Tackling Violence and Stigmatization to Decrease Cancer Disparities for Transgender Patients With Ash Alpert, MD, MFA

At the recent American Society of Clinical Oncology (ASCO) Annual Meeting in Chicago, Illinois, Dr. Ash Alpert, a postdoctoral fellow in health services research at Brown University, presented two posters regarding the associations between violence and cancer risk factors for transgender and cisgender people. In this follow-up interview with Oncology Data Advisor, Dr. Alpert delves further into the implications of these two studies’ results and shares how their ongoing research in this field seeks to improve the care of transgender people in the health care setting.  

Oncology Data Advisor: Welcome to Oncology Data Advisor. Today I’m here with Dr. Ash Alpert. Thank you so much for joining us.

Ash Alpert, MD, MFA: I’m Dr. Ash Alpert. I’m a postdoctoral fellow in health services research at Brown University, and I’m a hematologist and medical oncologist. My research focuses on improving the experiences and outcomes of transgender people with cancer.

Oncology Data Advisor: Would you like to tell us a little bit about the two posters that you presented at ASCO recently?

Dr. Alpert: Sure, I’d be happy to. One of the posters was about associations between violence and cancer risk factors for transgender and cisgender people, and the other poster was about the prevalence of cancer risk factors in transgender and cisgender people, so very similar.

What we did was we developed a database of transgender people seen at our institution, which was the University of Rochester, where I did my fellowship. We did this by a combination of keyword searches and diagnosis codes, and then there was a question in our electronic health record, “Does your gender differ from your sex assigned at birth?” We used those three methods, pulled all of the folks that we found with those methods, did a manual review of their charts, and then created a matched cisgender cohort based on age and follow-up time.

Then, trying to find experiences of violence was another challenge for us. Experiences of violence are not well documented with diagnosis codes, so we decided to develop a keyword search. We developed a list of keywords based on the literature around different types of violence.

We were looking for intimate partner violence and violence that people experienced in childhood, including in families. We were looking for violence experienced with strangers. We were looking for hate-based violence—so violence related to racism, transphobia, or other aspects like that—and then we were also interested in violence experienced with police and in prisons and in the context of war. We really wanted to find the breadth of the experiences that people were having.

We used various risk assessment tools. We used qualitative research. We brought in experts in different types of violence. We brought in emergency department physicians, social workers, and other folks to help us enrich this keyword list, and then we tested it with randomly selected cisgender people and then eventually a small group of transgender people as well, because we wanted to see how well it worked. We iterated on it over and over again until we felt like we had a pretty good list, and then we ran that in our transgender and cisgender cohort to look for experiences of violence.

We were never able to find realistic numbers of violence in the elderly population or violence experienced with police or in prisons, so that was interesting to us. What does it mean potentially about our list, but also what does it mean about what’s being documented in the electronic health record, and why?

Once we had looked for violence, we looked for associations between violence and cancer risk factors, including body mass index (BMI) greater than or equal to 40, smoking, and a number of other things, especially viruses like human immunodeficiency virus (HIV), hepatitis, and human papillomavirus (HPV). What we found was that trans people experience very, very, very high rates of violence, much higher than the rates of violence experienced by cisgender people at various times in the life course and in many, many different settings. It was not surprising to see that, but it was very upsetting and stark to see that.

In our sample, one half of the transgender people had experienced some type of violence. One third of transgender people had experienced violence in childhood. One quarter had experienced violence from family members, and the numbers go on and on. All of our P values comparing the violence experienced by trans people to the violence experience by cis people were less than 0.001. It’s very, very distressing to see those numbers.

Then the other thing that we found is that for cisgender and transgender people, violence is statistically significantly associated with BMI greater than or equal to 40 and smoking. The numbers of people with the viruses that we looked for were so small that we weren’t really able to assess for association, but for these cancer risk factors, they were strong, and the P values were always less than 0.05.

Oncology Data Advisor: So, with these results in mind, is there any way that practicing oncologists can begin to apply them to practice?

Dr. Alpert: I think in general, oncologists don’t think about violence as an issue that affects their patients. But in this study, I think the most important thing that we’ve shown is that violence is an issue for the oncology community to consider. In addition to talking about behavioral interventions and other things to help people quit smoking or lose weight, we really need to think about stigma, discrimination, and violence—how those are oftentimes outside of the control of the individual and how we have the power to impact them with laws and policies and even the ways that we conduct ourselves in our clinics.

So, although we did actually look at violence experienced in health care, we didn’t report this in the study, but we also looked at stigma that we found in the notes of clinicians. I think that is one thing that all clinicians can think about—what are the types of violence that patients are actually experiencing in the clinical setting, especially when those are patients who experience marginalization and stigma in general, and how can that be intervened upon?

Oncology Data Advisor: Do you have any other research ongoing in this area?

Dr. Alpert: The next steps are to think about how we can further explore stigma that trans people are experiencing in health care settings and add that to our data. We’re working with something called structural equation modeling, and the way that works is you create a model of how you think things fit together. In other words, people experience violence, this leads to mental distress, and that leads to cancer, but also the violence itself leads to cancer, so we are going to plug the stigma that trans people experience in medical settings into our model and see if that makes it fit better.

Oncology Data Advisor: That’s exciting. Thank you again for sharing this with us today.

Dr. Alpert: Thank you so much for asking about it. I really appreciate it.

About Dr. Alpert

Ash Alpert, MD, MFA, is a hematologist/medical oncologist and a postdoctoral fellow in health services research at Brown University School of Public Health in Providence, Rhode Island. Their research focuses on improving the outcomes of transgender people with cancer, particularly on creating patient-centered methods for gender identity data collection and understanding the connections between violence and cancer. They also work with oncology organizations, including ASCO, to ensure oncology guidelines are gender-inclusive. In 2020, Dr. Alpert was the recipient of a Young Investigator Award from ASCO’s Conquer Cancer Foundation.

For More Information

Alpert AB, Sayegh SJ, Strawderman MS, et al (2022). Cancer risk factors and cancer in transgender versus cisgender people: Real-world data from a tertiary health care institution. J Clin Oncol (ASCO Annual Meeting Abstracts), 40(suppl_16). Abstract 6538. DOI:10.1200/JCO.2022.40.16_suppl.6538

Alpert AB, Sayegh SJ, Strawderman MS, et al (2022). Associations between interpersonal violence and cancer risk factors for transgender and cisgender people. J Clin Oncol (ASCO Annual Meeting Abstracts), 40(suppl_16). Abstract 6516. DOI:10.1200/JCO.2022.40.16_suppl.6516

Transcript edited for clarity. Any views expressed above are the speaker’s own and do not necessarily reflect of Oncology Data Advisor. 

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