zee / Zir; Zeer / Hir; Hear

It is always better to ask rather than assume
You should not assume a person’s pronouns based on their appearance. Instead, when
meeting someone new, take the opportunity to respectfully check which pronouns they use.
Remember, some people may use multiple pronouns.
Be gender inclusive when addressing groups
Consider using gender inclusive openers such as “Welcome everyone” as opposed to “Ladies
and Gentlemen”. This care can also be applied to other things such as letters, mailing lists,
posters, information and other public or group statements.
Try introducing yourself with your own pronouns
Leading with your own pronouns shows the patient that you are aware of their importance andthat you are a person they can be confident in for receiving respectful care. A potential
introduction might be: “Hello, I’m Dr Jones and my pronouns are he and him. May I ask yours?”
You can also include your pronouns inyour email signature, name badge, social
media or screen name in video calls
IF YOU MAKE A MISTAKE
Mistakes can happen, but it is our recovery that matters. Remember, a person’s pronouns maychange in the time that you have known them so it is important to remain open to this andcontinue to be respectful. If you do misgender somebody by using the wrong pronouns, wesuggest that you:
Acknowledge your error and apologise.
Ask which pronouns they use so you can get it right.
Correct yourself and demonstrate your changed behaviour.
Commit to using their pronouns consistently. Do not rely on others to keep correcting you.
Please remember that the small effort to learn and respect pronouns makesa large impact on the inclusion of trans, non-binary and gender diverse people.
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Towards disclosure
Stonewall reports that 1 in 5 LGBT patients are not out to any healthcare staff and 1 in 7
have avoided healthcare for fear of discrimination. Encouraging and supporting safe
disclosure can lead to better health, engagement, satisfaction and access to cancer
screening.
Factors affecting disclosure:
Facilitators
Challenging heteronormative assumptions
Inclusive language
Open body language
Healthcare provider is perceived as acceptingof LGBTIQ+LGBTIQ+ Healthcare provider
Accepting visual cues

Barriers
Heteronormative assumptions
Fear of breach of confidentiality
Fear of poorer care / discrimination
Healthcare provider is perceived as nonaccepting of LGBTIQ+
Lack of knowledge on LGBTIQ+ issues fromhealthcare provider
Unwelcoming location or setting

Three opportunities to welcome disclosure:1) Introductions: Welcome your patient with your name and your pronouns. This will set thetone for the conversation to be LGBTIQ+ inclusive and affirming.
2) Small talk: Ask if they have a(ny) partner(s). Avoid making assumptions based on thedetails shared. Let the patient explain their identity in their own words.
3) History taking: Ask respectfully about sexual orientation and gender identity. Position
questions in the interest of patient health. Be clear about the reason for asking to avoid being
seen as inappropriately curious.
Coming Out: Voluntary self-disclosure of one’s LGBTIQ+ identity
Outing Someone: Revealing a person’s identity without permission
Disclosure can be encouraged but should never be forced or coerced. Outing someone is aharmful act and in the case of a trans person’s gender history, it is against the law.
Ask patients who have disclosed their identity if they want this recorded. Explain to themwhere it will be stored, who will see it and how it may be used.
Help to create a visibly inclusive environment by placing LGBTIQ+ leaflets or posters in
waiting rooms, a rainbow sticker in the window, wearing a rainbow badge or lanyard.
Patients are not always aware of their health risks. Expecting them to lead disclosure basedon their knowledge of community or identity based risk is a flawed model of practice. It is thehealthcare provider’s responsibility to consider their patient’s identity and how it may relate totheir care.
The goal is to make an environment where LGBTIQ+ patients feel safe enough to discloseand support them when they choose to do so.

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Intersectionality
Introduced by Prof. Kimberlé Crenshaw, intersectionality is a framework that helps us
understand how different aspects of one’s identity may combine to create distinct, compound
forms of discrimination.
Intersectionality helps us to appreciate when a person is being impacted by multiple
inequalities and create appropriate responses or support.
Some examples of intersecting factors resulting in inequality might include:
A Black woman
An older trans man
A bisexual Asian Muslim woman
A multitude of factors make upeach and every person.
A person may be affected byother factors than those listed
here.
Taking a one-dimensional
approach to discrimination limits
the ability to appreciate thenuance and complexity of aperson’s experience.
Intersectionality is an important
tool to help us appreciate thesocial and structural barriers
affecting LGBTIQ+ people when
they are accessing healthcare
such as cancer screenings.
These attributes and their intersections exist within a context of society, structure and power
which can give rise to the barriers and inequalities experienced by the individual.
When addressing inequalities:••••

Appreciate all parts of a person’s identity and their potential impact
Be aware of compound barriers to accessing equitable care
Consider the context that the inequality is operating in and how it is relevant
Try to address both the individual factors and how they intersect

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Visible Commitments
Our Visible Commitments poster is an opportunity for you to demonstrate your understandingof LGBTIQ+ issues and your commitment to patient centred, affirming care.
To use this poster effectively, we recommend that you create a pledge for each colour or the
rainbow. These pledges should be actions or attitudes that promote inclusion that LGBTIQ+
patients can hold you to.
We recommend that:
•
•
•
•
•
•
•
•
•

