Disparities in liver-related care among transgender adults with steatotic liver disease: a retrospective cohort study.

Background: Transgender (TGD) adults experience healthcare disparities across multiple domains, yet care for steatotic liver disease (SLD) remains uninvestigated.

Aims: Evaluate whether TGD adults with SLD receive equitable liver-related care compared with cisgender (CGD) adults.

Methods: Retrospective cohort study conducted at a tertiary medical center (2015-2025). Adults with SLD were identified by a 2-step process (ICD-10 codes, manual chart review). Patients with other causes of liver disease and missing data were excluded. TGD status was defined by ICD-10 codes for gender dysphoria, documented gender incongruence or use of gender affirming hormone therapy. Controls and cases were selected from the same cohort with a 2:1 sampling ratio. Primary outcomes, gastroenterology consultation, hepatology assessment (FIB-4, elastography, or biopsy), and advanced workup, were analyzed using logistic regression adjusting for age and cardiometabolic covariates. An age restricted (30-60) sensitivity analysis was performed. Secondary outcomes included viral hepatitis screening/vaccination, SLD-directed therapies, and 5-year BMI trajectories.

Results: Among 254 adults (85 TGD, 169 CGD), TGD individuals were younger (36.0 vs 57.0 years, P < .001) with higher MASLD prevalence (91.8% vs 77.5%, P = .05). TGD status was associated with lower odds of gastroenterology consultation (aOR 0.41; 95% CI .18-.93), any hepatology assessment (aOR 0.35; 95% CI .18-.70), advanced hepatology workup (aOR 0.34; 95% CI .17-.69), with robust findings in sensitivity analysis. GLP-1 agonist prescriptions were lower (9.4% vs 19.5%, P = .03), and BMI increased vs controls (P < .001).

Conclusion: TGD adults with SLD experience substantial disparities in care, requiring integrated, inclusive pathways to advance health equity.