November 2001: Lesbians and Breast Cancer

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Tell healthcare providers I'm gay?

Question from Celia: I have not told many people that I'm gay. Should I let my health care providers know that I'm gay?

Answers —Lisa Weissmann, M.D.: Absolutely. It's really important to be as open as possible with your health care provider. The only way I, as a physician, can take care of my patients is to know who they are and what their needs are. It takes a great deal of courage to come out to your health care provider, but finding somebody that you can trust and that you feel safe with is an important part of the physician-patient relationship.

Cheryl Pearson-Fields, : I think that safety is a very good point. It's important to come out to your health care provider so they can treat the entire person, but I also believe that you have to judge each situation individually and come out when you believe it's safe to do that, and sometimes that's difficult to do.

Making sure my partner has rights?

Question from One of Two: I want my partner to be accepted as an equal, just as the husband of a heterosexual woman would be accepted. How do I make sure she gets the information, concern for her well-being, and visiting and next-of-kin rights that she deserves?

Answers —Lisa Weissmann, M.D.: To the extent possible, include your significant other in the doctor visits so that the physician or health care provider will know who's important to you and in your life. There are many legal steps that we as lesbians should be taking to protect our relationship. Specifically, we should all look to having durable power of attorney health care proxies and wills so that our relationships are validated in law as well as in love.

Marisa Weiss,, M.D., president and founder: A good way to start this respectful relationship between your partner and your doctor is to make sure that you introduce your partner to your doctor on every visit until your doctor gets to know her. And when you do make this introduction, make it clear that this person is very important to you. And make it clear that the doctor can feel free to share private information to both of you—if that's what you want.

Cheryl Pearson-Fields, : I think all of those are very important. We have had instances of patients trying to bring their partners to health care visits, particularly to hear results from cancer screenings and have had their partners not allowed in the room.

Marisa Weiss,, M.D., president and founder: How did they handle that?

Cheryl Pearson-Fields, : They ended up hearing they had cancer alone. They weren't allowed to bring their partner in the room. One thing that's important is not only to have patients advocate for their own health care and their own comfort while accessing health care, but to work with providers around their patients and what's important to lesbians, and that any gay relationship is as valid as a heterosexual relationship and that partner should be included.

Marisa Weiss,, M.D., president and founder: I am a straight doctor, but I do take care of many women who are gay, and I feel very comfortable in that setting. But I have to say that as a doctor I feel like I have been the one to invite them to feel open with me. I have not yet had the experience of having a lesbian patient say to me that it's important that you know that I am gay and that I have special needs. And I think it would be easier for me to take care of such patients if they were so forthcoming.

Lisa Weissmann, M.D.: Marisa, you make a really interesting point, and it reminds us of the first question of this evening concerning whether it is safe to come out to your provider. Even though I'm a physician, as a lesbian I also feel anxiety when I go to my doctors and have to come out to them for the first time. Therefore, I can empathize with other lesbians who may be less comfortable with being in a doctor's office and that it would take a great deal of courage for someone to then educate the health care provider about what their needs are.

Part of this problem is trying to be dealt with by educating physicians about their own internal homophobia and the homophobia of the medical establishment. While this certainly is changing particularly in the major cities, it remains a problem for many of the physicians that patients need to see.

Marisa Weiss,, M.D., president and founder: I struggle with this because I'm not sure how to create the right feeling and atmosphere that will put this tough issue at greater ease. It is a delicate give and take. On one hand, I want to create an open environment that invites them to feel more comfortable, but on the other hand I'm not always sure what the preference is of the woman who is in front of me and what the relationship might be. I hope tonight that I will learn more from the participants of the conference so I can do a better job.

Cheryl Pearson-Fields, : One way we can do that is to ask questions of our patients.

Lisa Weissmann, M.D.: This is actually one of the areas where the Mautner Project has been looking at how to bring down the barriers to access to health care for lesbians and Removing the Barriers Program which is really looking as to how to sensitize health care providers to the presence of gays and lesbians in their practice and to be sensitive to their needs.

Marisa Weiss,, M.D., president and founder: Cheryl, do you think it's best to ask this question of each patient verbally or on an initial personal information form?

