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. Author manuscript; available in PMC: 2022 Sep 1.
Published in final edited form as: J Allergy Clin Immunol Pract. 2021 May 5;9(9):3396–3406. doi: 10.1016/j.jaip.2021.04.046

Asthma Remission Disparities among U.S. Youth by Sexual Identity and Race/Ethnicity, 2009–2017

Caleb W Curry 1,2,3,6, Dylan Felt 1,2,7, Kristin Kan 4,5,8, Megan Ruprecht 1,2,9, Xinzi Wang 1,2,10, Gregory Phillips II 1,2,11, Lauren B Beach 1,2
PMCID: PMC8434969  NIHMSID: NIHMS1701100  PMID: 33964511

Abstract

Background:

Sexual minority and racial/ethnic minority youth experience a higher burden of asthma. The frameworks of minority stress theory and intersectionality suggest sexual minority and racial/ethnic minority youth may experience disparities in non-remitting asthma.

Objective:

To examine adjusted odds of non-remitting asthma by sexual identity, race/ethnicity, and their intersections, along with their relationship with traditional non-remitting asthma risk factors (weight status and smoking) and victimization (bullying, cyberbullying, and forced sex).

Method:

We utilized data from the Youth Risk Behavior Survey (YRBS) pooled across 41 jurisdiction-years (biennially, 2009–2017), resulting in a sample of 21,789 U.S. youth. The prevalence of non-remitting asthma was examined by sexual identity, race/ethnicity, and their intersections, stratified by sex. Bivariate associations and backward logistic regression models, stratified by sex, were built to examine non-remitting asthma disparities and the effects of selected traditional correlates and victimization variables.

Results:

At the intersections, 8 sexual minority and racial/ethnic minority subpopulations were significantly more likely to have non-remitting asthma compared with White heterosexual sex-matched peers. White gay males and Black lesbian females had the highest odds of non-remitting asthma. Traditional risks of non-remitting asthma and victimization were associated with attenuated odds of non-remitting asthma.

Conclusion:

Many sexual minority and racial/ethnic youth sub-populations are more likely to have non-remitting asthma. Evidence suggests traditional non-remitting asthma risk factors and victimization may partly explain disparities in non-remitting asthma. Asthma management guidelines should be updated to include population health disparities of sexual and racial/ethnic minorities.

Keywords: Asthma, Asthma Remission, Non-remitting Asthma, Disparities, Sexual Minorities, Sexual Identity, Race/Ethnicity, Minority Stress, Intersectionality, Victimization, YRBS, Youth, United States

INTRODUCTION

Asthma is the most common chronic condition among children, affecting 8.4% of youth under 18 years.1,2 Among youth, asthma is a leading cause of hospitalization and is associated with an increased risk for developing diabetes and coronary heart disease in adulthood.3,4 Youth asthma management and surveillance, therefore, remains a top public health priority.2,5,6 Previous asthma surveillance reveals asthma prevalence disparities among youth and adults by sex, sexual identity, and race/ethnicity, as well as those multiply-marginalized by sexual identity and race/ethnicity1,7–16

Despite growing asthma surveillance research, non-remitting asthma is still not well understood. Clinical asthma remission is typically considered as the absence of asthma symptoms without the use of an asthma medication over a period of time (varying from 6 months to 5 years).17,18 In the present study, asthma remission was defined as the self-reported absence of asthma symptoms among those with a prior history of asthma. Most cases of asthma remission occur between ages 14 to 21, and the prevalence of remission has been estimated to be between 33% and 53% among youth under 18.17–19 Among youth and adult populations, there are sex-based differences in asthma remission with more males entering remission than females.18 Correlates of non-remitting asthma have also been identified: persons who smoke, have a body mass index percentile (BMIp) greater than 85, or have more severe asthma tend to have lower rates of remission.18 Notably, sexual minority and/or racial/ethnic minority (SM/REM) youth report a higher prevalence of smoking and elevated weight. 20,21 Additionally, although no studies have investigated asthma severity among sexual minority youth, asthma symptoms have been found to be more severe among racial/ethnic minority youth compared to their White counterparts.18,22 Taken together, the higher prevalence of non-remitting asthma risk factors among SM/REM youth suggests they may experience less asthma remission. Despite the evidence, though, no studies have investigated if such disparities exist by sexual identity. Only one study among youth has examined asthma remission by race/ethnicity, finding White individuals were more likely to experience asthma remission than non-White cohort members.23 Thus, additional surveillance with more precise populations is needed.

Minority stress theory (MST) and intersectionality are theoretical frameworks that can be applied to investigate health disparities of multiply-marginalized populations.24–26 MST posits that marginalized populations are disparately burdened with stigmatization, discrimination, and oppression that contributes to an overall heightened burden of stress.24 Minority stressors can take the form of proximal (e.g., internalized homophobia) or distal (e.g., prejudiced events such as victimization) stressors. The heightened chronic stress experienced can cause physiological changes, such as immune system dysregulation, which have been associated with the development of asthma.27 Stress-related coping can also manifest as maladaptive health behaviors that increase the prevalence of traditional risks of asthma non-remission, such as smoking and disordered eating that increases risk for a BMIp>95.18,24,28,29 Ultimately, the higher burden of chronic stress and stress-linked coping behaviors can exacerbate both mental and physical health conditions, potentially impacting the likelihood of asthma remission among marginalized populations.24,30,31

Furthermore, applying an intersectional lens expands the contextual scope of MST by specifically considering the health impacts of multiple marginalization.32,33 Intersectionality—a Black feminist framework developed by Crenshaw25 and Collins26—highlights that marginalization can manifest distinctly at the intersections of multiply-marginalized identities. At the person level, the framework emphasizes that individuals hold multiple characteristics (e.g., race/ethnicity and sexual orientation) but experience the world living in a single body. Applied to the present study, marginalization may be manifesting as excess experiences of victimization among SM/REM youth and impacting both maladaptive-stress coping behaviors and physiological stress responses that may disparately drive asthma remission outcomes among SM/REM sub-populations.

