As the population of transgender and other gender minority individuals continues to grow in the United States, the provision of competent and respectful health care services for these individuals has become a topic of increasing focus. In the limited available research regarding the health care challenges and needs of transgender individuals, multiple studies have demonstrated significant hardships compared with cisgender patients, including greater financial barriers to care, incompetent care, and even refusals to be treated by medical providers.1
While many medical associations in the United States have published statements or guidelines in support of gender-affirming care in recent years, there has been a paucity of guidance regarding concerns specific to subspecialties including pulmonology.2-5
In a paper published in February 2021 in the Annals of the American Thoracic Society, Grant A. Turner, MD, a pulmonary and critical care medicine fellow at the University of Nebraska Medical Center in Omaha, and colleagues wrote that “all healthcare providers need to be capable of providing care that is mindful of an individual’s gender identity, the process of transition, and the impact on evaluation and treatment of seemingly unrelated medical problems.”1
To that end, they conducted a systematic review to explore unique issues pertaining to the pulmonary care of gender minority patients. Selected findings are highlighted below.
- Smoking Trends
Higher rates of smoking combustible cigarettes, e-cigarettes, and marijuana have been observed in these individuals, although results are mixed overall.1
- Lung Cancer Screening
Although lung cancer represents the most frequently diagnosed cancer among gender minority patients, nationwide data indicate that only 2.3% of transgender individuals underwent low-dose computed tomography (CT) scans compared with 17.2% of cisgender individuals, despite similar eligibility rates.6
- Asthma and COPD Diagnoses
Compared to cisgender patients, Medicare data and other findings have shown higher rates of asthma (13.6% vs 29.6%) and chronic obstructive pulmonary disease (COPD; 20.8% vs 27.3%) among transgender patients.1 In addition, a study published in 2018 in the American Journal of Respiratory and Critical Care Medicine reported a higher lifetime risk of asthma in this patient group.7
While the underlying mechanisms have not been clarified, Grant et al explained that “both endogenous and exogenous sex hormones are implicated in the increased incidence of asthma in transgender individuals.”1 Regarding the elevated prevalence of COPD, it is unclear whether it is attributable to “increased smoking rates, increased secondhand smoke exposure, reduced access to treatment for tobacco dependence, discrepancies in PFT [pulmonary function testing] interpretation, or hormonally mediated.”1
Special issues in pulmonary function testing (PFT) in transgender individuals have been the focus of several recent studies. Pulmonary function testing utilizes a cisgender algorithm to estimate lung function, and a new study by Dinah Foer, MD, allergist and immunologist at Brigham and Women’s Hospital and Harvard Medical School in Boston, and colleagues found inconsistent use of female and male reference ranges in gender minority patients. They observed an overwhelming predominance of a female reference range regardless of the patient’s gender identity, which “may signal systemic or unconscious provider biases.”8
In a 2018 study, percent of predicted for forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were significantly higher in transgender women when female reference ranges were used (100.5% vs 118.5% and 78% vs 91.5%, respectively; P <.001). In transgender men, the percent of predicted were significantly lower when male reference ranges were used (102% vs 87.5% and 81.5% vs 70.5%, respectively; P <.001).9
According to the American Thoracic Society (ATS), a patient’s “gender identity should be identified and respected, but sex assigned at birth is the major determinant of lung size,” Grant et al noted.1 “More research is needed to identify reference values for gender minority individuals and define the effect of pre-pubertal gender affirming hormones on lung size in this population.”
We interviewed Dr Grant and Dr Foer to glean further insights and clinical recommendations for pulmonary care in transgender and gender minority patients.
What are some of the unique needs of transgender patients that may be particularly relevant to pulmonologists?
Dr Turner: There are many unique aspects to caring for a patient who is transgender or a gender minority that are relevant to physicians, and more specifically, pulmonologists. I think it is important to recognize that many gender minority individuals have experienced difficulty in accessing medical care that is respectful of their unique physiological and psychological needs, starting with ensuring correct gender, pronouns, and names are used during a clinical encounter.
