Chest medicine specialists serve diverse, clinically complex populations enriched with varied identities and lived experiences formed in the shadows of structural inequalities. Individuals identifying as lesbian, gay, bisexual, transgender, queer, and other sexual/gender minorities (LGBTQ+) continue to face significant disparities in health care access, quality, and outcomes. These disparities, which are not merely social concerns, have direct and measurable implications in pulmonary medicine, critical illness, and sleep medicine.
Sexual orientation has evolved throughout the generations. While individuals of the Baby Boomer generation (1946-1964) identify as 96% heterosexual, 3% homosexual, and 1% bisexual, Gen Z individuals (1995-2012) identify as 79% heterosexual, 11% bisexual, 4% homosexual, 3% pansexual, and 3% asexual, queer, or other.1 LGBTQ+ identification stands at 9.3% in the United States, though rates among younger people increased from 18.8% of Gen Z adults in 2020-2022 to 22.7% in 2025.2
Building rapport is vital to clinician/patient therapeutic relationships and can be improved with communication focused on small choices in language and approaches that demonstrate respect, curiosity, and professionalism, especially in vulnerable clinical environments. Neutral introductions and fidelity to pronouns establishes secure first steps to inquire about partners and support systems. Using anatomy-based and relevant clinical language further engenders trust and validates patient experiences. Providing high-quality care requires clinical expertise alongside cultural humility, acknowledgment of unique high-risk profiles, and the capacity to provide an inclusive and affirming environment.
LGBTQ+ patients experience higher risk factors pertaining to pulmonary health. LGBTQ+ older adults are disproportionately more likely to live alone and experience financial poverty and social isolation, thus facing housing insecurities and making access to routine health visits and medications more difficult.3 LGBTQ+ populations have higher rates of tobacco use, and gender minority individuals experience disparities in cancer screening.4–5 Asthma among gay men and bisexual men exists at higher rates in comparison to heterosexual men or gay/lesbian women. Bisexual women also have a higher incidence of asthma compared with heterosexual women, as do transgender men in comparison to cisgender individuals.5 Chest binding among transgender patients is subject to acute restrictive impairment, and exposure to testosterone therapy may be associated with changes in pulmonary function testing, thus requiring caution in diagnostic interpretation.6–7
In critical illness, evolving therapies are affecting LGBTQ+ populations. Critically ill HIV patients have transitioned from presenting and dying with AIDS to critically ill patients with HIV, as AIDS-defining illness hospitalizations have become less common.8 Patients with HIV comprise 0.5% to 1.5% of patients with end-stage renal disease.9 End-stage liver disease consistently accounts for 10% of deaths among adults with HIV.9 International experience with more than 1,000 HIV-positive solid organ transplants (SOTs) indicates that SOT is the optimal treatment for end-stage organ disease in individuals with HIV and should be the standard of care given the excellent survival outcomes and low incidence of opportunistic infections.9 Extracorporeal membrane oxygenation (ECMO) was once a relative contraindication for patients with HIV, though studies have demonstrated that ECMO may successfully bridge the time for pulmonary recovery in 93% of patients.10
Additionally, gender-affirming therapies impact the management of critically ill gender-diverse patients. Testosterone therapies impact serum hematocrit levels to be in the reference range of the perceived gender after three months from initiation.11 Serum creatinine is increased via augmentation in muscle mass, and hepatic enzyme activity may be altered.12 Feminizing therapies may increase the risk of myocardial infarction and stroke.13 Surgical gender-affirming care may impact catheterization and place patients at increased risk of urinary strictures, fistulas, and urinary tract infections.13 Anatomic alterations may also affect intubations.13 It is imperative to have knowledge of possible therapeutic interventions.
LGBTQ+ populations experience minority stress (prejudice events and conditions, anticipation of rejection and discrimination, concealment or disclosure of sexual and gender identity[ies], internalized stigma, or structural stigma), which can impact health, particularly sleep.14 Several studies have reviewed the association between sleep quality and disturbance in LGBTQ+ populations.15–17 Hormonal therapies are reported to affect sleep quality and insomnia, and they have not been associated with decreased odds of OSA.17 That’s why sleep medicine clinicians need to understand the social and therapeutic components of LGBTQ+ populations.
When a patient’s life is at risk, we have the privilege and a profound responsibility to treat them. For LGBTQ+ patients, these moments carry an added weight shaped by past experiences of invisibility, bias, or exclusion. Chest medicine specialists are uniquely positioned to alter that narrative by affirming dignity, building trust, and dismantling barriers once posed by identity.
