Health disparities experienced by sexual and gender minority individuals living with or at risk of chronic liver disease

INTRODUCTION

History of healthcare discrimination against Lesbian, Gay, Bisexual, Queer, Intersex, and Asexual (LGBTQIA+)¹ individuals hinders access to care and likely contributes to overall health disparities. Chronic liver disease (CLD) is the 11th leading cause of death in the United States and is increasingly prevalent in diverse populations.² Sexual and gender minority [SGM] (interchangeable with LGBTQIA+, as outlined in Table 1) communities are disproportionately affected by viral hepatitis^4,5 and potentially fatty liver disease,⁶ as well as traditional risk factors for CLD, such as alcohol use disorder (AUD),⁷ diabetes, and obesity.^8,9 There are now about 11.4–12.2 million individuals who identify as SGM in the United States, and the trend continues to increase, particularly in “Generation Z,” where 20.8% identify as LGBT.^10,11 To care for this population, clinicians should be aware of liver disease burdens in SGM individuals and risk factors. A recently proposed conceptual framework, adapted from the Minority Stress Model, links the effects of life stressors, psychosocial factors, behavioral factors, and physiologic factors with the burden of gastrointestinal diseases and outcomes for SGM individuals (Figure 1),³ which we use to frame our presentation of risk factors. For instance, behavioral factors, such as injection drug use (IDU),¹² more common in certain SGM communities,¹² are influenced by minority identity and life stressors (discrimination, violence, stigma, etc.) and increase CLD risk. In this article, we will discuss various CLDs that are more prevalent in SGM communities, which are associated with social determinants of health.

TABLE 1.

Sexual and gender minority (SGM) nomenclature

Asexual	Someone who has little or no sexual attraction to others. Asexual people can experience other forms of attraction.
Bisexual	A person who experiences sexual, romantic, physical, and/or spiritual attraction to people of their own gender as well as toward another gender.
Cisgender	A term used to describe people whose gender identity is congruent with what is traditionally expected based on their sex assigned at birth.
Gay	A term traditionally used to describe men who are attracted to men. Although usually associated with men, other gender identities may use the term to describe their same-gender attractions and relationships as well (such as women and nonbinary people).
Gender diverse	A term used to describe people whose gender identity is not constrained by binary concepts of gender.
Gender expression	The ways in which a person communicates femininity, masculinity, androgyny, or other aspects of gender, often through speech, mannerisms, gait, or style of dress.
Gender identity	A person’s inner sense of being a woman, a man, a combination of woman and man, something else, or having no gender at all.
Gender minority	A broad diversity of people who experience an incongruence between their gender identity and what is traditionally expected based on their sex assigned at birth, such as transgender and gender diverse persons.
Gender nonbinary	A term used by some people who identify as a combination of girl/woman and boy/man, as something else, or as having no gender. Often used interchangeably with “gender nonconforming.”
Gender nonconforming	A term used by some people who identify as a combination of woman and man, as something else, or as having no gender. Often used interchangeably with “gender nonbinary.”
Intersex	People born with differences in their biological sex traits including chromosomes, reproductive anatomy, and hormone production.
Lesbian	Used to traditionally describe women who are attracted to women; applies for cisgender and transgender women.
Queer	Historically a derogatory term used against LGBTQIA+ people, it has been embraced and reclaimed by LGBTQIA+ communities. Queer is often used to represent all individuals who identify outside of other categories of sexual and gender identity. Queer may also be used by an individual who feels as though other sexual, or gender identity labels do not adequately describe their experience.
Sex	Biological sex characteristics (chromosomes, gonads, sex hormones, and/or genitals); male, female, intersex. Synonymous with “sex assigned at birth.”
Sex assigned at birth	Usually based on phenotypic presentation of an infant and categorized as female or male; distinct from gender identity.
Sexual minority	A broad diversity of people who have a sexual orientation that is anything other than heterosexual/straight, and typically includes gay, bisexual, lesbian, queer, or something else.
Sexual Orientation	A person’s physical, emotional, and romantic attachments in relation to gender. Conceptually separate from gender identity and gender expression.
Straight	A man or woman who is attracted to people of the other binary gender than themselves; can refer to cisgender and transgender individuals; often referred to as heterosexual.
Transgender man	Someone who identifies as male but was assigned female sex at birth.
Transgender woman	Someone who identifies as female but was assigned male sex at birth.
Two-spirit	A person who identifies as having both a masculine and a feminine spirit and is used by some indigenous people to describe their sexual, gender, and/or spiritual identity.

Reprinted with permission from Vélez C, Casimiro I, Pitts R, Streed C Jr, Paul S. Digestive Health in Sexual and Gender Minority Populations. Am J Gastroenterol. 2022;117:865–75.³

FIGURE 1.