Next, it can be very important to understand the current stage that a gender minority individual is in to provide gender-affirming care in a nonjudgmental fashion. Knowing if they have started hormonal therapy, are using chest wall binding devices, or have had surgical interventions on the chest, for example, can be important for understanding the physiological differences that could explain differences in pulmonary mechanics and assist in evaluating and treating these patients.
Finally, while recognition of specific issues that might be unique to gender minority patients is important, remember that common problems for all patients are still the most likely problems that gender minority patients will experience.
Dr Foer: There are a number of issues that are relevant to pulmonologists and other subspecialists who care for patients with respiratory disease. For example, there are data indicating that transgender individuals are more likely to experience COPD and asthma than cisgender individuals and that cigarette (including e-cigarette) use is more prevalent in this population.1
Other issues to consider include the effect of hormone levels and exogenous hormone use on lung function and, of course, the deep mental health disparities that affect all aspects of patient health but may also be specifically associated with pulmonary disease, as with depression and asthma.1,7
We now also know that there are sex differences and major disparities contributing to COVID-19 outcomes and to the post-acute sequel of COVID-19 which I think will become increasingly relevant to our practice and to this population.10
What are recommendations for clinicians about how to address these specific needs in practice?
Dr Turner: There are multiple ways that clinicians and practices can be more attuned to the needs of gender minority patients. First, making simple changes to intake forms and ways that front desk staff are greeting patients can make huge changes to a patient’s experience. Educating all staff on ensuring proper preferred pronouns and names are used in all clinical encounters can be another step. Then, clinicians educating themselves on unique terms in the gender minority vocabulary and preparing for these conversations ahead of time can be helpful.
Dr Foer: A starting point is to familiarize ourselves with how to ask about gender identity and how to make this a standard part of our practice. Brigham and Women’s Hospital has mandatory training in this topic area, and I am sure other organizations do as well.
Depending on a patient’s specific pulmonary problem, share what we know and what we don’t know about the intersection of hormones, sex, and gender and pulmonary disease. I think this applies to the cisgender population too given the compelling research over the past several years about hormones and pulmonary diseases.
Discuss the role of sex-specific reference ranges in pulmonary function testing, and decide together what reference to use and the potential implications on the results and subsequent care.
On a very practical level in the COVID-19 era, doing things like including your pronouns as part of your name label on the screen during virtual visits can help set an inclusive tone for the visit.
What are other considerations regarding the provision of competent and compassionate care for these patients in general, and what are some suggested resources for clinicians seeking to learn more in this regard?
Dr Turner: An easy way to make a patient more at ease, or to normalize the use of pronouns, is to introduce yourself to all patients with your preferred pronouns. For example, “Hello, my name is Dr Turner, my preferred pronouns are he/him/his. I’ll be the pulmonologist meeting with you today.” If this feels too cumbersome, it can be as simple as adding a pin to your white coat that you wear daily which states your pronouns or a badge buddy to your ID badge.
A great starting point to learn more would be the National LGBTQIA+ Health Education Center.
Dr Foer: Like in many aspects of medicine, I think that it’s incumbent on pulmonary or allergy subspecialists to coordinate care with other physicians on the patient’s care team, such as PCPs [primary care physicians] and endocrinologists, to ensure that any pulmonary concerns are shared and to prioritize any issues (for example, smoking cessation) needing intervention.
In terms of general resources on transgender health, there are great review articles in general internal medicine journals such as the JAMA network, Annals of Internal Medicine, and reports put out by national advocacy organizations, as well as guidelines from health care institutions with transgender-focused health programs like UCSF [University of California, San Francisco].11 The Annals of the American Thoracic Society journal is an excellent resource for some of the more recent pulmonary-focused clinical research in this area.
