June marks Pride Month — an event that aims to recognize and celebrate LGBTQ+ communities worldwide. However, it also provides an opportunity to highlight the challenges that LGBTQ+ colleagues and nephrology patients continue to face, and the need to address health inequities.
The first Pride celebrations took place in the United States in 1970 — a year after the Stonewall uprising1. Hundreds of Pride events are now held globally, and the LGBTQ+ community has achieved greater visibility and action around key issues pertaining to LGBTQ+ rights. Despite this progress, sexual and/or gender minority (SGM) individuals continue to face vast challenges across the globe, including isolation, discrimination and violence. The nephrology community has an obligation to recognize and address these challenges through allyship and the promotion of equity and inclusion.
All people should benefit equally from medical advances, but throughout history, marginalized communities have often been exploited or disadvantaged. From violent practices driven by racism to enforced sterilization in the name of eugenics, medicine has a poor record of perpetuating structural inequities, including against SGM individuals. The American Psychiatric Association classified homosexuality as a mental illness until 19732; such discriminatory views were reflected in criminal laws and remain deeply rooted in cultural and religious beliefs. Today, homosexuality remains illegal in some countries and transgender rights remain under threat. For example, Florida has approved legislation to limit classroom discussion about sexual orientation or gender identity, while the UK government has excluded transgender and gender-diverse (TGD) individuals from protective legislation that bans conversion therapy. These continuing attacks on the freedoms of SGM individuals may underlie the failure of many to acknowledge the needs of these communities.
Current understanding of disease burden among SGM individuals is limited, but the available data indicate a greater prevalence of mental and physical health issues than in their heterosexual and cisgender counterparts. SGM identity does not cause disease; hence, these associations highlight the cumulative injurious effects of discrimination and structural inequities. This issue of Nature Reviews Nephrology highlights three areas of relevance to the health of SGM individuals.
First is the need to support SGM health-care workers (HCWs), who, like other members of the SGM community, can face discrimination and psychological distress3. Many SGM HCWs do not disclose their identity in the workplace owing to fears of job loss, discrimination or harassment. Constant exposure to such stressors and the need to stay hidden contribute to burnout and are not conducive to learning or to enabling individuals to function at their highest level. Empowering SGM HCWs requires active support from institutions and from heterosexual or cisgender allies to create safe and inclusive workplaces.
The need to accept individuals in all their diversity also applies to SGM patients; marginalization, discrimination and a fear of being misunderstood can prevent access to appropriate and timely care2. HCWs must receive training in non-discrimination policies and bias to ensure that all patients are treated equitably and with compassion. The creation of safe, inclusive environments, with visibility of HCWs who identify as SGM and their allies, is required to empower SGM patients to access and participate in their own care. Further research, similar to that of the All of Us research programme, is needed to increase understanding of SGM health needs and SGM-competent care.
More studies are also required to inform the care of TGD individuals with kidney disease. Special consideration is needed for those who are receiving gender-affirming hormonal therapy and for the evaluation of laboratory values, including serum creatinine, to ensure that they accurately reflect the health status of the individual4. HCWs should also be equipped to support paediatric and adolescent TGD patients. Increased funding and support of research into the health needs of SGM individuals will help achieve their right to high-quality and equitable care.
The nephrology community has an obligation to recognize and address these challenges
Pride Month is a time to celebrate and honour the historic contributions of SGM leaders and allies, and renew efforts to advance equity for SGM communities. Much progress has been made in the past 52 years. The voice of the SGM nephrology community is growing. But we all have a role, as individuals, colleagues and mentors: to advance the pursuit of justice through education, advocacy and holistic support.
Haynes, S. What’s changed — and what hasn’t — in 50 years of pride parades. Time https://time.com/5858086/pride-parades-history/ (2020).
Salcedo-Betancourt, J. D., Farouk, S. S. & Reddy, Y. N. V. Ensuring health equity for sexual and/or gender minority individuals. Nat. Rev. Nephrol. https://doi.org/10.1038/s41581-022-00572-1 (2022).
Holmberg, M. H., Martin, S. G. & Lunn, M. R. Supporting sexual and gender minority health-care workers. Nat. Rev. Nephrol. https://doi.org/10.1038/s41581-022-00573-0 (2022).
Eckenrode, H. E., Flynn, J. T. & Mohottige, D. Advancing kidney health justice through gender-affirming care. Nat. Rev. Nephrol. https://doi.org/10.1038/s41581-022-00575-y (2022).
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Bringing Pride to nephrology. Nat Rev Nephrol 18, 337 (2022). https://doi.org/10.1038/s41581-022-00584-x