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

Psychooncology. 2021 Jul;30(7):1145-1150. doi: 10.1002/pon.5670. Epub 2021 Mar 10.


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.

Keywords: African Americans; Psycho-oncology; decomposition; intersectionality; sexual and gender minorities; trust.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Black or African American
  • Breast Neoplasms* / diagnosis
  • Cross-Sectional Studies
  • Early Detection of Cancer
  • Female
  • Healthcare Disparities
  • Humans