The poster is printed in colour
The poster is completed in black ink only (manually or digitally)
Sufficient LGBTIQ+ training is provided before making pledges
The poster is completed and signed as a team with input from all levels of staff
Pledges are simple, affirming and achievable
You display the poster in a place where both patients and staff can see it
You laminate and monitor the poster to avoid it being vandalised
You place a point of contact below the pledges in the space provided
You review your pledges periodically should they need to be updated, expanded,
redefined or if any additional training is needed to meet them

We suggest that you follow any pledges dutifully. If an LGBTIQ+ person notices any
inconsistency between your actions and your pledges, this should be dealt with with utmost
humility and efforts be made towards a solution-focused resolution. If this resolution is not
immediately achievable, the person who raised the issue should be updated on, or be given
the opportunity to be involved in, the progress towards its resolution.
If non-LGBTIQ+ patients question the poster, we would suggest that you remind them thatthe pledges are there to create a more inclusive environment for all.
Pledges might include:
•
•
•
•
•

We treat everybody with respect
We have a gender neutral toilet which can be found (location)
We ask for and respect names and pronouns
We continue to train staff regularly on LGBTIQ+ inclusion
We provide private consultations rooms for those in needIf you are struggling to create your pledges, consider asking for patient input either directly,
via questionnaire or a focus group. Co-production and patient and public involvement are
fantastic ways to create authentic resources as well as build better connections with thecommunities in need.

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We strongly believe in supporting the LGBTIQ+
people who access our services. We do this by:Signed by: ____________________________________
If you have any feedback for our team, please direct it to:Registered Charity 1190756

Supporting and advocating for
LGBTIQ+ people affected by cancer

Virtual consultations
These top tips were developed to compliment the Virtual Consultation guidance produced by
the South East London Cancer Alliance. Please consider these points before virtual
appointments with trans patients.

T
R
A
N
S
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Treat me with respect
Every good conversations begins with respect. It is
important that I feel that I am accessing a service thatvalues me and my health without judgment. Asking me ifthere's anything you could do that might make me more
comfortable can be a great start.

Read my notes
Before calling me, make sure that you have read my notes
thoroughly. There may be information on my file that could
prepare you for our conversation regarding my gender orwhat support I might need when attending appointments.

Ask me for my name and pronouns
When you ask it shows me that our conversation is going
to be affirming of who I am. It also gives me an opportunity
to use the name that is safe for the environment I am inwhen you call. There may be times where I cannot use
certain details for personal safety or discretion.

Never assume my identity
When we are on the phone we lack the visual informationthat helps us to appreciate who we are speaking to. That
is why it is important not to make any assumptions about
me or my health based on characteristics like my voice.

Speak fluently and confidently
Any hesitation when discussing my identity, my care or my
options may be interpreted as discomfort or judgment. It is
important that you are able to speak in a way that shows
me that I am being treated fairly and with respect.

Accessing screening
Breast Screening
For trans men and non-binary people who have breast tissue:• Regular self-examination is recommended• Those who have not had top surgery/mastectomy should continue with regular screening• If they are registered as female they will be automatically invited for breast screening• If they are registered as male their GP should refer them to the breast screening service
for mammography
People who have undergone top surgery should continue independent monitoring of any
remaining breast tissue. They can use a standard cisgender male pattern for checking.
Please remember that they may wish to refer to their breast tissue as their “chest”.
Trans women registered as female with their GP will be routinely invited for screening fromages 50 to 71. Long-term hormone therapy may increase the risk of developing breast cancer
when compared to cisgender men. However, this risk is no greater than the risk experienced
by cisgender women.

Cervical Screening
Trans men and non-binary people registered as female with their GP will receive invitations
for cervical screening between the ages of 25 and 64.
Trans men and non-binary people registered as male with their GP will not be automaticallyinvited to screening and will need to request an appointment.
When conducting a cervical smear for a trans patient, the screening laboratory should becontacted directly advising them of a sample being sent from a trans person with a cervix.
This can also be included on relevant forms as “Patient with a cervix.”
To make the cervical smear more tolerable for transgender people with a cervix you can:• Check the name and pronouns the patient wants to use for the appointment• Arrange their appointment at the beginning or end of a clinic• Discuss the procedure and their options to improve comfort such as using a smaller
speculum, allowing the patient to insert it or taking one home to practice• Inform them of the higher rates of unsuitable samples and the possibility of a repeat test.
This may be related to testosterone or discomfort in the procedure• Explain that they will need to retrieve their results from the referring doctor/service andhow to do thisTrans women registered as female with their GP may receive invitations for cervicalscreening but will not be eligible. This should be explained to patients.
• When the patient re-registers their gender with their GP, the screening team should
contact the practice for a no cervix confirmation• If they do not, practices should submit a cease request via Open Exeter to CSAS before
the cut off shown on the Prior Notification List (PNL) to avoid inappropriate invitations

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