Systemic Issues Contribute to Health Inequities in LGBTQ+ Community

Individuals in the LGBTQ+ community are generally more likely to experience discrimination and health disparities, and this can have implications in nephrology care, according to Yuvaram Reddy, MBBS, MPh, FASN, an assistant professor and the director of Diversity, Equity, and Inclusion for the Renal-Electrolyte & Hypertension Division at the University of Pennsylvania in Philadelphia. Reddy spoke in a session at the American Society of Nephrology (ASN) 2023 Kidney Week Annual Meeting in Philadelphia, Pennsylvania, taking place November 2 to 5.

Behaviors often called “risky,” which can become a part of the patient narrative (i.e., tobacco use), may inadvertently be catalyzed by systemic issues, leading to worse health outcomes.

“The system isn't really designed for everyone,” Reddy said during the session.

Image credit: 9nong | stock.adobe.com

Reddy listed 6 factors that drive health disparities in the LGBTQ+ community: social determinants, inequalities, lack of access to inclusive care, safety, silos, and stigma. These could all contribute to the inability to, or discomfort in, receiving care within this community.

“But to be quite frank, you can take out the LGBTQ+ from the center of that circle and replace it with another underrepresented or marginalized community, and the disparities and buckets that are there are quite similar,” Reddy said.

Discrimination can be linked to depression—a health factor related to stigma—and LGBTQ+ youth are particularly vulnerable. A 2022 Trevor Project survey reported that 45% of youths in this community seriously contemplated suicide that year, Reddy said. And among adults, transgender adults were 4 times as likely to have made a suicide attempt in their lifetime compared to cisgender heterosexual adults.

Transgender adults are also more likely to feel mistrust toward the health care system, Reddy said. Although factors like economic security work to promote access to health care, 1 in 3 transgender adults have experienced homelessness. Further, 2 in 3 are reported to feel concern about health evaluations being impacted by sexual orientation or gender identity (SOGI), and this issue can directly relate to nephrology.

Reddy remarked that there are not many awareness campaigns about dialysis for LGBTQ+ individuals, which can lead to insecurity about receiving care and limit the number of people who are willing to self-report their sexuality or gender at transplant clinics or dialysis facilities.

At the dialysis or treatment center, more patients in this community will also say they live alone, Reddy added. A lack of social support (or feeling like there is a lack of social support) can seriously impact health outcomes.

“There may be folks that are going to a hemodialysis center and not really thinking about living donor donation because they're afraid about what their clinicians or their health care system might say,” Reddy said.

Ultimately, disease and stigma might just circle in an unhealthful, negative cycle; dealing with severe kidney disease can exacerbate mental health issues or contribute to concerns like smoking or obesity, and stigma and discrimination can increase stress which worsens health and exacerbates the disease, Reddy said.

In addition, obesity and tobacco use are risk factors for CKD, although gay women have a significantly higher rate of both compared to cisgender heterosexual women.

“You can postulate why this might be in concert with other [data] about [rates] of economic insecurity, housing insecurity and access to food,” Reddy said.

Other effects of discrimination include alcohol and drug use, financial instability, lack of social support, obesity, and not having health insurance, Reddy said. Moreso, the impact of discrimination on health equity is apparent at the political level—much of the United States does not have progressive laws or initiatives that support LGBTQ+ people.

“There are about 25 states that have harmful or discriminatory laws against the LGBTQ+ community [and] this is 40% of LGBTQ+ Americans,” Reddy said.

Fortunately, there are many ways to improve inclusivity in a kidney care practice, according to Reddy. These include, but are not limited to:

• Including gender or relationship options on patient intake forms
• Using the correct pronouns with the patient
• Avoiding the term “homosexual” or saying “partner” if the patient did not offer a specific title for their significant other
• Becoming comfortable with asking questions about sexual and substance use history
• Having single-use or all-gender bathrooms
• Promoting staff training about gender
• Following research related to caring for patients in the LGBTQ+ community
• Having pride flags (“because they do matter!” Reddy said) displayed in the space

“Many factors lead to health care disparities for members of the LGBTQ+ community…the prevalence of these factors [and] the exact mechanisms for how these happen are understudied, and more research is needed” Reddy concluded. “Intentional individual and organizational efforts can move the needle, and we're slowly starting to do that.”

Reference

Reddy Y. Health Care Disparities in the LGBTQ+ Population. Session. ASN Kidney Week Annual Meeting. November 2 to 5, 2023. Philadelphia, PA.