Liver Disease in Transgender Individuals - A Review

Introduction

Liver diseases are a significant cause of dysfunction and mortality in the world. Transgender individuals are those who identify themselves with a different gender than that assigned at birth. They face several challenges in terms of comprehensive healthcare, including liver health. This article aims to explore the various diseases of the liver found in transgender individuals.

What Does Transgender Mean?

The term transgender is used to describe those individuals who identify themselves as different from the gender they were assigned at the time of birth. A transman is described as a person who identifies the male though they are female by birth. A transwoman is an individual who identifies as a female despite being given the gender role of a male at birth. The term transgender also includes those people who do not identify with the classical gender of male/female. Usually, after realizing this gender change, transitioning is often desired and considered appropriate. Management might include psychological therapy, hormonal treatment, and surgical sex reassignment. It is a long process involving a lot of changes. Therefore, continuous hospital visits are mandatory. These individuals have a special need for medical treatment but are often faced with discrimination and a lot of mental pressure.

Are Liver Diseases Common In Transgender Individuals?

Transgender individuals face specific risk factors that increase their chance of having liver diseases. These include:

1. Hormonal Interventions: For transgender individuals under hormonal therapy, which is generally medicines like estrogen or testosterone. All these hormones are considered safe when monitored or taken appropriately in the long term. Improper use for a long duration has a serious ill effect on liver health.

2. Substance Abuse: Transgender individuals are at higher risk for engaging in the abuse of drugs, alcohol, or smoking. These also have an indirect negative effect on the liver, causing diseases like hepatitis and cirrhosis.

3. Mental Health: Most of the transgender community faces a higher rate of social challenges when they are abandoned by families and loved ones. They face depression and anxiety, and that might provoke an unhealthy lifestyle, which indirectly affects liver health.

Regarding liver diseases in transgender individuals, there have been studies showing that they are at increased risk of liver conditions compared to the other population. Among the various liver issues, hepatitis is the most common. There is more risk of transgender individuals abusing substances using shared needles for hormone injection or drugs by increasing the risk of hepatitis (liver inflammation).

How Is Liver Function Affected By Hormonal Therapy In Transgender Males?

The most common treatment in transitioning transmen is the hormonal treatment– with testosterone and its modifications.

1. C -17 Alpha Alkylation of Testosterone - Helps in oral administration.

Liver effects include-

i) Cholestasis (reduced bile flow, leading to liver accumulation and jaundice accumulation).

ii) Peliosis (the presence of blood-filled cystic spaces in the liver, which can lead to bleeding and liver failure).

iii) Nodular Regenerative Hyperplasia: Formation of small nodules in the liver due to exposure to medication.

v) Hepatic Adenoma (benign liver tumor).

vi) Hepatocellular Carcinoma (primary liver cancer).

2. C 17 Alpha Esterification - Increases potency and duration but needs parenteral administration. There are fewer side effects with this modification, but prolonged use of this leads to hepatic tumors and nodular transformation.

Possible reasons for hepatic damage after pharmaceutical usage of testosterone include:

1. Impairment of cellular growth processes.

2. Increase in oxidative stress within hepatic cells mediated by testosterone receptors.

How Is Liver Function Affected By Hormonal Therapy In Transgender Females?

They are usually administered with hormones, estrogens, or gonadotropin-releasing hormone agonists. The estrogens in high dosages for a long duration are associated with liver damage. Estrogens associated with intrahepatic complications with high dosages are not routinely given for gender translation, altering the coagulation factors, especially antithrombin 3. This risk is greater with oral treatment than with parental treatment. Estrogens have also been seen to show a decrease in the flow of bile, which can lead to jaundice. There is the occurrence of tumors in long-term usage, although all the evidence pointing towards this is not very strong.

Cyproterone acetate is a steroid routinely used in gender transition. Its role is to inhibit testosterone by blocking its receptors. This drug has shown altered enzyme levels and hepatotoxicity. The clinical symptoms could range from hepatitis with jaundice to acute liver failure. This reaction might be immunologically mediated and addressed.

What Are the Precautionary Measures to Be Taken to Avoid Liver Diseases?

• Transition therapy is an unavoidable method of management for these individuals to improve their quality of life. Most treatments lead to hepatotoxicity. Therefore, monitoring liver function is crucial to prevent therapeutic failures and avoid adverse side effects. Individuals should be monitored every three months during the first year, subsequently every six months or yearly. Liver enzymes are to be assessed to anticipate potential damage.

• Caution is required when undergoing a gender-changing treatment in patients with preexisting liver disease, as it can further deteriorate liver function. The hepatic damage is usually reversible with the stoppage of therapy, but full recovery means an extended period of no hormone therapy.

• Healthcare workers should prioritize screening and vaccination in transgender individuals for hepatitis A and B. Also, education and reinforcement for preventive measures should be provided.

• Healthcare should be open and accessible to all populations and should be available to meet the needs of transgender individuals.

Conclusion

To conclude, liver disease in transgender individuals is a complex condition with many risk factors. It is a known fact that these individuals face many health challenges related mainly to hormone therapy and surgical procedures; they also encounter high risk for substance abuse and viral hepatitis infections. Healthcare workers must adopt a balanced approach to care and address their needs and issues. They must be educated about liver health, disease, and its prevention. This can be achieved by promoting an inclusive healthcare environment. Individuals on hormone therapy must be encouraged to monitor their liver health regularly by following enzyme levels. In case of any uncontrolled alteration, the therapy must be stopped until there is regulation. With all this, the liver health of the transgender individual can be improved, and any disease can be managed.