Cheryl Pearson-Fields, : I think so. It should be on the form because often that's a first thing that a new patient encounters in your practice, and so it will set the stage for a perception of your openness to talking about these issues. The fear of some providers is that if they ask some patients may be offended by the question. But I think it's easy to explain you want to provide the best care possible to all of your patients, so you ask the same questions of everyone.

Marisa Weiss,, M.D., president and founder: That's an excellent point.

Lisa Weissmann, M.D.: Speaking as a breast cancer specialist, one of the ways that I ask the question of whether my patient is gay, bisexual, or straight is who do they turn to for support and who would they like me to include in the conversations. I find that often feels very open-ended, which really allowed them to tell me where they turn. It's a great question for me when I'm talking to my straight patients because I may find that their support does not come from their husband or partner, but may come from other family members or their friends. And it's a wonderful way to allow my gay and bisexual patients to identify who's important to them.

Marisa Weiss,, M.D., president and founder: Do you ask this in front of the person they're with?

Lisa Weissmann, M.D.: If they introduce me to their partner and have told me this is their significant other, and unless they've made that very clear and explicit, I will ask them who I should include in the conversation.

Cheryl Pearson-Fields, : Other ways that you can show your openness to discussing this issue is by displaying in your office a non-discrimination policy statement that includes sexual orientation, along with a host of other characteristics such as race, ethnicity, age, disability, gender, etc. Another way is to have available lesbian health education information. Mautner has education pamphlets for lesbians that people can put in their offices. It's important to put information where it is accessible and where patients can get it. So, instead of putting a lesbian health information display or brochures in the waiting room, maybe put them in the exam room, so people can grab it. It also sends a message and they can get the info they need.

Marisa Weiss,, M.D., president and founder: Can individual patients get the brochures from Mautner and bring them into doctor's offices for other women?

Cheryl Pearson-Fields, : Yes. Absolutely.

Keeping records confidential?

Question from Marylnn: How can I be sure that if I come out to my health provider my personal records will stay confidential? I am not comfortable with the thought of this information falling into the wrong hands (i.e., work).

Answers —Lisa Weissmann, M.D.: Wow, that's a tough question. It has far-reaching ramifications and is being intensely debated as we look towards protecting patient privacy, particularly in this age of the Internet and computerized charts. Having said that, if you feel comfortable coming out to your health care provider, you should discuss with him or her how you would like that information recorded in your chart. Some euphemisms that health care providers use to protect patient confidentiality are statements such as "sexually active, no contraception needed," which is a clue that the person is a lesbian. What I do in my practice is I will identify whom the person wishes me to include in the conversation, so I may say "support provided by" and list the person, but I don't identify the relationship in any sexual connotation.

Cheryl Pearson-Fields, : You can also (before disclosing) ask what your provider's policies are on sharing your chart information in a general way, one that doesn't tip your hand about orientation. And if you feel comfortable with those answers, then you may be able to pursue disclosure.

Lisa Weissmann, M.D.: The problem is in this day and age, even though we may think a person's charts are held confidentially by the physician, the insurance company has full rights to obtain information if they're paying the bill for a diagnosis. And so some physicians will turn over the chart or copy the chart if the patient gives signed consent. One of the most important things a patient can do is to read the fine print really carefully about what they're being asked to disclose about their medical information, because without a signed consent no physician can release any information from the chart unless the patient agrees.

Doctors' stereotypes about lesbians?

Question from Non-stereotype: Why do so many medical professionals assume all lesbians smoke, drink, and are stressed out? It really makes me angry.

Answers —Lisa Weissmann, M.D.: I hear you and much of that information comes from data on lesbians that was drawn from research that was obtained at bars and softball games—wherever researchers could find a high concentration of lesbians. Therefore, much of the original data on lesbian health was somewhat skewed because if you ask how many people drink in a bar, it will probably be pretty high. Newer epidemiologic studies trying to incorporate a much broader and diverse group of self-identified lesbians are showing while some of these stereotypes do indeed characterize lesbians in general, there is as much diversity within the lesbian population as without. Nevertheless, lesbians as a whole tend to have a slightly higher weight and have slightly higher rates of alcohol use and cigarette use, past or present, than similarly aged straight women. This clearly is of concern for the health of the lesbian population.

Cheryl Pearson-Fields, : This issue really speaks to the importance of funding population-based research on lesbian health because while there has been a number of studies on lesbian health, as Dr. Weissmann pointed out, they got to the people that were easy to get to. It takes money to do randomized studies of lesbians. It's very difficult methodologically to do those studies, but I think the next wave of lesbian health research will be moving in that direction.