Neither the epidemiology of non-remitting asthma among SM/REM youth nor the association between non-remitting asthma and minority stress-related factors have ever been described. In the present study, we aim to advance the field of pediatric asthma remission research by describing patterns of non-remitting asthma within a large and geographically diverse dataset of high school-aged youth. Specifically, we aim to: (1) examine non-remitting asthma disparities among youth by sexual identity, race/ethnicity, and their intersections and (2) explore the impact of selected traditional asthma non-remission factors (weight status and smoking) and—based on MST—victimization (bullied, cyberbullied, and forced sex) on odds of non-remitting asthma.34 Informed by theory and the related background literature, we hypothesize differential prevalence of non-remitting asthma among SM/REM youth. We also expect traditional correlates of non-remitting asthma, as well as experiences of victimization to be associated with increased odds of non-remitting asthma.

METHODS

Data Source

The Youth Risk Behavior Survey (YRBS) is a biennial survey conducted by the Centers for Disease Control and Prevention (CDC) to collect health data on students in grades 9–12.35 We utilized local administrations of the YRBS, pooling data across jurisdictions of states and large, urban school districts. Jurisdictions use a two-stage cluster sample design to identify a representative sample of students.35 A new sample is selected each year the survey is administered. The YRBS data weights adjust for student non-response and distribution of students by grade, sex, and race/ethnicity in each jurisdiction.

Study Design

Local YRBS data were pooled across multiple jurisdictions and years (biennially, 2009–2017). Only jurisdiction-years including sexual identity, lifetime asthma, and current asthma measures were included in the sample, representing 137,107 students. For the present analyses, students were excluded if they were missing any of the primary demographic variables of interest (Sexual Identity, Race/Ethnicity, Age, Region), resulting in 129,196 participants. Finally, only individuals who reported having lifetime asthma and who answered “yes” or “no” to still having asthma were included, leaving a final analytic sample of 21,789 youth across 41 jurisdiction-years.

Measures

The following measures were used: Demographics (Sex, Sexual Identity, Race/Ethnicity, SM/REM Sub-Populations, Age, Region); Traditional Non-remitting Asthma Risk Factors (Obese and Overweight, Smoking Status); the Primary Outcome (Non-remitting Asthma); and Victimization Indicators (Bullied, Cyberbullied, Forced Sex). These victimization variables were selected because prior research has used victimization variables to represent manifestations of stigma that contribute to excess minority stress levels among SM/REM youth.34,36 These specific variables cover a range of social settings (school and non-school), and bullying is the most common form of victimization among SMY.7,34,36–38 Moreover, besides bullying, forced sex is the most common type of victimization experienced by sexual minority females, particularly bisexual women and women of color.7,38 For information on survey questions and classification for measures, see Table I.

Table I:

Measures, Question Wording, Response Options, and Classification, YRBS, 2009–2017

Measures Question Wording, Response Options, and Classification
Demographics
 Sex Assessed by asking participants, “What is your sex?” Response options: male and female.
 Sexual Identity (SI) Assessed by asking participants, “Which of the following best describes you?” Response options: heterosexual (straight); gay or lesbian; bisexual; and not sure.
 Race/Ethnicity (RE) Participants were asked if they identified as Hispanic or Latino (yes or no) and to then select all races that applied to them: American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or Other Pacific Islander; and White. For our analyses, these were joined into 4 racial/ethnic groups: White; Black; Hispanic; and an Additional-race (including multiple-races).
 SM/REM Sub-Populations Participants who responded to both sexual identity and race/ethnicity questions were placed into 1 of 16 categories—a combination of (1) heterosexual; (2) gay or lesbian; (3) bisexual; and (4) not sure with (1) White; (2) Black; (3) Hispanic/Latinx; and (4) additional-race.
 Age Assessed by asking participants, “How old are you?” Response options ranged from 12 to 18 years old. Students selecting between 12 and 14 years old options were collapsed into “14 years old or younger.”
 Region Assessed by grouping jurisdictions together based on U.S. Census regions: Northeast; Midwest; South; and West.
Traditional Non-remitting Asthma Correlates 18
 Obese and Overweight Respondents were classified as obese or overweight based on body-mass index (BMI) calculated using participant-reported age, sex, height, and weight. Individuals with a BMI ≥ 95th percentile were classified as obese, while individuals with a BMI ≥ 85th percentile and < 95th percentile were classified as overweight.65
 Smoking Status Participants were first asked, “Have you ever tried cigarette smoking, even one or two puffs?” Response options: yes and no. Students responding no were classified as (1) never smoked. Participants were then asked, “During the past 30 days, on how many days did you smoke cigarettes?” Response options ranged from 0 to 30 days. Students who selected yes to the first question and 0 days to the second were classified as (2) former smoker; those selecting yes to the first and more than 0 days to the second were classified as (3) current smoker.
Victimization Indicators
 Bullied Assessed by asking participants, “During the past 12 months, have you ever been bullied on school property?” Response options: yes and no.
 Cyberbullied Assessed by asking participants, “During the past 12 months, have you ever been electronically bullied? (Include being bullied through e-mail, chat rooms, instant messaging, Web sites, or texting.).” Response options: yes and no.
 Forced Sex Assessed by asking “Have you ever been physically forced to have sexual intercourse when you did not want to?” Response options: yes and no.
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The primary outcome of non-remitting asthma was formed by first asking, “Has a doctor or nurse ever told you that you have asthma?” Response options: yes; no; and not sure. Participants were then asked, “Do you still have asthma?” Response options: I have never had asthma; yes; no; and not sure. For our analyses, those who responded yes to both questions were considered to have non-remitting asthma. Those who responded yes to the first question but no to the second were classified as in asthma remission. Participants responding differently from above were dropped from all models.

