A new study from Keck Medicine of USC published in The American Journal of Gastroenterology finds that transgender adults have double 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 supportive, preventive care. 

“Our study reveals that cirrhosis disproportionately affects transgender individuals and highlights a pressing health issue that needs addressing,” said Brian P. Lee, MD, MAS, a hepatologist and liver transplant specialist with Keck Medicine and principal investigator of the study.   

Lee and his colleagues launched the study to provide scientifically backed liver health guidance for physicians so they could offer transgender patients a higher level of care. 

Besides discovering that transgender cirrhosis rates are double that of the cisgender population, the study authors also learned that the majority of transgender adults with cirrhosis (60%) have a diagnosis of anxiety and/or depression, compared to 40% of the cisgender patients with cirrhosis.  

They also found that alcohol was the leading cause of cirrhosis in the transgender group, accounting for some 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 larger portion were 44 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 the increased rates of depression and anxiety may be driving higher rates of alcohol use among transgender patients, which in turn, may result in greater cases of cirrhosis.  

The increased rate of HIV/AIDS among transgender patients may also be a factor in that both conditions are known to be associated with liver disease progression, according to Lee.  

Lack of access to quality health care could also play a role, hypothesizes Jeffrey Kahn, MD, a hepatologist and liver transplant physician with Keck Medicine and co-author of the study.  

Researchers also studied the five-year outcomes among all transgender and cisgender patients with cirrhosis. Interestingly, despite the differences in the two groups, the number of possible negative outcomes of cirrhosis — liver failure, liver transplant and liver cancer, as well as death, by any cause — was the same.  

“This finding suggests that the transgender community is underserved in the initial stages of liver disease, but individuals are able to secure the care they need once cirrhosis is diagnosed,” said Kahn. “Early prevention is key because if liver disease is caught in time, there is less of a chance it will progress to cirrhosis.”  

To reach their conclusions, study authors culled data from a large national database, Optum Clinformatics® Data Mart Database (Optum), that contained medical claims for more than 60 million patients covered by commercial insurance or Medicare between the years of 2007-2022. They first identified all transgender and cisgender adults, and then compared the incidences of cirrhosis among each group as well as causes of the disease. Additionally, researchers tracked depression and anxiety in patients. 

Lee and Kahn hope the study will spur more research and motivate health care practitioners to provide transgender patients with extra support, including liver screenings and access to mental health resources. “This population requires specific attention from clinicians and researchers alike,” said Lee.  

Keck Medicine efforts to support transgender patient wellness  

Keck Medicine launched the USC Gender-Affirming Care Program to provide tailored, supportive health care to the transgender population. The program provides a full range of expert, compassionate health care services for the transgender, non-binary and gender-diverse community, including everything from routine health care, such as preventive cancer screenings, yearly checkups and flu shots, to gender-affirming hormone therapy and surgery.  

The program is comprised of physicians from several disciplines, including family medicine, plastic surgery, gynecology, urology and otolaryngology. Specialists in voice, occupational and physical therapy are also available to patients.  

Additionally, Keck Medicine hospitals have been awarded the ‘LGBTQ+ Healthcare Equality Leader’ designation in the Human Rights Campaign Foundation’s 2024 Healthcare Equality Index (HEI) for seven times in recent years. HEI is the leading national benchmarking survey of health care facility policies and practices dedicated to the equitable treatment and inclusion of LGBTQ+ patients, visitors and employees. 

HEI is the leading national benchmarking survey of health care facility policies and practices dedicated to the equitable treatment and inclusion of LGBTQ+ patients, visitors and employees. A record 1,065 health care facilities participated in the 2024 HEI survey; only 36% (384 facilities) earned ‘LGBTQ+ Healthcare Equality Leader’ designation. 

“Keck Medicine is proud to serve the LGBTQ+ community through patient-centered care, dedicated advocacy and fostering a safe, welcoming and inclusive environment,” said Rod Hanners, CEO of Keck Medicine. “This recognition is a testament to our commitment to delivering quality care tailored to the diverse needs of the LGBTQ+ community within a supportive and inclusive setting.” 

Keck Medicine hospitals include Keck Hospital of USC, USC Norris Cancer Hospital, and community hospitals, USC Verdugo Hills Hospital (USC-VHH) and USC Arcadia Hospital (USC-AH). This marks the seventh time in recent years that Keck Hospital, USC Norris and USC-VHH have received the 'LGBTQ+ Healthcare Equality Leader' distinction, and it is the first time USC-AH is honored with this distinction since joining Keck Medicine in 2022. 

“Receiving this designation is a significant milestone for USC Arcadia Hospital,” said Ikenna (Ike) Mmeje, CEO of USC-AH. “We are proud to stand with our health system colleagues in support of our LGBTQ+ community.” 