Lisa Weissmann, M.D.: Cheryl, you bring up an excellent point, and some of the real political work that is going on in lesbian health is really looking to push the government agencies, such as the CDC and the NIH, to start including lesbians as a group to be studied in large national surveys. There are many national health surveys where we would love to see sexual orientation included in the demographics so we can finally get a real picture of what the state of lesbian health is and what the risks are for lesbians in the future. The recent Healthy People 2010 (health policy for the entire country looking at where we should be in ten years for the health of the nation) has a 60-page addendum (or white paper) attached to this document looking at the health concerns of gays and lesbians which will hopefully push the government towards looking specifically at funding gay and lesbian research. And then maybe we'll find out whether we all drink and smoke and are stressed too much, or maybe that's only because we worry about softball.

Cheryl Pearson-Fields, : There are two critical things around that document. One is in addition to the white paper, earlier this year there was a Healthy People 2010 companion document that was released that addressed exclusively the need of lesbian, gay, bisexual, and transgender people. That is a 500-page document. The other issue is that for the first time in history lesbian and gay issues were added to the data tables for Healthy People 2010. Hopefully we will see data being collected on sexual orientation in those large studies that will continue in the future.

Marisa Weiss,, M.D., president and founder: Where can our breastcancer.org community users go to read the existing report?

Lisa Weissmann, M.D.: www.glma.org (The Gay and Lesbian Medical Association) was one of the major contributors, along with many others including Mautner and Columbia. But on the website of GLMA they have a link where you can order a copy of the companion document.

Cheryl Pearson-Fields, : The White Paper is available on their site as well.

Reaching out to estranged family?

Question from Janis D: My family hasn't spoken with me since they learnt of my relationship. Now I have been diagnosed, I really need their support but don't know how to approach them.

Answers —Lisa Weissmann, M.D.: Without knowing the specifics, what I would say is that most families will hopefully reach out to you in your time of need. I think that being able to speak with your family honestly about your diagnosis and explaining to them how important it is to you at this moment in time to feel that you have their support at least around this medical issue may help them find some way to be able to reach out to you. Many families may have difficulty acknowledging and/or accepting a gay child's lifestyle, but will be moved to be a parent in support of their child when they are ill or suffering emotionally. So how comfortable you feel telling your family about your medical condition and your diagnosis and explicitly asking for their support will at least let you know where you stand and where you need to turn to get the support you need.

Marisa Weiss,, M.D., president and founder: This hope and expectation of your family is so natural and important. It is also possible that they may not come through and that will feel like a profound disappointment.

Cheryl Pearson-Fields, : I think people have to judge their family realistically. And sometimes they will disappoint you. We have certainly had patients whose families found out about their partner and their homosexuality after they were diagnosed with cancer, and there have been many scenes around the country and in hospitals between partners and families. It's really important to be clear in those cases with your health care provider on who you designate as responsible if you can't make your own health care decisions, and that's where having legal documentation is important.

Marisa Weiss,, M.D., president and founder: I have sat through several uncomfortable meetings where these issues were brewing. I was able to help my patients in those settings by asserting a level of respect for each person in the room and by addressing my patients and her partner as a team, but also being respectful of the parents. I think that helps a great deal establish a healthy atmosphere in which to take the best care of each other. In two of these situations, this was orchestrated ahead of time after a careful discussion with my patients. Together we decided how to handle it. She told me how she wanted me to lead this situation. Again, by letting your doctor know who you are and the issues that challenge you, you can help them take better care of you.

Increased breast cancer risk?

Question from My Day: I read somewhere that there is an increased chance of a lesbian contracting breast cancer. What is the reasoning behind these findings and what can I be doing to ensure I am minimizing my risks?

Answers —Lisa Weissmann, M.D.: That is a common thought in the lesbian community, and there may be some truth to the possibility that lesbians as a group have a higher risk for developing breast cancer. This was first suggested by Dr. Suzanne Haynes, based on the data that was available at the time showing that lesbians had an increased number of risk factors for the future development of breast cancer, specifically obesity, increased alcohol consumption, lower rate of having children, and a lower rate of breast screening. Further studies by Doctors Dibble and Bowen suggest that while perhaps not all of these risk factors are present in the lesbian population, at least several may indeed increase our risks for the future development of breast cancer. However, until we have large national studies, we won't know for sure. Some of these risk factors are certainly in our individual control, such as alcohol consumption and obesity.