Statistical Analyses

All data cleaning and recoding was conducted in SAS Version 9.4 (SAS Institute, Cary, NC). SAS-Callable SUDAAN Version 11.0.1 (RTI International, Research Triangle Park, NC) was used to appropriately weight estimates and account for the complex sampling design of the YRBS. First, bivariate logistic regressions with traditional non-remitting asthma risk factors and experiences of victimization, stratified by sex, were conducted. Multivariate logistic regressions were used to assess any potential correlates of asthma remission. Predictors were removed in a stepwise manner until only those with p<0.10 (to capture any potential correlate) remained in the model. All adjusted models contained demographics (age, region, race/ethnicity, and sexual identity) and survey year.

RESULTS

The analytic sample (n=21,789) consisted of nearly equal proportions of males (49.2%) and females (50.8%; Table II). The sample predominately identified as heterosexual (87.4%), followed by bisexual (6.9%), not sure (3.2%), and lesbian or gay (2.4%). Slightly over half were White (51.2%)—followed by Black (24.0%), Hispanic or Latinx (17.7%), and additional-race (7.1%). Approximately one-third (33.3%) of respondents had experienced asthma remission. By sex, 40.5% of males experienced remission compared with 26.3% of females (p<0.001), corresponding with prior literature.7,18,19

Table II.

Participant Demographics and Non-remitting Asthma among High School Youth, YRBS, 2009–2017

Total Male Female
n % n % n %
Demographics 21,789 -- 10,323 49.21 11,466 50.79
Sexual Identity (SI)
 Heterosexual 19,076 87.43 9,521 92.62 9,555 82.41
 Lesbian/Gay 533 2.43 236 1.93 297 2.92
 Bisexual 1,494 6.91 282 2.54 1,212 11.15
 Not Sure 686 3.22 284 2.91 402 3.52
Race/Ethnicity (RE)
 White 11,100 51.15 5,198 50.98 5,902 51.31
 Black 2,920 24.02 1,376 23.91 1,544 24.12
 Hispanic/Latinx 4,105 17.73 1,944 17.97 2,161 17.5
 Additional-Race 3,664 7.10 1,805 7.14 1,859 7.07
Age, years
 14 or younger 2,941 10.55 1,342 10.63 1,599 10.47
 15 5,627 24.89 2,637 25.03 2,990 24.76
 16 5,732 26.98 2,762 26.93 2,970 27.04
 17 5,077 24.14 2,363 22.83 2,714 25.1
 18 or older 2,412 13.44 1,219 14.58 1,193 12.33
Region
 Northeast 9,306 5.49 4,354 5.48 4,952 5.5
 Midwest 3,169 32.52 1,469 31.58 1,700 33.43
 South 4,928 51.90 2,376 52.81 2,552 51.01
 West 4,386 10.09 2,124 10.13 2,262 10.05
SI and RE Intersections
Heterosexual
 White 9,906 45.52 4,871 47.95 5,035 42.97
 Black 2,546 20.88 1,265 22.03 1,281 19.76
 Hispanic/Latinx 3,484 15.17 1,757 16.27 1,727 14.1
 Additional-Race 3,140 5.97 1,628 6.37 1,512 5.58
Lesbian/Gay
 White 208 0.92 89 0.65 119 1.19
 Black 103 0.8 41 0.56 62 1.04
 Hispanic/Latinx 124 0.55 54 0.56 70 0.55
 Additional-Race 98 0.16 52 0.17 46 0.14
Bisexual
 White 691 3.14 116 0.92 575 5.3
 Black 184 1.74 42 0.86 142 2.59
 Hispanic/Latinx 339 1.34 63 0.37 276 2.28
 Additional-Race 280 0.69 61 0.39 219 0.98
Not Sure
 White 295 1.66 122 1.47 173 1.86
 Black 87 0.6 28 0.47 59 0.73
 Hispanic/Latinx 158 0.67 70 0.77 88 0.58
 Additional-Race 146 0.28 64 0.21 82 0.36
OUTCOME
Non-remitting Asthma
 Yes 14,849 66.71 6,323 59.5 8,526 73.69
 No 6,940 33.29 4,000 40.5 2,940 26.31
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Bivariate Associations with Non-remitting Asthma

Across sexual identity and race/ethnicity separately, gay (odds ratio [OR]: 2.71; 95% confidence interval [CI]: 1.51–7.84), Black (OR:1.80; 95% CI:1.38–2.34), and additional-race (OR:1.30; 95% CI:1.01–1.69) male students were significantly more likely to have non-remitting asthma compared with heterosexual or White, sex-matched students (Table III). Among females, only Black respondents (OR:1.52; 95% CI:1.20–1.92) were significantly more likely to have non-remitting asthma compared with White female respondents. Hispanic/Latinx females were less likely to have non-remitting asthma (OR:0.68; 95% CI:0.56–0.83) than White females.