What are examples of remaining research needs pertaining to transgender issues in pulmonology?
Dr Turner: Unfortunately, research into the needs of gender minority issues in pulmonology is greatly lacking. As we discuss in our review article, observational studies have found that gender minority patients, especially those who are not White, are at much higher risk for COPD, asthma, and HIV. They are also more likely to smoke and less likely to follow lung cancer screening guidelines.1
Finally, some of the gender-affirming practices such as chest wall binding have been shown to cause shortness of breath but do not have guidelines or research regarding their usage overall to help gender minority patients who may want to use them.1
Our hope with summarizing the current literature for our review article was to highlight the many areas that need attention in coming years, as the number of individuals who identify as gender minority only continues to increase over time.
Dr Foer: This area is wide open for advances in clinical care and research, and we need the funding to support these efforts. Preclinical studies on the role of hormones in lung function, as well as broad epidemiologic studies on sex and pulmonary disease, have set the groundwork. But I am looking forward to seeing research in the pulmonary domain that is specifically geared toward the transgender and gender nonbinary populations.
We need patient-facing studies in this area: How do transgender patients experience pulmonary care? How can we do better? Are there systemic issues we can identify that have a downstream impact on pulmonary care — for example, how information is entered into the electronic health record (EHR), how EHR information interfaces with data used for reference range determination in spirometry labs, etc.
Our group now has funding from a national patient safety-oriented organization to study gender identity in the EHR because we recognize that this is a quality and safety issue shared by physicians across specialties, and in turn by health systems more broadly. We need to learn from each other and, most importantly, from our patients if we are going to improve pulmonary care.
1. Turner GA, Amoura NJ, Strah HM. Care of the transgender patient with a pulmonary complaint. Ann Am Thorac Soc. Published online February 19, 2021. doi:10.1513/AnnalsATS.202007-801CME
2. American Medical Association. AMA: Leading medical organizations fight for transgender Americans | American Medical Association. Published July 19, 2019. Accessed online April 19, 2021. https://www.ama-assn.org/press-center/press-releases/ama-leading-medical-organizations-fight-transgender-americans
3. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75-e88. doi:10.1097/AOG.0000000000004294
4. Safer JD, Tangpricha V. Care of the transgender patient. Ann Intern Med. 2019;171(1):ITC 1-ITC 16. doi:10.7326/AITC201907020
5. Rafferty J; Committee on psychosocial aspects of child and family health; committee on adolescence; section on lesbian, gay, bisexual, and transgender health and wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162. doi:10.1542/peds.2018-2162
6. Stowell JT, Parikh Y, Tilson K, Narayan AK. Lung cancer screening eligibility and utilization among transgender patients: An analysis of the 2017-2018 United States Behavioral Risk Factor Surveillance System Survey. Nicotine Tob Res. 2020;22(12):2164-2169. doi:10.1093/ntr/ntaa127
7. Morales-Estrella JJ, Boyle M, Zein JG. Transgender status is associated with higher risk of lifetime asthma. Am J Respir Crit Care Med. 2018;197:A1371
8. Foer D, Rubins D, Almazan A, Wickner PG, Bates DW, Hamnvik OR. Gender reference use in spirometry for transgender patients. Ann Am Thorac Soc. 2021;18(3):537-540. doi:10.1513/AnnalsATS.202002-103RL
9. Haynes JM, Stumbo RW. The impact of using non-birth sex on the interpretation of spirometry data in subjects with air-flow obstruction. Respir Care. 2018;63(2):215-218. doi:10.4187/respcare.05586
10. Pivonello R, Auriemma RS, Pivonello C, et al. Sex disparities in COVID-19 severity and outcome: are men weaker or women stronger? Neuroendocrinology. Published online November 26, 2020. doi:10.1159/000513346
11. Deutsch MB. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. UCSF Transgender Care. Published July 17, 2016. Accessed online April 19, 2021. https://transcare.ucsf.edu/guidelines