Nutrition for Transgender Individuals: Insights from a Sodexo Dietitian

  • Jul. 17, 2024

woman giving a dietitian consultation

“Transgender” is an umbrella term for persons whose gender identity or gender expression does not align with their sex assigned at birth. Gender identity refers to a person’s internal sense of being male, female or something else; gender expression refers to the way a person communicates gender identity to others through behavior, clothing, hairstyles, voice, or body characteristics.1

Approximately 1.6 million people (1–2%) in the United States identify as transgender, and current worldwide numbers range between 0.6–3%.2 Despite increased acceptance of transgender persons and awareness of their social, emotional, and medical needs, discrimination exists along with inequity in the healthcare system. There can also be elevated rates of disordered eating and food insecurity related to the combined stressors of discrimination, financial inequity, and lack of access to appropriate medical care. 

While there are many ways individuals may choose to transition to align their appearance with their gender identity, medical transitioning is an option which involves hormone therapy and sometimes surgery. Nutrition-related considerations are both clinical and psychosocial in nature and require the intervention of a knowledgeable Registered Dietitian Nutritionist (RDN). A pioneer in this emerging area is one of Sodexo’s Dietetic Internship Directors, Jennifer Waters, PhD, RDN, LDN. Dr. Waters has studied the current state of nutrition for transgender individuals and shares the following insights from her published research (the most recent in the April 5, 2024, issue of Frontiers in Nutrition).3-5 

What are some of the nutritional implications of gender-affirming medical treatment? 

Persons undergoing masculinizing or feminizing hormone therapy may experience weight gain and changes in body composition. Insulin resistance, diabetes, dyslipidemia, hypertension, and other biochemical alterations are common. The combined effects result in physical and emotional stress for the patient.

What challenges have you identified in providing nutrition care to patients undergoing gender-affirming treatment? 

Various aspects of nutrition assessment require RDNs to choose between male or female sex. These include reference standards for energy expenditure, vitamin and mineral requirements, body fat percentages, bone density, and biochemical markers such as hemoglobin, hematocrit, and cholesterol. Without evidence-based standards to guide the nutritional care of transgender and gender-diverse individuals, it can be difficult for nutrition professionals to decide which sex-specific standards to use. Also, many research studies on dietary behaviors and nutritional status are not as useful for the transgender population, because they merge sex and gender into one binary category (male or female). 

What guidance do you suggest for RDNs working with transgender patients? 

Transgender research is an emerging science and medical guidelines are evolving. Based on current clinical reasoning, there are three strategies for nutrition assessment where RDNs can individualize care for transgender patients.4

  1. Use reference values consistent with sex assigned at birth for patients who have not medically transitioned or are early in the process (<6 months).
  2. Individualize nutrition assessment to align with the patient’s medical transition. The World Professional Association for Transgender Health (WPATH) guidelines specify the expected time of onset and maximum effect of masculinizing or feminizing hormone treatment.6 These can be helpful to determine which sex-specific reference values may be most appropriate.
  3. Express data as a range between the female/male reference values, such as estimated energy needs. This applies especially to patients who are on hormone therapy for a relatively short period (i.e., <6 months) or who are on low-to-moderate hormone regimens.

What are the future implications?  

Guidelines on interpreting lab values for the transgender population are critically needed. Nutrition surveillance programs and other systematic research should include the transgender population to study dietary intake and eating behaviors, utilization of food and nutrition assistance programs, food access and security, weight history, engagement in physical activity, and consumption of dietary supplements. Ultimately, a sex- and gender-informed approach within systematic research will expand the body of knowledge related to transgender health. This is an area where the expertise of RDNs can be of tremendous value for the health and well-being of this vulnerable population.

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References:

  1. Understanding transgender people, gender identity and gender expression. American Psychological Association. Updated May 16, 2024. Accessed May 22, 2024. https://www.apa.org/topics/lgbtq/transgender-people-gender-identity-gender-expression
  2. How Many Adults and Youth Identify as Transgender in the United States? UCLA School of Law. Williams Institute. Published June 2022. Accessed May 22, 2024. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
  3. Linsenmeyer W, Waters J. Sex and gender differences in nutrition research: considerations with the transgender and gender nonconforming population. Nutr J. 2021;20(1):6. Published 2021 Jan 15. doi:10.1186/s12937-021-00662-z
  4. Linsenmeyer W, Garwood S, Waters J. An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients. J Acad Nutr Diet. 2022;122(6):1081-1086. doi:10.1016/j.jand.2022.02.014
  5. Waters J, Linsenmeyer W. The impact of gender-affirming hormone therapy on nutrition-relevant biochemical measures. Front Nutr. 2024;11:1339311. Published 2024 Apr 5. doi:10.3389/fnut.2024.1339311
  6. WPATH Standards of Care for the Health of Transgender and Gender Diverse People. Version 8. World Professional Association for Transgender Health (WPATH). Published online September 15, 2022. Accessed May 22, 2024. https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644