Table III:

Prevalence and Unadjusted Odds Ratios for Non-remitting Asthma by Sexual Identity (SI), Race/Ethnicity (RE), and their Intersections, YRBS, 2009–2017.

Male Female
Non-remitting Asthma (weighted %) N/Total OR 95% CI Non-remitting Asthma (weighted %) N/Total OR 95% CI
Selected Demographics
Sexual Identity
 Heterosexual 58.80 5776/9521 REF -- 73.19 7026/9555 REF --
 Lesbian/Gay 78.63 162/236 2.71 (1.51, 4.84) 80.66 236/297 1.37 (0.87, 2.18)
 Bisexual 63.68 192/282 1.17 (0.66, 2.06) 75.84 956/1212 1.09 (0.78, 1.52)
 Not Sure 65.39 193/284 1.48 (0.85, 2.58) 72.72 308/402 0.99 (0.61, 1.61)
Race/Ethnicity
 White 55.94 3159/5198 REF -- 73.68 4471/5902 REF --
 Black 69.44 949/1376 1.80 (1.38, 2.34) 81.14 1237/1544 1.52 (1.20, 1.92)
 Hispanic/Latinx 55.37 1127/1944 0.97 (0.80, 1.17) 65.68 1483/2161 0.68 (0.56, 0.83)
 Additional-Race 62.06 1088/1805 1.30 (1.01, 1.69) 68.18 1335/1859 0.81 (0.61, 1.06)
Age, years
 14 or younger 68.46 898/1342 REF -- 76.96 1215/1599 REF --
 15 60.07 1681/2637 0.86 (0.63, 1.16) 74.09 2247/2990 0.86 (0.63, 1.16)
 16 59.50 1680/2762 0.93 (0.68, 1.26) 75.61 2217/2970 0.93 (0.68, 1.26)
 17 56.91 1388/2363 0.79 (0.59, 1.05) 72.41 1980/2714 0.79 (0.59, 1.05)
 18 or older 56.07 676/1219 0.65 (0.46, 0.93) 68.52 867/1193 0.65 (0.46, 0.93)
Region
 Northeast 63.04 2758/4353 REF -- 76.48 3811/4952 REF --
 Midwest 62.58 943/1469 0.98 (0.82, 1.17) 76.05 1313/1700 0.98 (0.82, 1.16)
 South 57.18 1367/2376 0.78 (0.67, 0.92) 72.01 1798/2552 0.79 (0.67, 0.94)
 West 60.1 1255/2124 0.88 (0.70, 1.12) 72.83 1604/2262 0.82 (0.67, 1.01)
SI and RE Intersections
Heterosexual
 White 54.82 2922/4871 REF -- 74.62 3790/5035 REF --
 Black 69.75 876/1265 1.94 (1.48, 2.54) 79.36 1012/1281 1.27 (0.98, 1.64)
 Hispanic/Latinx 50.24 999/1757 0.97 (0.79, 1.18) 63.41 1156/1727 0.58 (0.46, 0.72)
 Additional-Race 62.62 979/1628 1.40 (1.07, 1.83) 65.10 1068/1512 0.66 (0.49, 0.88)
Lesbian/Gay
 White 93.36 68/89 17.65 (6.98, 44.67) 67.7 93/119 0.60 (0.31, 1.16)
 Black 76.77 28/41 2.67 (0.98, 7.24) 95.07 55/62 7.07 (2.01, 24.77)
 Hispanic/Latinx 61.31 33/54 1.20 (0.46, 3.14) 84.86 53/70 1.79 (0.63, 5.11)
 Additional-Race 85.61 33/52 4.79 (1.74, 13.18) 67.89 35/46 0.75 (0.17, 3.38)
Bisexual
 White 71.44 76/116 1.95 (0.76, 5.01) 71.21 456/575 0.77 (0.46, 1.29)
 Black 55.40 28/42 0.95 (0.35, 2.63) 86.04 118/142 2.03 (1.03, 4.01)
 Hispanic/Latinx 71.83 44/63 1.80 (0.61, 5.32) 71.58 211/276 0.83 (0.52, 1.34)
 Additional-Race 56.00 44/61 1.01 (0.33, 3.15) 83.76 171/219 1.84 (0.92, 3.68)
Not Sure
 White 66.27 93/122 1.86 (0.83, 4.15) 62.94 132/173 0.57 (0.29, 1.14)
 Black 71.80 17/28* 1.61 (0.39, 6.71) 91.94 52/59 3.52 (0.96, 12.92)
 Hispanic/Latinx 67.44 51/70 2.16 (0.91, 5.16) 79.42 63/88 1.45 (0.66, 3.19)
 Additional-Race 36.87 32/53 0.61 (0.19, 1.98) 73.41 61/82 0.91 (0.34, 2.42)
Selected Variables
Smoking Status
 Never smoked 61.39 2265/3629 REF -- 75.18 3199/4274 REF --
 Former smoker 59.66 673/1134 0.93 (0.70, 1.24) 79.71 1047/1366 1.30 (1.01, 1.66)
 Current smoker 58.78 448/705 0.90 (0.65, 1.25) 79.46 542/685 1.28 (0.83, 1.96)
Obese
 Yes 64.07 1232/1893 1.29 (1.03, 1.61) 77.51 1019/1288 1.28 (0.95, 1.72)
 No 58.08 4730/7882 REF -- 72.97 6891/2473 REF --
Overweight
Yes 55.87 931.1563 0.85 (0.67, 1.08) 74.46 1479/1967 1.06 (0.83, 1.35)
No 59.82 5031/8212 REF -- 73.35 6431/8685 REF --
Bullied
Yes 64.34 1261/1868 1.29 (1.03, 1.62) 79.55 2199/2754 1.54 (1.23, 1.92)
No 58.3 4937/8258 REF -- 71.65 6153/8494 REF --
Cyberbullied
Yes 65.25 699/1017 1.34 (0.95, 1.88) 78.28 1818/2295 1.39 (1.10, 1.76)
No 58.34 4602/7736 REF -- 72.12 5348/7362 REF --
Forced Sex
Yes 65.93 381/524 1.30 (0.88, 1.90) 79.97 990/1244 1.49 (1.13, 1.97)
No 59.9 4912/8026 REF -- 72.82 6016/8149 REF --
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Boldface indicates statistical significance (p<0.05)