But it's really difficult to counsel lesbians to have children under the age of 25 to reduce their risks of breast cancer. Therefore, the same things that increase the risk for breast cancer in straight women similarly increase the risks for lesbian women. So it's not something unique to being a lesbian that confers the risk of breast cancer, but that lesbians as a group may have risk features at a higher percentage. For you as an individual, all the things that we have to be able to do to reduce the risk of breast cancer hold true, such as eating a healthy diet, avoidance of alcohol, exercise, and don't smoke. The statistics on alcohol would suggest drinking less than 3-5 drinks of alcohol per week.

Marisa Weiss,, M.D., president and founder: Also, I would add that whatever you can do to reduce the stress in your life and increase the enjoyment of your life will make you feel better in general. While no direct connection has been made between high stress and a high risk of breast cancer, it all makes sense that reducing the stress in your life will improve your health. Connecting with each other can make a big difference. The Mautner Project offers programs that allow you to develop this connection.

Cheryl Pearson-Fields, : We offer support groups for lesbians with cancer. We also offer opportunities for lesbians to come together through volunteer work that creates an environment that is supportive of women in general.

Marisa Weiss,, M.D., president and founder: breastcancer.org has ongoing discussion boards that enable women to connect with each other.

Lisa Weissmann, M.D.: I'd like to talk a little about stress because one thing that all lesbians share is the stress of homophobia and that has not been researched. As lesbians in this homophobic country (some places more and some less), how does this stress affect our health? Is the obesity and smoking and alcohol a reaction to the external stress that we feel from homophobia, and how does that impact on our health?

Cheryl Pearson-Fields, : In addition to the behavioral risk factors that Dr. Weissmann talked about earlier is that these factors are compounded by the barriers to accessing health care, so that even if all things are equal, lesbians tend to delay seeking health care because of those heterosexual assumptions and barriers related to homophobia. Often what happens is that cancers are found at later stages or lesbians put off going to the doctor until it's almost too late.

Marisa Weiss,, M.D., president and founder: I think as part of the critical issues to look at is how you view your own diagnosis of breast cancer relative to the guilt you may feel or a complex you might have in response to the homophobia. I've had patients who've admitted that they think their breast cancer occurred as punishment for being gay. This is a painful way to live. And these types of feelings often need to be addressed so that you can move through this experience to (hopefully) a better place.

Cheryl Pearson-Fields, : Sometimes that victim blaming is external as well—messages are communicated that it's the patient's fault. And while not specific to breast cancer, physicians have told patients that their vaginal infections were due to abnormal sex practices; i.e., lesbian sex practices. That's a huge burden for a patient.

Lisa Weissmann, M.D.: We all know there are people out there who will seek to assign blame to those groups that they fear. We need look no further than after 9/11 when Jerry Falwell decided it was the fault of the gays and lesbians—a retribution—for blowing up the World Trade Center.

Will doctor's attitude change?

Question from Michelle: I have recently been diagnosed with breast cancer. I have to go back to the surgeon next week and want to take my partner with me, but am afraid that my doctors' attitude towards me will change if they know I am gay.

Answers —Lisa Weissmann, M.D.: If your doctor's attitude changes because you're gay, find another doctor. You need to feel comfortable with the person who's about to take care of your body, and if you have the ability or the option of choosing your physician (which not all of us have the luxury of doing), I urge you to take or include your partner with you. You may be pleasantly surprised that your physician is more open than you might otherwise think, but even if you're disappointed in their response, it will give you information you need about who you want to be part of your team taking care of you. So as much as is possible, absolutely include your partner and see if your physician will live up to the expectations that you should require.

Marisa Weiss,, M.D., president and founder: When you bring your partner for the first time, if you feel very uncomfortable and nervous, your doctor may sense this and feel unsure of how to relate to you. You may assume your doctor knows that the person with you is your partner. But two things can happen here. One is that your doctor may have no idea who this person is unless you communicate that. Also, if your doctor feels uncomfortable because you feel uncomfortable, it may not be hostility but rather just simple social discomfort. Here's where clear communication can make a big difference. It would be a shame if these important things were misinterpreted and you lost confidence in your doctor unnecessarily.

