Disparities impact asthma care, research among LGBTQ+ community

Key takeaways:

• Sexual and gender minorities are health disparity populations for research.
• Poor insurance coverage reduces engagement in specialty care.
• Clinical guidelines do not call out sexual orientation.

WASHINGTON — Research about how sexual orientation and gender identity impacts asthma is beginning to emerge, but gaps remain, according to a presentation at the American Academy of Allergy, Asthma & Immunology Annual Meeting.

“There is a significant portion of the U.S. population that identifies as lesbian, gay, bisexual, transgender or queer questioning,” Dinah Foer, MD, assistant professor, divisions of allergy and clinical immunology and general internal medicine and primary care, Brigham and Women’s Hospital, said during her presentation.

Finding the differences

Although approximately 7.2% of adults in the United States identify themselves as members of these groups, Foer said, reference populations in research and in society at large typically are heterosexual, cisgender and male.

“So much so that the NIH has recognized that sexual and gender minority populations are a health disparity population for research,” Foer said.

Foer cited a U.S.-based scoping review of 22 articles that found higher rates of asthma among sexual minority women, although these results were not uniform. But in more than 50% of the studies reviewed, there were no differences in asthma rates between men who were heterosexual and those who were not.

“The authors of this scoping review suggest that there was a variability that could be due to unmeasured factors, many of which are going to be related to social determinants of health but were not systematically studied in the articles,” Foer said.

Potential modifiers may include BMI among women, stress and smoking.

“There were significant differences in smoking histories between gay and bisexual men and women compared to heterosexual populations, with the most significant smoking burden seen in bisexual men and lesbian women,” Foer said.

Another cross-sectional study that used data from the U.S.-based All of Us Research Program found lower odds for asthma among gender-diverse people assigned male at birth and transgender women compared with cisgender heterosexual women.

“But in contrast, all the other sexual orientation and gender minority groups have higher odds of asthma compared to the nonminority groups,” Foer said.

Compared with other frequently studied diseases such as cardiac disease, HIV, and depression and anxiety, Foer continued, these findings indicate considerable variation in asthma risks based on sexual orientation and gender identity.

Foer also participated in a study conducted at a small, single institution that explored the effect of sex in choosing reference ranges during pulmonary function testing (PFT) among transgender and nonbinary patients.

“Then we did post hoc calculations by substituting the opposite gender as the reference range,” she said.

Changing the gender did not change the detection of obstruction, although there were values above and below lower limits of normal for FEV₁ in five of 15 patients and for forced vital capacity (FVC) in five patients, with changes in both FEV₁ and FVC in three patients.

Based on these findings, the researchers said that the use of male predicted FEV₁ and FVC values for female-sized bodies could lead to pseudo-restrictions, with the reverse scenario masking true restrictions.

However, they continued, the gender reference assignment did not affect the presence of obstruction based on predicted FEV₁/FVC. Also, the effects of concurrent and prior or pubertal hormone use on lung function and height both was unknown.

“We also found that regardless of the sex assigned at birth, or the gender identity of the patient, or if in current hormone use, most providers had chosen a female gender reference range for the PFT,” Foer said. “If you’re scratching your head, we were too.”

These findings prompted Foer and her colleagues to ask how providers decide what gender they use when they conduct PFTs for their transgender and nonbinary patients.

Social determinants of health

Additionally, Foer asked how social determinants of health (SDOH) may contribute to differences in asthma prevalence by sexual orientation and gender.

“Unfortunately, while SDOH is extensively studied in the LGBTQ+ population, there’s really a lack of studies applying and quantifying those effects in asthma,” Foer said. “So, I don’t think that should stop us or should be used as an excuse to stop us from looking at the evidence that’s already here and thinking about how it might apply to our patients.”

For example, transgender individuals are twice as likely to live in lower income housing compared with the general U.S. population, Foer said, adding that traffic-related air pollution exposures and condemned or infested housing may have an impact.