*

Analyses performed with small sub-population

Among males, a BMIp>95 (OR:1.29; 95% CI:1.03–1.61) and being bullied (OR:1.29; 95% CI:1.03–1.62) were significantly associated with increased odds of non-remitting asthma. Among females, being a former smoker (OR:1.30; 95% CI:1.01–1.66), being bullied (OR:1.54; 95% CI:1.23–1.92), being cyberbullied (OR:1.39; 95% CI:1.10–1.76), and experiencing forced sex (OR:1.49; 95% CI:1.13–1.97) were associated. Unadjusted models for SM/REM subpopulations across males and females are included in Table III.

Sex-Stratified SM/REM Analyses

Among males and in models adjusted for demographics (Table IV Model I; Figure 1), all four sub-populations with significantly elevated odds of non-remitting asthma from unadjusted models remained—Black heterosexual (adjusted OR [AOR] 2.05; 95% CI: 1.52–2.75), additional-race heterosexual (AOR 1.40; 95% CI: 1.06–1.86), White gay (AOR 11.56; 95% CI: 4.29–31.14), and additional-race gay (AOR 1.99; 95% CI: 1.79–13.95) males.

Table IV:

Stepwise Adjusted Odds Ratios for Non-remitting Asthma by Sexual Identity (SI) and Race/Ethnicity (RE) Intersections among Males, YRBS, 2009–2017.

Model I: Demographics N = 10,323 Model II: Model I + Selected Factors N = 8,293
n AOR 95% CI n AOR 95% CI
SI and RE Intersections
Heterosexual
 White 4871 REF -- 4871 REF --
 Black 1265 2.05 (1.52,2.75) 1265 2.01 (1.47, 2.75)
 Hispanic/Latinx 1757 1.00 (0.79,1.25) 1757 1.02 (0.80, 1.31)
 Additional-Race 1628 1.40 (1.06,1.86) 1628 1.44 (1.04, 2.00)
Gay
 White 89 11.56 (4.29,31.14) 89 11.09 (3.58, 34.38)
 Black 41 2.98 (0.96,9.26) 41 2.95 (0.66, 13.14)
 Hispanic/Latinx 54 1.35 (0.44,4.13) 54 1.03 (0.37, 2.85)
 Additional-Race 52 1.99 (1.79,13.95) 52 3.06 (1.00, 9.39)
Bisexual
 White 116 2.10 (0.80,5.51) 116 2.64 (0.91, 7.70)
 Black 42 1.11 (0.41,2.98) 42 1.11 (0.36, 3.41)
 Hispanic/Latinx 63 2.17 (0.69,6.80) 63 1.96 (0.45, 8.53)
 Additional-Race 61 1.15 (0.29,4.51) 61 1.08 (0.21, 5.50)
Not Sure
 White 122 1.57 (0.72,3.41) 122 1.3 (0.59, 2.88)
 Black 28* 2.07 (0.51,8.33) 28* 1.23 (0.23, 6.66)
 Hispanic/Latinx 70 1.72 (0.67,4.43) 70 1.65 (0.52, 5.22)
 Additional-Race 64 0.51 (0.17,1.57) 64 0.93 (0.26, 3.35)
Selected Demographics *
Region
 Northeast 4354 REF -- 4354 REF --
 Midwest 1469 0.92 (0.77,1.11) 1469 1.05 (0.84, 1.31)
 South 2379 0.66 (0.54,0.82) 2379 0.73 (0.58, 0.91)
 West 2124 0.81 (0.62,1.06) 2124 0.74 (0.56, 0.99)
Selected Variables
Cyberbullied
 Yes -- -- -- 1017 1.39 (0.96, 2.02)
 No -- -- -- 7736 REF --
Obese
 Yes -- -- -- 1893 1.31 (1.02, 1.68)
 No -- -- -- 7882 REF --
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Models were also adjusted for year of survey administration and age of respondent

Boldface indicates statistical significance (p<0.05)

*

Analyses performed with small sub-population

Figure 1. Non-remitting Asthma Forest Plot Odds Ratios for SM/REM vs White Heterosexual Male Youths.