Cheryl Pearson-Fields, : If your doctor does not rise to the occasion after clear communication, if it is at all possible take advantage of referral networks for gay and lesbian friendly health care providers. These can be available from the Gay and Lesbian Medical Association or from a gay and lesbian community center or lesbian cancer project, should you be lucky enough to have either one in your community. Also take advantage of word of mouth. Talk to other lesbians about providers that they have found to be sensitive. Unfortunately, in our society with managed care, it's becoming more and more difficult to find lesbian-friendly health care providers or to access the ones that do exist because you're restricted to a certain number of providers, but if you can, those referrals are there, and it can make your health care experience less threatening.

Helping partner after mastectomy?

Question from Wonder: My partner has had a mastectomy and it has affected her attitude towards me. Now she won't let me touch her and is shutting me out. I want to show her that I love her with or without the breast.

Answers —Cheryl Pearson-Fields, : I think that's a common issue for all women who have had mastectomies, and often we forget that support needs of partners of cancer patients. But it's important to allow your partner time to accept what's happened to her body. That may take a longer period of time than you think, and she may not be ready for you to show her that it's okay with you. She may need to go through her grieving process first, and it's important for you to be there and accessible when she panics at your attention.

Marisa Weiss,, M.D., president and founder: Many women who've had breast cancer sometimes feel much less attractive, particularly if they've lost a breast. They may assume that their experience is their partner's experience. If you want to support her, you should let her know that you still feel very attracted to her, in spite of the changes that breast cancer treatment has brought on. Clearly, this process of accepting yourself as changed and bringing each other back into a feeling of intimacy will take time and a lot of sensitive attention.

Lisa Weissmann, M.D.: Again, to follow up on what Cheryl and Marisa said, it's really important to understand that cancer affects not only the patient but those who love her. Just as any person whose been diagnosed with cancer should be offered emotional and psychological support, so should her partner. In many cities, lesbians are lucky enough to have support groups, not only for the patient with cancer, but for their partner as well, so that they can explore and examine some of their emotional needs and feel supported as they, too, are having to make changes and adjustments in their relationship. For other women who do not have access to such support groups, perhaps finding a supportive family counselor or therapist may help the couple be able to have clear lines of communication and support around these changes between them.

Cheryl Pearson-Fields, : The Mautner Project coordinates the National Coalition of Feminist and Lesbian Cancer Project. If you're interested in finding out whether or not there is a lesbian or lesbian-friendly support group in your area, you can contact the Mautner Project. If there's not a support group in your area, there are also wonderful online lesbian cancer support groups where partners are included in the discussions and are involved, and that might be a wonderful place to receive support.

Cancer more difficult for lesbian partners?

Question from Pat-2: Would you agree that the experience is more difficult for lesbian partners than it is for male partners? Is this why couples sometimes split up?

Answers —Cheryl Pearson-Fields, : I think it's difficult for all partners. There aren't the obvious support systems for lesbian families or couples that exist for heterosexual couples. That places an added burden on lesbian couples. But I'm not sure if it's more difficult than for heterosexual couples.

Marisa Weiss,, M.D., president and founder: Do you think there are ways that it's easier for lesbian couples than for heterosexual couples to counterbalance this a little, in terms of communication and talking things through?

Cheryl Pearson-Fields, : I think that intimacy levels are different for lesbian couples. Communication may be different for lesbian couples. There is a sense of 'us against the world' that may add to resilience for our families in facing health crisis, but I don't have any research on that.

Lisa Weissmann, M.D.: To echo what Cheryl said, I think that much of the perceived increased difficulties for lesbian partners is from the lack of support from the external world, and I think it's a sign of amazing lesbian resilience that more couples don't divorce during these stressful times.

Support groups for friends of lesbians?

Question from SF Carl: Are there support groups for friends of lesbians with cancer?

Answer —Cheryl Pearson-Fields, : I have not seen any for friends of lesbians, although the Mautner Project offers support groups for partners and caregivers. So, if you are the friend of a lesbian and are asking as her caregiver, you can access that support group.

Self-conscious with new partners?

Question from Jessie: I have only just accepted my sexuality. I have not had many relationships and now have to face this. I have had a partial mastectomy and feel very self-conscious about how I look. What are new partners going to think when they see me?

