Multiple Barriers Impact Kidney Care Disparities in LGBTQ+ Individuals

The American Society of Nephrology (ASN) Kidney Week 2023 featured a group of presenters who focused on the health care disparities in the LBGTQ+ community and how these factors influence kidney care outcomes, discussed the value of considering intersectionality for patient care, and evaluated the impacts of gender-affirming care on kidney function.

To begin, Yuvaram Reddy, MBSS, MPH, FASN, assistant professor, Renal-Electrolyte & Hypertension, Perelman School of Medicine, Penn Medicine, dedicated his presentation to highlighting the disparities affecting LGBTQ+ patients with kidney disease and their clinicians. Data he displayed painted a detailed picture of the factors that drive health disparities in this population, including social determinants, legal and insurance inequity, lacking access, safety concerns, and stigma.

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

A primary factor Reddy emphasized is mistrust in the health system stemming from generations of discrimination and fear. These challenges have contributed to data revealing that transgender adults are significantly less likely to receive their flu shot or attend routine doctor visits compared with cisgender adults. Furthermore, stigma surrounding LGBTQ+ individuals in the health care setting have led to 2 in 3 transgender adults reporting concerns that their orientation or gender identity will affect their health evaluations.

Stethoscope and Pride Flag | Image Credit: Verin - stock.adobe.com

The LGBTQ+ community also has a higher prevalence of risk factors for chronic kidney disease (CKD), such as smoking tobacco and obesity. Speculating on these influences, Reddy pulled data demonstrating that 1 in 3 transgender individuals report annual household incomes below $25,000. The culmination of these data is important because it demonstrates how not one singular factor contributes to disparities experienced by LGBTQ+ individuals, that it's a conglomeration os several factors. Reddy pointed to economic and food insecurity that can influence obesity rates and bar culture (historical safe spaces for the LGBTQ+ community) and pride parade sponsors influencing tobacco use.

Demonstrating how multiple factors can put LGBTQ+ individuals at higher risks for kidney disease, Reddy emphasized the value of taking intersectionality into consideration when thinking about patient care and the issues that have an impact on their health. Dinushika Mohottige, MD, MPH, adjunct assistant professor, Department of Medicine, Duke University of Medicine, continued the discussion by exploring how race and class interact with LGBTQ+ identity and affecty health outcomes.

Insurance rates for sexual and gender minorities differ according to race, he noted. For example, data from The Williams Institute show that Black patient insurance rates are 5% higher among LBGTQ+ individuals than non-Black individuals, and this trends similarly for White, Native Hawaiian/Pacific Islander, and Native American/Alaskan Native patients. Furthermore, the impact of social determinants of health varies within sexual and gender minority communities, such as low income, which affects LGBTQ+ Black and Latinx individuals at nearly 20% higher rates compared with LGBTQ+ White individuals.

Overall, sexual orientation and gender identity data are lacking, according to Mohottige’s assessment. She presented figures showing that Black individuals, women, and those with annual incomes less than $20,000 are statistically more likely to discuss dialysis than transplant; however, these data do not account for the unique experiences of individuals whose identity encounters multiple intersecting dimensions of inequality. For example, a transgender woman of color living with HIV is simultaneously affected by racial structures; stigma surrounding her gender identity, expression, and HIV status; and possibly class.

She asserted, “Being a sexual and gender minority person is not the risk factor,” and highlighted the need to truly understand how backgrounds, social positions, and values have an impact on data collection, care, and analysis of many of these patients.

Nephrologist David Collister, MD, MPH, assistant professor, University of Alberta, built upon the sentiments of Reddy and Mohottige by presenting data on how acute kidney injury (AKI) and CKD impact transgender, nonbinary, and gender diverse patients. Referring to Mohottige’s presentation specifically, he mentioned the lack of data in this subject is due to many studies not including transgender individuals in their cohorts.

The main focus of his presentation analyzed the impact of gender-affirming hormone therapy (GAHT) on kidney function. In short, studies on hormone replacement therapy have indicated that estrogen does not affect blood pressure in these patients, although it can decrease albuminuria. Analyses of testosterone in the human body, too, have indicated that low testosterone is associated with increased mortality in the setting of CKD and dialysis. Furthermore, anabolic steroid use is associated with a decline in estimated glomerular filtration rate (eGFR), and androgen deprivation therapy is linked with AKI. Collister highlighted the importance of understanding how these hormones interact with kidney function, because recent analyses shown AKI and CKD impact the transgender population at rates exceeding 30%.

Collister continued by presenting findings from 24 studies on the impact of GAHT on kidney function. Across these studies, effects on serum creatinine, blood urea nitrogen levels, eGFR, and 24-hour urine creatinine were reported. No studies reported on cystatin C, nor the performance of measured GFR, albuminuria, or proteinuria. An important takeaway from these results is that creatinine in transgender men increased, while in transgender women it did not.

Samira Farouk, MD, MS, FASN, transplant nephrologist, Icahn School of Medicine at Mount Sinai Mount, brought the panel discussion to a close by addressing transplant care for transgender patients. Similar to her colleagues, she highlighted the lack of data on this subject and the need to increase research efforts.

Much of her data echoed that presented by Collister, as she reiterated what clinicians know about the impact of GAHT on kidney function. She also presented data on how gender-affirming surgeries can affect kidney allograft. Complications from procedures modifying patients’ genitals or breasts can influence the development of scar tissue, difficulty urinating, and injuries to the urinary tract, as well as contribute to AKI or hypercalcemia with silicone injections.

Farouk highlighted the need for thoughtful GFR estimations as well because current models for eGFR related to sex assigned at birth may cause confusion or not apply patients in the transgender community.

As each presenter concluded their discussions, they addressed for mitigating the disparities and challenges that LGBTQ+ individuals face in health care settings. Among these solutions, they suggested implementing inclusive language before clinicians get to know their patients’ preferences, working to fully understand the effects of intersectionality and stigma on patient access to care, and increasing and modifying research efforts to gather appropriate data and improve care approaches for this communities.