Figure 1.

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Forest Plot of Table IV Model I. Model is adjusted for year of survey administration, age, and region.

Among females and in models adjusted for demographics (Table V Model I; Figure 2), compared with unadjusted models, all four previous significant associations with non-remitting asthma remained—Black lesbian (AOR 7.13; 95% CI: 2.10–24.17), Black bisexual (AOR 2.35; 95% CI: 1.12–4.92), Hispanic/Latinx heterosexual (AOR 0.61; 95% CI: 0.48–0.76), and additional-race heterosexual (AOR 0.63; 95% CI: 0.47–0.86) females. A higher chance of non-remitting asthma among Black heterosexual (AOR 1.43; 95% CI: 1.09–1.87) and Black not sure females (AOR 3.89; 95% CI: 1.17–12.97) compared with White heterosexual females emerged.

Table V:

Stepwise Adjusted Odds Ratios for Non-remitting Asthma by Sexual Identity (SI) and Race/Ethnicity (RE) Intersections among Females, YRBS, 2009–2017.

Model I: Demographics N = 11,466 Model II: Model I + Selected Factors N = 9,206
n AOR 95%CI n AOR 95%CI
SI and RE Intersections
Heterosexual
 White 5035 REF -- 5035 REF --
 Black 1281 1.43 (1.09,1.87) 1281 1.31 (0.99, 1.73)
 Hispanic/Latinx 1727 0.61 (0.48,0.76) 1727 0.57 (0.45, 0.73)
 Additional-Race 1512 0.63 (0.47,0.86) 1512 0.63 (0.45, 0.88)
Lesbian/Gay
 White 119 0.75 (0.36,1.54) 119 0.32 (0.14, 0.72)
 Black 62 7.13 (2.10,24.17) 62 4.62 (1.18, 18.08)
 Hispanic/Latinx 70 2.16 (0.78,5.96) 70 1.32 (0.49, 3.51)
 Additional-Race 46 0.72 (0.15,3.37) 46 3.79 (0.88, 16.34)
Bisexual
 White 575 0.85 (0.50,1.47) 575 0.55 (0.28, 1.08)
 Black 142 2.35 (1.12,4.92) 142 2.02 (0.86, 4.75)
 Hispanic/Latinx 276 0.90 (0.55,1.46) 276 0.66 (0.39, 1.10)
 Additional-Race 219 1.82 (0.92,3.61) 219 1.70 (0.71, 4.05)
Not Sure
 White 173 0.55 (0.28,1.09) 173 0.38 (0.16, 0.91)
 Black 59 3.89 (1.17,12.97) 59 3.52 (0.84, 14.71)
 Hispanic/Latinx 88 1.30 (0.60,2.80) 88 1.05 (0.46, 2.41)
 Additional-Race 82 0.94 (0.34,2.59) 82 1.53 (0.57, 4.13)
Selected Demographics*
Region
 Northeast 4952 REF -- 4952 REF --
 Midwest 1700 0.94 (0.78,1.13) 1700 0.97 (0.78, 1.20)
 South 2552 0.71 (0.56,0.89) 2552 0.73 (0.55, 0.95)
 West 2262 0.95 (0.75,1.20) 2262 0.81 (0.62, 1.07)
Selected Variables
Bullied
 Yes -- -- -- 2754 1.49 (1.16, 1.92)
 No -- -- -- 8494 REF --
Forced Sex
 Yes -- -- -- 1244 1.53 (1.10, 2.13)
 No -- -- -- 8149 REF --
Open in a new tab

Models were also adjusted for year of survey administration and age of respondent

Boldface indicates statistical significance (p<0.05)

Figure 2. Non-remitting Asthma Forest Plot Odds Ratios for SM/REM vs White Heterosexual Female Youths.

Figure 2.

Open in a new tab

Forest Plot of Table V Model I. Model is adjusted for year of survey administration, age, and region.

Adjusting for Correlates

Among males, being cyberbullied (AOR 1.39; 95% CI: 0.96–2.02) and having a BMIp>95 (AOR 1.31; 95% CI: 1.02–1.68) were the most robustly associated with non-remitting asthma (Table IV). Their inclusion in models reduced odds of non-remitting asthma for 9 subpopulations compared with models only adjusted for demographics. Most significant disparities in non-remitting asthma remained in the fully adjusted model; however, additional-race gay males (AOR: 3.06; 95% CI: 1.00–9.39; p=0.0504) lost significance.

Among females, being bullied (AOR 1.49; 95% CI: 1.16–1.92) and experiencing forced sex (AOR 1.53; 95% CI: 1.10–2.13) were the most robustly associated with non-remitting asthma (Table V). Their inclusion in models reduced the odds of non-remitting asthma for 12 subpopulations. Only Black lesbian females maintained significantly greater odds of asthma non-remission (AOR 4.62; 95% CI: 1.18–18.08). Four subpopulations (Hispanic/Latinx heterosexual, additional-race heterosexual, White lesbian, and White not sure) were significantly less likely than White heterosexual females to experience non-remitting asthma.

DISCUSSION

Consistent with prior work, we report differences in asthma remission by sex, with males having a higher prevalence than females.18 In partial agreement with the previous study on differences by race/ethnicity,23 we found significantly elevated rates of non-remitting asthma among Black males and females, as well as among additional-race males. Hispanic/Latinx females, however, experienced significantly lower rates of non-remitting asthma than White females. By sexual identity, only gay males were significantly more likely than their sex-matched heterosexual peers to have non-remitting asthma.

