The Power of Words: Liver Transplant Centers Continue to Use Stigmatizing Language

Wei Zhang, MD, PhD

Credit: Mass General Brigham

Although practice recommendations from several medical societies advise against potentially stigmatizing language for alcohol use disorder (AUD) and alcohol-associated liver disease (ALD), findings from a recent Massachusetts General Hospital study suggest many liver transplant center websites continue to use outdated terms like “alcoholism” and “alcoholic.”¹

Published in JAMA Network Open, results showed language considered to be stigmatizing was prevalent across 88% of transplant center websites and 46% of addiction psychiatry websites from the same institutions, potentially hindering patient care and their willingness to seek treatment and posing important implications for disease detection and intervention strategies.¹

“The gap between professional society recommendations and actual practice is concerning since patients frequently use these online resources for information which can significantly influence their behavior and perceptions about alcohol-associated liver disease,” said Wei Zhang, MD, PhD, transplant hepatologist at Massachusetts General Hospital and assistant professor at Harvard Medical School, in a press release.² “Our findings underscore the need for hospitals to improve their communications by updating their language to align with patient-first, non-stigmatizing approaches which we know from experience can lead to better health outcomes.”

The National Institute on Alcohol Abuse and Alcoholism recommends the use of several nonstigmatizing terms when discussing alcohol-related issues, highlighting the importance of non-pejorative, person-first language. The US Centers for Disease Control and Prevention makes similar recommendations, including avoiding nonclinical language and demonstrating empathy. However, whether or not these suggestions are implemented at an institutional level remains to be seen.^3,4

To investigate the adoption of non-stigmatizing language recommendations among accredited liver transplant centers in the US, investigators conducted a cross-sectional study systematically reviewing their websites and addiction psychiatry websites at the same institutions. Of note, pediatric centers were excluded due to their low ALD rates.¹

Investigators examined each website, assessing the use of stigmatizing language (“alcoholism,” “alcoholic,” “alcohol abuse”) and nonstigmatizing language (“alcohol use disorder,” “alcohol misuse,” “alcohol-associated,” “alcohol-related”). Websites using both stigmatizing and nonstigmatizing terminology were categorized as using mixed language.¹

Of the 114 liver transplant center websites reviewed, 82 (71.9%) described ≥ 1 of the following: AUD, ALD, alcohol-associated hepatitis, and alcohol-associated cirrhosis. Of the 104 addiction psychiatry websites reviewed, 39 (37.5%) described AUD and none mentioned liver diseases. Stigmatizing language was observed among 72 of the 82 transplant websites (87.8%) and 18 of the 39 addiction psychiatry websites (46.2%).¹

When investigators assessed AUD-related terminology on transplant center websites, stigmatizing language was used 79.2% of the time compared with 20.8% for nonstigmatizing language. Of note, this was significantly higher than on addiction psychiatry websites, which used stigmatizing language at a rate of 30.8% (P <.001). A total of 60 transplant centers described AUD on their own and corresponding addiction psychiatry department website, 19 (31.7%) of which had consistent language use between the 2.¹

Among the 60 websites with ALD-related terminology, 66.7% used stigmatizing language, 20.0% used nonstigmatizing language, and 13.3% used mixed language. Investigators also observed stigmatizing language on websites discussing alcohol-associated hepatitis (n = 47), noting 95.7% used stigmatizing language while 2.1% used nonstigmatizing language and 2.1% used mixed language. A similar trend was observed for websites discussing alcohol-associated cirrhosis (n = 28), where 85.7% used “alcoholic cirrhosis,” 10.7% consistently used nonstigmatizing language, and 3.6% used mixed language.¹

Investigators called attention to potential limitations posed by the challenge of comprehensively defining stigmatizing language. Despite potential oversights in their definition, investigators noted the greater prevalence of terms such as “alcoholic,” “alcoholism,” and “alcohol abuse” on transplant websites compared with psychiatry counterparts.¹

“Our findings suggest there is a need for these websites to use kinder language which would help patients feel more comfortable and supported when they look for health information or treatment they need,” said Rachael Mahle, MD, internal medicine resident at Massachusetts General Hospital.²

References:

1. ^{Mahle R, Okanlawon A, Luther J,et al. Stigmatizing Language for Alcohol Use Disorder and Liver Disease on Liver Transplant Center Websites. JAMA Netw Open. 2024;7(2):e2355320. doi:10.1001/jamanetworkopen.2023.55320}
2. ^{Massachusetts General Hospital. Stigmatizing language on liver transplant center websites may discourage patients from seeking treatment. EurekAlert! February 8, 2024. Accessed February 16, 2024. https://www.eurekalert.org/news-releases/1033675}
3. ^{National Institute on Alcohol Abuse and Alcoholism. When It Comes to Reducing Alcohol-Related Stigma, Words Matter. Alcohol’s Effects on Health. Accessed February 16, 2024. https://www.niaaa.nih.gov/alcohols-effects-health/reducing-alcohol-related-stigma}
4. ^{US Centers for Disease Control and Prevention. Remove Stigma: Talk with Your Patients About Substance Use Disorder. Addiction Medicine Toolkit. July 7, 2022. Accessed February 16, 2024. https://www.cdc.gov/opioids/addiction-medicine/conversation-starters/remove-stigma.html}