Biopsychosocial model for social determinants of health and the impact on gastrointestinal disease. Abbreviations: LGBTQ+, Lesbian, Gay, Bisexual, Transgender Queer. Reprinted with permission from Vélez C, Casimiro I, Pitts R, Streed C Jr, Paul S. Digestive Health in Sexual and Gender Minority Populations. Am J Gastroenterol. 2022;117:865–75.³

Hepatitis C

Two million people live with HCV¹³ in the United States, and men who have sex with men (MSM) likely represent a new wave of infections.^4,14–16 Prevalence is higher in MSM over 30, with HIV (6.5 vs. 1.5%),¹⁷ history of IDU,¹⁸ and endorsing high-risk sexual practices.¹⁹ HIV increases the odds of HCV 6-fold,²⁰ is associated with HCV reinfection,²¹ and has been cited to be present in up to 57.1% of male-to-female transgender individuals with HCV.²² Methamphetamine use is increasing among MSM, particularly Black and Latino communities,²³ and is associated with a higher risk of transmission, not only through IDU but also potentially through the lowering of sexual inhibitions.¹⁹ High-risk sexual practices,¹⁷ such as sex with multiple partners, unprotected receptive anal intercourse, and practices associated with higher rectal trauma, are also associated with increased transmission.^21,22 Key points: clinicians should strongly consider screening for HCV infection and reinfection in MSM, particularly with HIV. Though certain behavioral risk factors for HCV transmission are common in MSMs, it is imperative that clinicians take detailed histories for such factors (ie, sexual history, IDU, etc.) to inform counseling but not equate these risk factors to being MSM.

Hepatitis B

MSM represents up to 24% of new HBV infections²⁴ in the United States, and HBV testing and vaccination are recommended.^25,26 Previous efforts that focused on linking “high-risk” (defined by the number of sexual partners) MSM to HBV vaccination have successfully reduced HBV incidence;^27,28 however, men over 40,⁵ with limited education status²⁹ and underinsured,^28–30 have lower immunization rates. Though HIV infection within MSMs is associated with a higher presence of HBV core antibody and surface antigen,³¹ increasing the use of PrEP and treatment for HIV infection has likely played a role in decreasing HBV incidence.³² Key points: clinicians should ensure that MSM is screened for HBV and linked to vaccination for both HBV and HAV and, if applicable, HBV treatment. Providers should offer PrEP for HBV-positive patients.

Alcohol-associated liver disease

While the incidence of ALD in SGM communities is unknown, AUD is prevalent, particularly in sexual minority women and transgender individuals.^7,33–35 The PRIDE Study reported up to 51% of binge drinking in SGM communities.³⁶ Compared with controls, sexual minority women had higher odds of severe AUD and drink 2 to 3 times more than the standard cutoff for women.^7,35 Although higher age was protective in heterosexuals, it was less protective in sexual minority women.³³ The presence of life stressors, such as discrimination, in sexual minority women was associated with an increased risk of alcohol consequences.^37,38 Key points: despite the lack of data on the prevalence of ALD in SGM communities, there are disproportionately higher rates of AUD, particularly among sexual minority women and transgender individuals. Clinicians should have a lower threshold to screen for AUD, elicit life stressors, and recommend linkage to substance use care.

Nonalcohol-associated fatty liver disease

While the prevalence of NAFLD in SGM groups is unknown, there is a higher prevalence of physiologic factors (metabolic syndrome, HIV, and HCV) and other clinical (hormone therapy use) and behavioral (eating disorders) factors compared with heterosexuals. Lesbian and bisexual females have greater odds of being overweight and obese compared with heterosexual females,⁸ as well as a 27% higher risk of diabetes.⁹ Bisexual men also have a higher risk of diabetes compared with heterosexual men.^39,40 Although the role of eating disorders in NAFLD remains unclear, the PRIDE study reports that binge eating, weight, and shape concerns in cisgender gay men are common.⁴¹ A higher prevalence of NAFLD is seen among individuals infected by HIV (22%–35%)⁶ and HCV (55%).⁴² Compared with cisgender men, transgender women undergoing hormone therapy had higher fat mass and higher insulin resistance.⁴³ Although not specifically studied in transgender patients, high total testosterone levels (relevant for female-to-male hormonal therapy) can increase the odds of NAFLD in biological females.⁴⁴ Though also not specifically studied in SGM populations, there is growing evidence that, in addition to hormonal contraceptive therapy, metabolic risk factors can also play a role in hepatocellular adenoma pathophysiology and risk of malignant transformation.⁴⁵ Key points: clinicians should be aware of unique clinical (hormonal therapy) and behavioral (eating disorders) factors, in addition to traditional physiologic factors (HIV, HCV, and diabetes), which may drive NAFLD development in SGM individuals.

Future research

We have summarized key gaps in our understanding of CLD prevalence and risk factors in SGM communities to inform a future research agenda (Table 2). In general, greater efforts toward collecting gender and sexual identity data, in addition to reporting the prevalence of CLD, are critically needed. Based on the data that exist, we highlight the research needed to develop culturally sensitive clinical pathways that serve this population.

TABLE 2.

Opportunities for future research in hepatology for sexual and gender minority (SGM) communities

CONCLUSIONS

Health systems are rapidly adapting to promote high-quality and individualized care to SGM individuals, including populations that have or are at risk of CLD. Clinicians should feel comfortable obtaining more information from SGM individuals regarding risk factors, which can facilitate earlier detection of disease, harm reduction, and linkage to care. More research is critically needed.