Gender differences in stigma and care avoidance among people living with MASLD: an international survey

Background & aims: Metabolic dysfunction-associated steatotic liver disease (MASLD) affects women and men differently, and both perceived and self-stigma may contribute to care avoidance. This study aimed to assess gender-specific patterns of stigma and their associations with care avoidance in MASLD. Methods: A cross-sectional, international survey was administered in 2023 by the Global MASH/NASH Council (GNC) among adults with a confirmed diagnosis of MASLD. The survey collected sociodemographic and clinical data, assessed perceived stigma and self-stigma using the validated Self-Stigma Scale-Short Form, generating domain-specific and total scores. Severe self-stigma (simply named self-stigma) was defined as a total score above the 75th percentile, stratified by gender. Care avoidance in primary or secondary care (gastroenterology, hepatology, and endocrinology) was reported. Results: Among 1,313 respondents with MASLD (51% men; 50% aged ≥55 years; 28% Europe, 26% USA/Canada, 30% South East/West Asia, 16% MENA), care avoidance was more frequent among men (23.6% vs. 18.9%, p=0.04), occurring predominantly in the primary care. Women reported higher self-stigma scores (all p<0.001) and more discrimination-related perceived stigma (27.8% vs. 19.1%). In adjusted analyses, both perceived stigma [adjusted OR(95%CI): 1.84(1.07-3.18)] and self-stigma [1.84(1.19-2.85)] were associated with care avoidance in men, whereas only perceived stigma was associated with care avoidance in women [2.29(1.25-4.22)]. In women, perceived stigma was linked to younger age, multimorbidity, and history of medical weight loss (p<0.05), while no predictors were identified in men. Lower socioeconomic status and advanced fibrosis predicted self-stigma in both genders. Conclusions: Stigma emerges as a major, gender-specific barrier to care in MASLD, with distinct mechanisms in men and women. Integrating gender-sensitive, stigma-informed strategies into MASLD care may improve access and continuity of care. Impact and implications: The presence of stigma due to liver disease is associated with avoiding care. However, despite women reporting a higher degree of stigma than men, men more often avoided healthcare visits especially when self-stigma was present. These differences in stigma and care avoidance by gender necessitates that healthcare providers who treat patients with MASLD develop gender-sensitive interventions to help ensure continued engagement with the healthcare system.