This Pride Month, let us recommit to a principle of care that surpasses clinical excellence but is also inclusive, compassionate, and just. Honor not only the diversity of those we serve but also the essence of our profession—healing, advocacy, and care—fully and without exception.
References
1. Richter F. Generational differences in U.S. sexual orientation. Statista. June 4, 2024.
2. Jones, Jeffery M. LGBTQ+ identification in U.S. rises to 9.3%. Gallup. February 20, 2025.
3. Shastri VG, Erney EJ. Psychosocial and financial issues affecting LGBTQ+ older adults. Clin Geriatr Med. 2024;40(2):309-320. doi:10.1016/j.cger.2023.10.004
4. King JL, Shan L, Azagba S. Trends in sexual orientation disparities in cigarette smoking: Intersections between race/ethnicity and sex. Prev Med. 2021;153:106760. doi:10.1016/j.ypmed.2021.106760
5. Buchting FO, Emory KT, Scout, Kim Y, Fagan P, Vera LE, Emery S. Transgender use of cigarettes, cigars, and e-cigarettes in a national study. Am J Prev Med. 2017;53(1):e1-e7. doi:10.1016/j.amepre.2016.11.022
6. Job SA, Kaniuka AR, Reeves KM, Brooks BD. Interactions of sexual orientation and gender identity with race/ethnicity in prevalence of lifetime and current asthma diagnosis. LGBT Health. 2023;10(5):372-381. doi:10.1089/lgbt.2022.0186
7. Heitzman A, Browy JR, Britton D, Conn J, Ziegler A. Impact of testosterone therapy on pulmonary function in transgender and gender expansive individuals assigned female at birth: a cross-sectional comparative study. Int J Transgend Health. 2025;26(4):1093-1110. doi:10.1080/26895269.2024.2323522
8. Gajewski, AJ, Mora A, Hong AS. Incidence of hospital admissions for AIDS-defining illness and intensive care unit admissions for individuals with HIV in Texas from 2006 to 2024. Proc Bayl Univ Med Cent. 2026;39(3):446-448. doi:10.1080/08998280.2026.2626899
9. Werbel WA, Durand CM. Solid organ transplantation in HIV-infected recipients: history, progress, and frontiers. Curr HIV/AIDS Rep. 2019;16(3):191-203. doi:10.1007/s11904-019-00440-x
10. Rajsic S, Breitkopf R, Kojic D, Bukumiric Z, Treml B. Extracorporeal life support for patients with newly diagnosed HIV and acute respiratory distress syndrome: a systematic review and analysis of individual patient data. ASAIO J. 20231;69(12):e513-e519. doi:10.1097/MAT.0000000000002047
11. Defreyne J, Vantomme B, Van Caenegem E, et al. Prospective evaluation of hematocrit in gender-affirming hormone treatment: results from European Network for the Investigation of Gender Incongruence. Andrology. 2018;6(3):446-454. doi:10.1111/andr.12485
12. Boekhout-Berends ET, Wiepjes CM, Nota NM, Schotman HH, Heijboer AC, Heijer M den. Changes in laboratory results in transgender individuals on hormone therapy: a retrospective study and practical approach. Eur J Endocrinol. 2023;188(5):457-466. doi:10.1093/ejendo/lvad052
13. Flower L, Cheung A, Connal S, et al. Management of transgender patients in critical care. J Intensive Care Soc. 2023;24(3):320-327. doi:10.1177/17511437221145102
14. Flentje A, Sunder G, Tebbe E. Minority stress in relation to biological outcomes among sexual and gender minority people: a systematic review and update. J Behav Med. 2025;48(1):22-42. doi:10.1007/s10865-024-00539-6
15. Dolsen EA, Byers AL, Flentje A, et al. Sleep disturbance and suicide risk among sexual and gender minority people. Neurobiol Stress. 2022;21:100488. doi:10.1016/j.ynstr.2022.100488
16. Nikolaidis-Konstas A, Mournet AM, Pachankis JE, Kleiman EM, Clark KA. The role of sleep quality and duration in associations between daily minority stress and next-day suicidal ideation in LGBTQ+ youth. J Affect Disord. 2025;391:119951. doi:10.1016/j.jad.2025.119951
17. Hershner S. Care of the transgender patient. Sleep Med Clin. 2026;21(1):41-52. doi:10.1016/j.jsmc.2025.10.004