Furthermore, using an applied intersectional lens, we report disparities in asthma remission among SM/REM youth. Understanding that each subpopulation experiences distinct overlapping stigmatization helps to explain the varying magnitudes of disparities we report.24,25,30 Overall, 8 SM/REM minority subpopulations experienced significantly increased odds of non-remitting asthma compared with White heterosexual, sex-matched peers. There were no significant disparities among females by sexual identity alone; however, among SM/REM youth, significant disparities were found among Black heterosexual, lesbian, bisexual, and not sure females compared with White heterosexual females. Moreover, black females with a minority sexual identity, particularly lesbian and not sure identities, had higher odds of non-remitting asthma than did Black heterosexual females. These findings highlight the value of intersectionality-informed analyses, as worsened disparities among sexual minority females of color were not seen when examining only sexual identity, indicating that interlocking oppressions experienced by these sub-populations may be driving their distinct asthma outcomes.

For males, being cyberbullied or having a BMIp>95 tended to attenuate odds of non-remitting asthma among sub-populations, with additional-race gay males losing statistically significant increased odds of non-remitting asthma in fully adjusted models. The evidence suggests victimization and traditional risk factors like BMI may partially moderate disparities in asthma remission among marginalized populations. As described above, victimization may increase levels of minority stress among marginalized populations, initiating physiological (e.g., immune system dysregulation) and stress-linked coping behaviors (e.g., disordered eating that increases BMIp) that increase the risk for non-remitting asthma.24,30,31 Addressing the levels of stigmatization and minority stress that lead to such correlates could prove efficacious in reducing asthma remission disparities among male youth. Based on significantly elevated disparities, Black heterosexual; additional-race heterosexual; White gay; and additional-race gay male youth should receive special consideration in future asthma remission research and intervention.

For females, including being bullied and experiencing forced sex in fully adjusted models reduced the odds of non-remitting asthma for all subpopulations except additional-race heterosexual, lesbian, and not sure females. These variables eliminated the significantly higher odds of non-remitting asthma among Black heterosexual, bisexual, and not sure females. Of considerable note is the loss of statistical significance for increased odds of non-remitting asthma among Black bisexual females in the model including forced sex. Nationally, experiencing forced sex is most common among bisexual women and women of color.39 While the reasons for these higher levels of sexual victimization remain poorly studied, scholars have posited that such violence is linked directly to stereotypes and stigmatization of women of color and bisexual women (as well as among bisexual women of color).40 The evidence, then, in line with MST suggests that reducing occurrences of victimization and stigmatization may reduce risk for non-remitting asthma among marginalized female youth. Research into asthma remission among Black female youth, particularly those with a sexual minority identity, should be prioritized.

Interestingly, smoking status did not meet the significance cut-off for either fully-adjusted model. The lack of correlation may be explained by youth having not smoked long enough to see the observed patterns common in adults of smoking as a risk factor for non-remitting asthma.18 Having a BMIp>95%, however, was significantly associated with non-remission for males, indicating its potential role in pediatric non-remitting asthma.

Regarding the formulation of the asthma remission measure, we cannot confirm that a greater than 6 month period of symptom remission without medication occurred due to the wording of the questions in the YRBS. Thus, some respondents considered in our analyses to have entered asthma remission may not meet the clinical definition for this diagnosis. The term “asthma remission” has been used by many previous cross-sectional studies without a defined period of symptom remission.18 Additionally, the clinical definition of asthma remission is imprecise, with periods of no symptoms ranging from 6 months to 5 years to be considered in remission.17,18 The term “current asthma” has been used previously in epidemiological literature; however, current asthma studies use a different methodological approach.41–43 Studies using the term current asthma include respondents who have never had lifetime asthma. Thus, the term current asthma is in response to among the general population, how many youths have had asthma and still do. These studies estimate between 10–15% of youth have current asthma. Our study, however, along with other cross-sectional studies of asthma remission explore the absence of symptoms among lifetime asthmatics.18 Thus, the term asthma remission is in response to among people who have had asthma, how many of them no longer have asthma. The literature have estimated between 33% to 53% of youth asthmatics under 18 years have entered asthma remission, in line with our present estimate of 33.3%. Additionally, for adults with non-remitting asthma that began before age 16 years, the mean age of onset is at 7 years which is well below the age of the present analytic sample.44

Informing Clinical Practice and Asthma Management Guidelines

Asthma, unlike chronic conditions such as diabetes or cardiovascular disease, is not responsive to primary prevention or early intervention.45 However, similar to other chronic conditions, there are notable population-level health disparities impacting SM/REM populations.46 Despite the well-documented disparities, clinical guidelines of chronic conditions often do not include their mention.47–50 Included are the most referenced clinical guidelines for asthma—the Global Initiative for Asthma (GINA) and the Expert Panel Report (EPR) 3 Guidelines from the National Heart, Lung, and Blood Institute (NHLBI) published in 2007—which do not include considerations of the health inequalities among sexual or racial/ethnic minority populations.49,50 These considerations are similarly omitted from the recent focused updates to the EPR-3.51,52 Accordingly, we recommend GINA and future EPRs to include a section in their upcoming guidelines for the established disparities in asthma outcomes by marginalized status. The effects of structural issues such as stigmatization, discrimination, and oppression of marginalized persons on health disparities must be conceptualized by providers to begin combating their effects. To realize this goal, we recommend clinical asthma guidelines to include further research on the relation between social determinants of health, structural-level factors, and health disparities.53 The guidelines should specifically encourage health systems and providers to implement the National Standard for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care from the U.S. Department of Health and Human Services.54 GINA and the EPR should consider adding the stigmatization of SM/REM populations to be assessed and addressed along with environmental factors, education, and comorbidities in the management of asthma.49,51 Further, culturally-tailored asthma practices from the peer-reviewed literature predominantly focus on race/ethnicity.55–62 We posit the need for the development of culturally-tailored asthma interventions for SM/REM youth; hence, these guidelines must be expanded to also include sexual identity and the impacts of multiple-marginalization.

