Cirrhosis is a chronic, progressive, end-stage liver disease that occurs when scar tissue prevents the liver from functioning normally. Studies have shown that two of the leading causes of cirrhosis—alcohol use disorder and viral hepatitis—occur more frequently in transgender individuals, but there has been little research examining whether these risk factors translate into a higher incidence of cirrhosis among transgender patients.
A new study from Keck Medicine of USC published in American Journal of Gastroenterology finds that transgender adults have twice the prevalence of cirrhosis compared to cisgender adults (people whose gender identity matches the sex they were assigned at birth), suggesting a need for more preventative and supportive care.
“Our study reveals that cirrhosis disproportionately affects transgender people and highlights an urgent health issue that needs to be addressed,” said Brian P. Lee, MD, MAS, a hepatologist and liver transplant specialist at Keck Medicine and principal investigator of the study.
Lee and her colleagues launched the study to provide scientifically supported guidance on liver health to physicians so they could offer transgender patients a higher level of care.
In addition to finding that transgender cirrhosis rates are twice that of the cisgender population, the study authors also found that the majority of transgender adults with cirrhosis (60%) have a diagnosis of anxiety and/or depression, compared to 40% of cisgender patients with cirrhosis.
They also found that alcohol was the main cause of cirrhosis in the transgender group, accounting for about 60% of cases, while the percentage of cisgender adults with alcohol-associated cirrhosis was approximately 50%.
In other findings, transgender patients with cirrhosis also tended to be younger (a greater proportion were 44 years old or younger), had higher rates of viral hepatitis, and were five times more likely to have HIV/AIDS than their cisgender counterparts.
Possible reasons behind the disparity
Lee hypothesizes that higher rates of depression and anxiety may be driving higher rates of alcohol use among transgender patients, which in turn may result in higher cases of cirrhosis.
The higher rate of HIV/AIDS among transgender patients may also be a factor, as both conditions are known to be associated with the progression of liver disease, Lee said.
Lack of access to quality health care could also play a role, hypothesizes Dr. Jeffrey Kahn, a hepatologist and liver transplant physician at Keck Medicine and co-author of the study.
The researchers also studied five-year outcomes among all transgender and cisgender patients with cirrhosis. Interestingly, despite the differences between the two groups, the number of possible negative outcomes of cirrhosis (liver failure, liver transplant, and liver cancer, as well as death, from any cause) was the same.
“This finding suggests that the transgender community is underserved in the early stages of liver disease, but people can get the care they need once they are diagnosed with cirrhosis,” Kahn said. “Early prevention is key because if liver disease is detected early, it is less likely to progress to cirrhosis.”
To reach their conclusions, the study authors mined data from a large national database, the Optum Clinformatics® Data Mart Database (Optum), which contained medical claims for more than 60 million patients covered by commercial insurance or Medicare between 2007 and 2022. They first identified all transgender and cisgender adults, then compared incidences of cirrhosis between each group, as well as the causes of the disease. In addition, the researchers tracked depression and anxiety in the patients.
Lee and Kahn hope the study will spur further research and motivate health care providers to provide transgender patients with additional support, including liver screening and access to mental health resources. “This population requires specific attention from both clinicians and researchers,” Lee said.
Keck Medicine’s efforts to support the well-being of transgender patients
Keck Medicine launched the USC Gender Affirming Care Program to provide personalized, supportive health care to the transgender population. The program provides a full range of compassionate, specialized health care services for the transgender, nonbinary and gender diverse community, including everything from routine medical care, such as preventative cancer screenings, annual checkups and flu shots, to hormone therapy and gender-affirming surgery.
The program is staffed by physicians from a variety of disciplines, including family medicine, plastic surgery, gynecology, urology, and otorhinolaryngology. There are also occupational therapy, physical therapy, and voice specialists available to patients.
Additionally, Keck Medicine hospitals have received the “LGBTQ+ Healthcare Equality Leader” designation in the Human Rights Campaign Foundation’s 2024 Healthcare Equality Index (HEI) seven times in recent years. HEI is the leading national benchmarking survey of healthcare facility policies and practices dedicated to equitable treatment and inclusion of LGBTQ+ patients, visitors, and employees.