Occupational exposures based on gender roles also contribute to asthma triggers, Foer continued.

“Similarly, social and community contexts have higher rates of mental health conditions that are known asthma comorbidities,” she said.

These populations also have lower rates of insurance coverage that reduce engagement in subspecialty care such as allergy and asthma treatment, Foer said. Education and income advantages might not translate to better health outcomes either, she added, particularly among lesbian adults, which is unique among minoritized populations.

“While the contribution of SDOH to asthma outcomes in gender minority patients has not been systematically studied, I think we can use some existing data to foresee how those studies might turn out,” Foer said.

Foer noted work indicating significantly less likelihood for transgender adults to get flu shots and attend routine doctor visits compared with cisgender adults, along with findings indicating that three in five transgender adults smoke cigarettes.

“So, we start to see how all these features, these considerations of SDOH, may likely drive a significant portion of the increase in asthma risk that we see in gender minority populations,” Foer said.

Research challenges

Although clinical guidelines inform care, Foer said that she was unaware of any guidelines that specifically call out sexual orientation in relation to asthma management, although some guidelines now reference gender, and PFT guidelines recommend the use of sex assigned at birth.

Global Initiative for Asthma and other asthma guidelines have not considered these populations yet, Foer continued, although the National Institute for Occupational Safety and Health has begun evaluating how pulmonary disability should be determined in transgender and nonbinary workers.

“They’ve actually developed this two-question screen and then a more complex algorithm that informs which PFT reference range that they use,” Foer said.

Another challenge in determining how asthma impacts these populations can be found in the limitations of the data sources for this research, Foer said.

“In recent years, there have been increasing calls from journals, from funding organizations, to include diverse populations in our research, including sexual orientation and gender,” she said.

“But in our rush to do so, I think it’s incredibly important to slow down and to acknowledge the limitations of existing datasets before we actually do more damage than we intend to do with these data,” she continued.

Data sources such as convenience samples, population-based surveys, social media, community-engaged research, electronic health records and claims have limitations, Foer said, adding that sample size and diversity, missing data and ascertainment of gender identity, sex assigned at birth and sexual orientation also are challenging.

These problems are particularly evident in studies of asthma and SDOH based on EHRs, Foer said, noting one system that uses three demographic fields — administrative sex, gender identity and assigned sex at birth — for sex and gender.

“Among all health system patients, only 19% of patients had all three fields filled out,” Foer said. “This highlights one reason why the inclusion of gender minority populations in research remains so challenging, even when we’re using this real-world health data.”

Further examination of the EHR metadata revealed changes to the information in these fields. Although patients directed providers in making these changes in some cases, Foer said, most were made by administrative staff, with other changes caused by the EHR’s interactions with other record systems.

“We want all the EHRs in the world linked so it’s going to be easy for us, right? But those EHRs can actually change the fields, the data in those fields, about our patients, about ourselves,” Foer said. “We’re raising a lot of questions about the accuracy of the data that we are using for our research studies.”

To circumvent these incomplete entries and changes, Foer said that she and her colleagues trained and validated a deep learning model to predict gender based on data and free text notes, including validated patients, that outperformed other approaches with excellent predictive performance.

“While I think we’re all appropriately wary about replicating the systemic biases in our emerging artificial intelligence systems, I think there are also clearly tremendous opportunities that might actually benefit our efforts to include more diverse populations in research,” she said.

Conclusions, next steps

Although sexual orientation and gender are relevant to asthma, Foer said, their relationship to asthma has not been systematically studied.

“I think that probably many of the differences that we see are driven by SDOH considerations,” she said.

Foer also called for additional research to inform asthma guidelines and translate findings into clinical care settings.

“Finally, it is always important to think what is the accuracy of our data sources and what are the tools available to us, because that is really the prerequisite for clinically meaningful interventions for our patients with asthma,” she said.