Answers —Cheryl Pearson-Fields, : I think it's important to be honest up front, and not to have this discussion in the bedroom.

Marisa Weiss,, M.D., president and founder: The best sex and intimacy occurs within the context of a good relationship, so the best place I think to start is working on and enjoying the building of a relationship together, so that when the right time comes to get to know each other on a more physical level, you will have a greater chance of acceptance and excitement and confidence in what's possible with this new person in your life.

Lisa Weissmann, M.D.: As we start new relationships with anybody, one of the challenges (and also one of the joys) is getting to know the other person, with all the history and baggages and events that have made the person who it is that you're falling in love with. If this is a relationship that you hope to make more serious, then developing a trusting open line of communication should help ease your concerns and your fears as you approach physical intimacy.

Partner angry at my diagnosis?

Question from Hopeful: My partner has been very angry since my diagnosis—I can't put my finger on why. I need her support, but she seems to be blaming me for getting this disease and interrupting our lives.

Answers —Cheryl Pearson-Fields, : Your partner may be experiencing a lot of fear about what's happening to you, and that may be being expressed as anger. It's important for the two of you to be able to talk about your emotions around this diagnosis, and it may be important for her to take some time or to go outside the relationship for support to a support group and work through her issues and fears. That might be helpful for the two of you.

Marisa Weiss,, M.D., president and founder: It is also very normal, as we've pointed out this evening, to be angry—for you to experience anger as well as the people who are close to you. Cancer really stinks! The whole experience can turn your lives upside down and really shake things up. I think the anger is a healthy response to what's happened, but it's also important to work through that anger and then, more specifically, address the various things that you might be upset, fearful, angry, jealous, shamed, etc. about. A diagnosis of cancer can bring on all kinds of 'ugly' feelings, and these feelings can make you feel worse about yourself. You may end up feeling less worthy and less in many different categories. You really have to work hard to hold on and get some help to get out of that way of thinking, getting the support that you need, and learning to accept help from others is an important part of that process.

International lesbian health organizations?

Question from Pat-2: Does the Mautner Project have links with anything similar in the U.K. and Europe? Can we contribute to the work of the project in any way?

Answers —Cheryl Pearson-Fields, : Of course! I'm not aware of any similar organizations that exist in the U.K. There is some work being done in Canada around lesbian health, and I believe in Australia around lesbians with cancer.

Marisa Weiss,, M.D., president and founder: Thank you to our U.K. participant who is up at 4AM to participate in this event.

Cheryl Pearson-Fields, : You can always contribute to the Mautner Project. You can go to our website. There are ways to contribute through that. In the United States, you can designate the Mautner CFC (Combined Federal Campaign).

Marisa Weiss,, M.D., president and founder: Also breastcancer.org would welcome your support for a program such as this and the support of our discussion boards in this area.

Cheryl Pearson-Fields, : I don't remember if I said this before we got on the conference or after, but the Mautner Project will be convening the National Lesbian Cancer Conference in 2002. This will be the second national conference on lesbians and cancer, and it will be held in Washington, D.C. Information will be announced on the Mautner Project website about the conference (dates, times, etc.). This conference is really geared toward inviting lesbians with cancer and their partners, as well as health care professionals, lesbian cancer organizations, grassroots activists, and lesbian cancer researchers.

Lisa Weissmann, M.D.: I would like to thank Marisa and breastcancer.org, and Cheryl from the Mautner Project for doing fabulous work on the issues of breast cancer and lesbians with breast cancer. I urge lesbians who are dealing with new diagnoses of breast cancer to look for support from their communities, from their health care providers, and from the organizations that you've heard about tonight to support you during the difficult times of your diagnosis and in the years to come.

Marisa Weiss,, M.D., president and founder: Thank you, Dr. Weissmann, who has been an amazing member of our professional advisory board, and to Cheryl Fields, for your invaluable contribution tonight, and to the Mautner Project, which has been a terrific collaborator on this event. And thank you to Pat in the U.K., who's on our Consumer Advisory board that helps us devise new programs that are enlightening, youthful, and appropriately sensitive.

Cheryl Pearson-Fields, : I want to thank Marisa and breastcancer.org for including this issue in their conference and recognizing the unique needs and concerns of lesbians with cancers.