USC Student Health, which provides comprehensive health care to USC students, participated in the survey for the second time and joins a select group of college health care providers in receiving the leader designation. 

Continued Commitment to Inclusivity and Equity 

Keck Medicine leads multiple initiatives and programs in support of the LGBTQ+ community, demonstrating a steadfast commitment to inclusivity and equity.  

The USC Gender Affirming Care Program offers comprehensive health care tailored to transgender, non-binary and gender-diverse patients. The program’s dedicated patient navigator assists patients with their personalized needs throughout their health care journey. 

Keck Medicine also maintains a collaboration with The TransLatin@ Coalition, a trans-led nonprofit organization that advocates for the needs of transgender, gender non-conforming and intersex immigrants. The collaboration includes education and training opportunities for faculty and staff across both organizations regarding best practices in LGBTQ+ health care, as well as community engagement, focus groups and forums to advance dialogue to share progress and solicit input and feedback. 

As a sponsor of the Latino Equality Alliance LGBTQ+ Youth College Scholarship Program, the health system created the Keck Medicine of USC scholarship to support LGBTQ+ students pursuing health care careers and has awarded more than $20,000 in scholarships since 2019. 

Keck Medicine has also been a medical sponsor of AIDS/LifeCycle since 2020, supporting riders and volunteers, including staff, who raise funds to provide access to HIV/AIDS medical care and end stigma. 

Since its inception in 2015, the Keck Pride employee resource group has been a pillar in creating a welcoming environment for LGBTQ+ patients, families, staff and the community and is a driving force in many of the health system’s initiatives.   

HEI Criteria  

The HEI evaluates and scores health care facilities on detailed criteria in four categories: 

• Foundational non-discrimination protection for patients, visitors and staff via policies and training in LGBTQ+ patient-centered care. 
• LGBTQ+ patient services and support. 
• LGBTQ+ inclusive employee policies and benefits.  
• LGBTQ+ community and patient engagement. 

To receive ‘LGBTQ+ Healthcare Equality Leader’ designation, health care facilities must receive the maximum score in each criteria and earn an overall score of 100. 

The Human Rights Campaign Foundation is the educational arm of the Human Rights Campaign, a civil rights organization working to achieve equality for LGBTQ+ people. 

She was quickly disappointed. One provider admitted they knew nothing about transgender health, and another labeled her transgender status as a “medical problem.” 

She then discovered the Keck Medicine of USC Gender-Affirming Care Program and met with Laura Taylor, MD, a Keck Medicine family medicine specialist and medical director of the program. Taylor has been Bridget’s primary care doctor ever since.

As Bridget experienced, transgender people often face barriers to equitable health care. According to a 2021 study from the Center for American Progress, one in three transgender adults said they had to teach their doctors about transgender health to receive appropriate care. Nearly one-half reported having negative or discriminatory experiences with a health care provider.

To address the many health care disparities faced by transgender individuals, Keck Medicine  has launched the Gender-Affirming Care Program to meet the comprehensive needs of the transgender, nonbinary and gender-diverse community. Services include everything from routine health care, such as preventive cancer screenings, yearly checkups and flu shots, to gender-affirming hormone therapy and surgery.  

The program is comprised of physicians from several disciplines including family medicine, plastic surgery, gynecology, urology and otolaryngology. Specialists in voice, occupational and physical therapy are also available to patients.

A nurse navigator coordinates care with the providers to ensure patients receive seamless specialized treatment. The physicians and program staff have collectively received more than 600 hours of gender-affirming sensitivity and inclusivity training.

“Our program brings together a multidisciplinary group of physicians across specialties to address the specialized needs of this underserved population,” said Taylor. “We’re proud to offer a full range of health care services in a safe and supportive environment.”

Another key aspect of the Gender-Affirming Care Program is that it was designed with input from the local transgender community.

“Due to historic marginalization of the transgender population, some within the community view medical providers with distrust,” said Roberto Travieso, MD, surgical director of the program. “It was important to make our local community part of the process as we built the program.”

As part of its outreach, Keck Medicine partnered with The TransLatin@ Coalition, the largest trans-led nonprofit organization in Los Angeles that advocates for the needs of transgender, gender non-conforming and intersex immigrants across the country.

This collaboration helps Keck Medicine establish a strong foundation within the transgender community and provides ongoing feedback on how the program can best serve patients.

The Gender-Affirming Care Program was in development for several years, but came to full fruition with the arrival of Taylor and Travieso to Keck Medicine, respectively in 2020 and 2021. Taylor is trained in LGBTQ+ health care and Travieso is fellowship-trained in gender-affirming surgery.

The program leaders hope to hire and train more gender-affirming practitioners, build more mental health services into care and foster additional community partnerships.

Meanwhile, for patients like Bridget, the Gender-Affirming Care Program is a gift.

“I am doing really well under Dr. Taylor’s care, and feeling happy and healthy,” she said.