Along with additional considerations for clinical asthma guidelines, we encourage providers, researchers, and health care systems to adopt a systematic approach for identifying and ameliorating disparities on the basis of marginalization.24,25,53 Such approaches include the examination of culturally-tailored interventions designed to impact health systems and patient- provider interaction, as well as ways to increase provider conceptualization of the structural issues at hand.

Limitations

The present study is not without limitations. All data were self-reported, and secondary data analyses of a cross-sectional dataset do not allow for any commentary on causality or control over the questions asked. Moreover, the “not sure” response to sexual identity could have meant students were unsure of the question—not necessarily that they were unsure of their sexual identity. The YRBS only includes adolescents who attend high school; results may not be representative of students who are home-schooled or do not attend school. The use of clinician-diagnosed asthma could have led to an underestimation of asthma among marginalized youth populations, as engaging with physicians to receive a diagnosis is less likely among these groups.63 The asthma remission variable had to be constructed using self-report measures with no specific time period mentioned, which could have introduced symptom perception bias.18 As most remission occurs between the ages of 14 and 21 years of ages and our sample falls toward the early part of this range, there could be an underestimation of asthma remission.19 Moreover, due to wording of the asthma questions, we cannot define the length of symptom remission or medication use. Thus, some respondents considered to have enter remission in the present study may not meet the clinical definition.

Adjusting for all known traditional correlates was also not possible.18 The small sample size of many sub-populations likely contributed to their not reaching significance. Specifically, the sample size for Black not sure males was fewer than 30 individuals and should be interpreted with caution.64 Finally, we used SM/REM youth sub-populations as proxies for intersectional oppression. Despite these limitations, our study is the first to explore and introduce inequalities in asthma remission by sexual identity and at the intersections of sexual identity and race/ethnicity. Our study is also the first to frame remission based on MST and intersectionality frameworks, which are critical to population health studies. Finally, we identified potential factors for non-remitting asthma among male and female SM/REM youth and, for the first time, suggested the role that victimization may play.

In total, asthma remission disparities exist by sexual identity, race/ethnicity, or both with those of marginalized status generally being more likely to experience non-remitting asthma. Viewed through the lens of intersectionality and MST, our findings provide empirical support that victimization may be associated with asthma non-remission. The construction of an asthma remission variable allowed for an innovative and comprehensive examination of the disparity subpopulations and correlates of non-remitting asthma among U.S. youth. Correlates such as being cyberbullied or BMIp>95% for males and being bullied or forced to engage in sex for females may partly explain the dipartites in asthma remission observed in our study. The present study, along with previously published literature on asthma prevalence and remission disparities experienced by marginalized persons, should be used to set a research agenda designed to improve asthma management.1,7–16,18

HIGHLIGHTS BOX.

  1. What is already known about this topic?
    • 1.1. There are reported disparities in asthma remission by sex and race/ethnicity. Asthma remission negatively associates with asthma severity, smoking, and increased weight. Minority stress theory and intersectionality are imperative frameworks to study population health.
  2. What does this article add to our knowledge?
    • 2.1 Sexual minority and/or racial/ethnic minority youth tend to be at higher risk for non-remitting asthma. Traditional risk factors and victimization are associated with increased odds of non-remitting asthma among these populations.
  3. How does this study impact current management guidelines
    • 3.1. Asthma management guidelines should include population-level disparities on the basis of marginalization. Clinicians should stay up-to-date on cultural responsiveness training and implement the National Standard for Culturally and Linguistically Appropriate Services (CLAS) in practice.

Acknowledgements

We thank Blair Turner for her contributions that assisted in the analyses of this manuscript.

Funding Acknowledgement

This research was funded under R01 AA024409 (PI: Phillips) by the National Institute on Alcohol Abuse and Alcoholism, as well as under K12 HL143959 (PI: Beach) by the National Heart, Lung, and Blood Institute and K12 HS026385 (PI: Kan) by the Agency for Healthcare Research and Quality.

Abbreviations:

(CDC)

Centers for Disease Control and Prevention

(SM/REM)

Sexual Minority and/or Racial/Ethnic Minority

(YRBS)

Youth Risk Behavior Survey

(BMIp)

Body Mass Index Percentile

(GINA)

Global Initiative for Asthma

(NHLBI)

National Heart, Lung, and Blood Institute

(EPR)

Expert Panel Report

Footnotes

Disclaimer

The funding source had no role in the study design; collection, analysis, or interpretation of data; the writing of the report; nor in the decision to submit the article. The content solely represents the views of the authors and not necessarily the National Institutes of Health.

Conflict of Interest Disclosures

We declare no competing interests.

Human Participant Protection

All current study activities were classified as non–human participant research by the institutional review board at Northwestern University.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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