People under 45 have been driving an increase in liver-related deaths, especially those caused by alcohol. But a sliver of that young adult population is being hit disproportionately hard by alcohol-associated liver disease: transgender people.
Although trans adults make up less than 1% of the United States population, a study published in The American Journal of Gastroenterology last month shows they face double the risk of severe liver disease, and a higher share of cirrhosis from heavy drinking.
The paper’s authors looked back on 15 years of health data from 330,000 cirrhosis patients on commercial insurance plans. They found that alcohol-driven disease was higher among trans people, begging the need for better, more timely interventions. Viral infections, including hepatitis B and C, were the second-leading cause of cirrhosis in this group — leading to about 31% of cases (roughly half the burden of alcohol-driven disease).
STAT spoke about the findings with the paper’s senior author, Brian P. Lee, a liver transplant physician at Keck Medicine of the University of Southern California. This interview has been edited for brevity and clarity.
Why did you decide to investigate this question?
There was really no data regarding transgender individuals and liver health. And we really hypothesized that this would be a unique subpopulation that would need specific research and attention. Trans individuals are known to have higher risk of substance misuse disorders, mental health conditions. And we hypothesized that this could put them at higher risk for liver-related conditions, since alcohol and viral hepatitis are such important contributors to liver disease.
Why is it that we have such a dearth of research on transgender patients with liver disease?
They represent a small proportion of the overall population. So when you’re trying to really study and look for specific, unique features in health, you often need to have large groups of people to be able to study them and see how things might be different from other groups. That was a practical challenge, and that’s why we use a very large database here. Another challenge is transgender individuals really face a lot of stigma. A lot of people may not access health care and be in these databases, or really want to disclose their [gender] identity.
You found there’s double the prevalence of cirrhosis in trans adults versus cisgender adults. What was your reaction when you crunched the numbers and saw that?
It’s remarkable, right? Over double the prevalence. Double the risk, really, of having end-stage liver disease. That’s shocking. It should really prompt further research, but also clinical initiatives to screen for cirrhosis and then also screen for risk factors for cirrhosis.
Alcohol was the most prevalent cause of cirrhosis in trans patients, at about 60% of cases. Were you at all surprised by that?
Alcohol was the most common etiology even in the general population — about 50%. So we weren’t surprised that it was the most common. But the fact that it accounted for 60%…that significant proportion tells you the risk factors and possible interventions that are needed to address alcohol misuse in this population. That’s what we’re seeing in this study: the end and late stage of drinking patterns. We typically think that it takes several years of heavy drinking to develop cirrhosis. So my hope is that, if we’re able to have interventions that are really tailored to transgender individuals but also the broader LGBTQ community — about education, awareness, access to treatments for alcohol use — we would be able to address the really alarming rates of liver disease.
Anxiety and depression were common in trans people with cirrhosis. How does that tie into their disease?
This is kind of hypothesis-generating, but we found that there are higher rates of depression and anxiety among transgender individuals with cirrhosis (about two-thirds of people) than cisgender individuals with cirrhosis. We know that alcohol can be used as a coping mechanism for depression and anxiety. Our hypothesis is that having depression and anxiety leads to increased alcohol use, which can then lead to higher rates of liver damage and then eventually cirrhosis.
You also reported that trans patients with cirrhosis were more likely to report female gender. What more can you share about that, or how hormone therapy might impact how the body processes alcohol?
We know that women, at the same quantities of alcohol, can develop liver damage at a faster rate (at lower quantities of alcohol, in fact). We know that testosterone and estrogen balance is important for mediating liver damage and scarring. So it’s an interesting finding that needs further study.
There’s one positive finding in the paper, which is that trans people with end-stage liver disease appear to have similar rates of transplantation and five-year survival probabilities after transplant. Still, transplant is kind of the last resort. What do the study findings tell you about where providers should be targeting care?
Once transgender individuals with cirrhosis are able to be linked to care, their outcomes are actually quite good in that they’re comparable to cisgender individuals. What we need is to be able to link these patients to care before they develop cirrhosis. If we’re able to prevent liver disease or prevent the complications of having liver disease, then you don’t need a transplant. Preventing disease and restoring health should really be the priority here.
STAT’s coverage of chronic health issues is supported by a grant from Bloomberg Philanthropies. Our financial supporters are not involved in any decisions about our journalism.
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