The collaboration will  streamline the development of health care services that address the varied needs of the transgender, non-binary and gender-diverse community through a social, economic and racial justice lens. It also further establishes a strong community foundation with the LGBTQ+ community as Keck Medicine develops specialized services for patients to access comprehensive, affirming health care.

“Keck Medicine embraces the diversity of our patients, staff and faculty,” said Rod Hanners, CEO of Keck Medicine. “Our collaboration with The TransLatin@ Coalition allows us to provide health care that holistically addresses the needs of our transgender, non-binary and gender-diverse patients and deliver access to comprehensive resources in a safe, supportive and welcoming environment.”

The collaboration includes:

• Establishment of a patient/peer navigator to assist patients in navigating through the health system to meet their personalized needs and facilitate access to care between organizations.
   
• Education and training opportunities for faculty and staff across both organizations regarding best practices in LGBTQ+ health care.
   
• Community engagement, focus groups and forums to advance dialogue to share progress and solicit input and feedback.

“The TransLatin@ Coalition understands the many social and economic issues that disproportionately impact the TGI community,” said Bamby Salcedo, president and CEO of The TransLatin@ Coalition.  “We are historically underserved by health systems, making it difficult for the TGI community to feel heard and access the care we need. This important collaboration with Keck Medicine allows us to share the resources and expertise of a top-tier academic medical center to help improve the health and lives of our local TGI community.”

Keck Medicine also recently received the designation of “LGBTQ+ Healthcare Equality Leader” in the Human Rights Campaign Foundation’s Healthcare Equality Index (HEI) for the sixth time in recent years. The index is a leading national benchmarking survey of health care facility policies and practices dedicated to the equitable treatment and inclusion of LGBTQ+ patients, visitors and employees. 

The TransLatin@ Coalition was founded in 2009 by transgender immigrant women in Los Angeles to address the specific needs of the TGI community. The national trans-led organization addresses social determinants of health and advocates for racial and social justice for the TGI community.

HEI is a leading national benchmarking survey of health care facility policies and practices dedicated to the equitable treatment and inclusion of LGBTQ+ patients, visitors and employees. A record 906 health care facilities participated in the 2022 HEI survey, and 496 of those earned “LGBTQ+ Healthcare Equality Leader” designation.

The HEI evaluates and scores health care facilities on detailed criteria in four categories:

·       Foundational policies and training in LGBTQ+ patient-centered care.

·       LGBTQ+ patient services and support.

·       Employee benefits and policies.

·       Patient and community engagement.

To receive “LGBTQ+ Healthcare Equality Leader” designation, institutions must receive the maximum score in each section and earn an overall score of 100. You can find the HEI 2022 results here.

“This distinction is a reflection of our hospitals’ dedication to providing quality health care to all LGBTQ+ patients in a safe, welcoming environment,” said Rod Hanners, CEO of Keck Medicine. “Keck Medicine has adopted numerous initiatives to support LGBTQ+ patient-centered care, and we will continue to be champions of this community.”

Keck Medicine’s hospitals include Keck Hospital of USC, USC Norris Cancer Hospital and USC Verdugo Hills Hospital, a community hospital in Glendale.

This is the sixth time in recent years that Keck Medicine hospitals have received “LGBTQ+ Healthcare Equality Leader” distinction.

USC Student Health, which offers comprehensive health care to USC students, participated in the survey for the first time and is one of a select group of college health care providers to receive the leader designation.

“We are proud to implement policies, training and education to ensure that all students feel safe, supported and respected as they seek care,” said Sarah Van Orman, MD, MMM, FACHA, chief health officer for USC Student Health. “As providers, we will continue to work to ensure that all our patients feel empowered to seek the care they need and deserve.”

Keck Medicine has taken many steps to care for the LGBTQ+ community. The Keck Medicine Gender Affirming Care Program provides transgender, non-binary and gender- diverse patients access to comprehensive, affirming health care.

The Keck Pride committee, founded in 2015, helps design and implement strategies to foster a welcoming environment for LGBTQ+ patients, families and employees. The health system also offers various training opportunities around LGBTQ+ health.

Additionally, Keck Medicine sponsors local LGBTQ+ events, such as the AIDS Walk, the AIDS/LifeCycle, the USC LGBTQ+ Student Center Lavender Celebration — an annual graduation ceremony for LGBTQ+ students — and celebrations hosted by The TransLatin@ Coalition and the Latino Equality Alliance.

As a sponsor of the Latino Equality Alliance’s LGBTQ+ Youth College Scholarship Program, the health system created the Keck Medicine of USC scholarship to support LGBTQ+ students pursuing health care careers.

The Human Rights Campaign Foundation is the educational arm of the Human Rights Campaign, a civil rights organization working to achieve equality for LGBTQ+ people.