ASN President's Update: Embracing Pride Month and Nephrology's Ongoing Inclusion

Susan E. QuagginSusan E. Quaggin, MD, FASN, is with the Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, and is ASN President.

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As we approach the middle of the year, those of us who live in locations with long, harsh winters are basking in the remainder of spring and its glorious diversity: multi-colored blossoms and greenery, rain, sun, and ever-changing temperatures. During my #850challenge (1) run this morning, I was struck how fitting it is that the joy of spring and oncoming summer coincides with Pride month—a month filled with opportunities to celebrate diversity and all the power and growth it brings to the kidney community.

Pride month is celebrated annually in June in the United States, culminating in festive and colorful parades—this year on June 28th—to commemorate the Stonewall riots in New York, NY, in 1969, which sparked the U.S. lesbian, gay, bisexual, transgender, queer (or sometimes questioning), and others (LGBTQ+) revolution. In other countries, Pride month is celebrated in October where it aligns with national coming out day on October 11 or at other times throughout the year.

Pride month also provides us an important opportunity to remember all that has been gained during the past 50 years and to recognize the critical importance and value LGBTQ+ communities bring to all aspects of our society (2). Although milestones (Table 1) show important advances in civil rights, we must acknowledge there is much more to do and explore where we risk losing ground.

Table 1

Examples of LGBTQ+ progress in the United States since 1969

Table 1

As physicians and other members of the kidney care team, we took an oath when we entered the profession: We must ensure trainees, faculty, and experienced practitioners receive appropriate education to provide inclusive and affirming care for all members of LGBTQ+ communities, and we must have leaders and professionals who represent diverse populations across all aspects of society and our profession to realize health justice.

In the health community, patients—including those with kidney diseases—who identify as LGBTQ+ and/or as other sexual and gender minority (SGM) individuals face injustices in their everyday lives, including a disproportionate rate of kidney diseases compared with those who are not in LGBTQ+ communities (3). As outlined in an editorial by Mohottige and Lunn (4), non-discrimination policies across the United States exist in a patchwork manner and “do not universally prohibit discrimination based on sexual orientation and gender identity…in public accommodations, including in health care centers, such as dialysis facilities” (5). People who identify as SGMs may be discouraged from seeking medical care because of potential denial of care, job loss, and/or fear of discrimination and harassment. Within the health care system, individuals who are SGMs face an excess burden of suboptimal health care due to implicit and explicit bias (6). For some kidney care and treatment options, such as transplant and home dialysis, demonstration of a supportive home environment and care partners are needed. Without inclusive and affirming health care, some patients may not feel comfortable sharing their family situation with a care team.

Progress

What can we do within the kidney community? Nephrology is best when it leads from the front. It is time we stand up to disparities that face our colleagues and patients, as well as others in LGBTQ+ communities, and implement changes in education, increase awareness, and reexamine practices or lab tests that may cause harm.

Last year, the race modifier was removed from the kidney estimating formula and replaced by a new race-free formula. In the new chronic kidney disease-Epidemiology Collaboration (CKD-EPI) 2021 formula, the sex coefficient remains. It is tantamount that as kidney care professionals, we examine the role of the female sex coefficient in the context of our patients who are transgender and/or gender expansive and are reported to be at higher risk of acute kidney injury and CKD (7). The sex variable is binary and does not take into account the role of gender-affirming hormone therapies (e.g., estrogen and testosterone) that may impact muscle mass and creatinine production.

As we celebrate Pride month and consider Kidney Week, which will be held this year in Florida, November 3−6, it is impossible not to recognize the legislative actions in the United States that may reverse gains in civil rights and freedoms. Perhaps most frighteningly for patient care, the sanctity of the patient-physician relationship is threatened by proposed policies in a number of U.S. states. As kidney health professionals, we are bound by oath to do what is right for patients, always.

In 1987, during the early days of the HIV epidemic, I vividly remember a morning in late June. I was a clinical clerk (4th-year medical student) on the internal medicine service. In Toronto, internal medicine ward rounds were the focus every day, with an emphasis on clinical acumen. Each morning, the attending physician would round with the trainees. He/she/they would perform a history and physical examination on each patient and confirm or refute a trainee's findings and diagnosis. On this particular morning, we stopped by the room of a young man admitted with a provisional diagnosis of pneumocystis carinii pneumonia, the most common complication of HIV infection at that time. We discussed the patient's history before entering the room. As I stood and watched the attending physician, tradition was broken. Unlike with the three patients before this one, my attending did not shake the patient's hand, and he did not lay his stethoscope on the patient's chest. In fact, he did not lay his hands on the patient at all. I was bewildered by the behavior, and as we exited the room, the attending discussed HIV briefly, as well as lifestyle choices. To this day, I am overcome by emotion—with anger and heartbreak—when I remember this encounter, because I had realized for the first time that not all MDs are physicians or healers.

The following year, I rotated on the benign hematology service, which was run by a chief with a formidable reputation. She had studied at the National Institutes of Health in the 1970s, which was unprecedented in those days for women. She was known for her incredibly high expectations of trainees. Throughout the 2 months I spent on this service, I came to view her as a role model and as a physician whose approach to patients I would aspire to throughout my career. She was instrumental in supporting the launch of Casey House, a caring and equitable hospice for patients living with AIDS in Toronto.

The discrimination that marked the early days of the HIV epidemic was fueled by fear and hatred. We cannot step backward. Earlier this month, I shared a letter (8) with the membership regarding the ASN Council's decision to hold Kidney Week in Orlando, FL, this fall, as well as a series of action steps to demonstrate our unwavering support for LGBTQ+ communities (Table 2). Since I sent the letter, I have received feedback from ASN members and other stakeholders. Most comments have strongly supported the council's decision, plan, and perspective. However, importantly, several colleagues and friends have urged caution. They are understandably concerned about ASN taking a political position. We all know that sometimes politics and medicine collide. ASN, other specialty societies, and health leaders worldwide will be judged on how they navigate our increasingly difficult, acrimonious, and uncertain world. As ASN president, my North Star is always asking, “What is best for patients and for people living with kidney diseases?”

Table 2

ASN will bring its values to Florida

Table 2

This iridescent spring season should remind us of the transformation occurring in nephrology through innovation—a transformation that will never be fully realized without full inclusion. As we celebrate Pride month, let us remember who we are and what we can accomplish when we stand united (9). Let us remember we are stronger when we build solutions that incorporate perspectives from all professionals and patients.

References

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