One of the most important roles of the registered dietitian nutritionist is to provide medical nutrition therapy that is relevant to an individual’s culture, ethnicity and dietary preferences. In order to improve transgender individuals’ access to quality nutrition care, it is important to understand conditions for which this population is most at risk, the role of hormone therapy and appropriate social interaction.
What does transgender mean?
The term transgender refers to someone’s expression of gender. Gender expression (or gender identity) is unrelated to the physical attributes of a person (i.e. sex). For individuals who are transgender, the sex they were assigned at birth and their gender identity do not match.
Cisgender individuals have the same gender identity as their birth-assigned sex. Furthermore, someone may identify as gender non-binary, meaning they do not associate themselves with any socially identified gender expression. Someone who is transgender, gender non-binary or intersex (born with a combination of male and female sexual anatomy) may further identify as queer, gay, bisexual, lesbian or asexual, to name a few. However, sexual orientation is not related to gender expression.
While research suggests the number of people who identify as transgender has increased, it is difficult to know for sure, as population surveys often do not include gender identity. Greater awareness and cultural understanding by society has led to increased visibility of transgender people. This also impacts how research protocols are developed and established. Studies are continuing on a large scale, including a consortium of five research institutions in Europe and the United States that is exploring whether there is a component in the genome that contributes to one’s gender identity.
Should RDNs use nutrition interventions for a transgender patient as birth-assigned sex or identified/ expressed gender?
Information found in the medical chart may not provide a clinician with the most accurate understanding of someone’s gender.
Situations still exist where an individual’s birth-assigned sex is listed as gender despite the person identifying as transgender. In fact, many medical institutions and insurance companies do not accept transgender expression as an option in the personal identifiers portion of the medical chart.
Maintaining rapport with patients is of the utmost importance when providing nutrition recommendations. Therefore, regardless of information in the medical chart, it is essential to ask patients about their gender expression and use those identifiers when referring to them and their nutrition status.
What are recommended nutrition guidelines for transgender people?
There currently are no specific nutrition guidelines for transgender patients. While evidence is limited on using gender identity for estimating nutrition requirements, research has shown testosterone hormone therapy to change metabolic needs. Health practitioners should use clinical judgment when making nutrition recommendations based on gender identity. Calorie, protein and fluid requirements are not significantly different than they are for cisgender individuals. For those who wish to undergo surgical interventions as part of the transition process, a standard elevation in protein and calorie needs post-surgery are applied for wound healing. Furthermore, many people who identify as transgender may use hormone therapy as part of the transition process. Because the time it takes for hormone therapy to produce results varies from person to person, it is sometimes difficult to tell where an individual is in the process. For those individuals, hormone therapy may cause weight gain and glucose intolerance. As for specific transgender considerations regarding hormone therapy:
Transgender Men (Female to Male): Testosterone hormone therapy (“T”) increases muscle mass, possibly resulting in bone tissue production and an increase in bone mass, at least in the short term. However, long durations of “T” may decrease bone mass and contribute to an increased risk of osteoporosis. Additionally, the effects of “T” may significantly reduce or eliminate the menstrual cycle, which would impact iron needs. It is important to note that once “T” is initiated, it typically is used indefinitely.
Transgender Women (Male to Female): Estrogen may increase risk of thromboembolic disease and progesterone can cause weight gain. In those who have their testicles removed, estrogen replacement can play an important role in preserving bone mass. Compared to cisgender females, whose natural estrogen can decrease over time, consistent estrogen replacement use has been shown to have no negative changes in bone density.
Transgender Adolescents: In 2017, the Endocrine Society published a clinical practice guideline for endocrine treatment of adolescents who are gender-dysphoric/ gender-incongruent. There are multiple considerations for this population. Hormone suppressants may cause complications related to bone health. Recommendations include weight bearing exercises and supplementation with calcium and vitamin D may be warranted.
Use clinical judgment when seeing a patient who identifies as transgender. It is completely reasonable to ask the patient if hormone therapy is being administered as part of the transition process. Because not every person who is transgender goes through the physical transition process (the out-of-pocket cost of physical transition is high due to lack of insurance coverage), the only way to know is to speak to the patient directly. Additionally, using nutrition-focused physical examination tools, such as the triceps skinfold measurement, to assess alterations in lean body mass may help determine how to assess protein requirements in someone who may or may not be on “T,” which increases muscle mass and therefore affects protein needs.
Collaborate with the medical team and other ancillary medical services to ensure consistent care is maintained. In a survey of transgender individuals, 50 percent reported having to teach their medical providers about transgender care. The more information an RDN can provide to the multidisciplinary team, the more comfortable the patient will be receiving nutrition and medical care.
How can we approach body acceptance and psychological support for people who are transgender?
Although RDNs are not therapists or licensed mental health counselors, they have a valuable ability to listen. Emotional sensitivity, understanding and acceptance are key not only to establishing rapport, but also to gaining knowledge about where the patient may be regarding body acceptance and other psychological markers.
According to the National Transgender Discrimination Survey, those who are transgender have an increased risk of eating disorders and an increased risk of abusing diet pills to meet social norms. This increased prevalence affects transgender females disproportionately more than males and is related to feeling the need to meet ideal body standards, emotional trauma from the process of accepting gender identity, and stress from social stigma and discrimination. In the same survey, 28 percent of participants reported postponing medical care due to discrimination from their health care providers, while 19 percent reported being refused medical care completely.
RDNs should provide a welcoming and judgment-free atmosphere for patients. The slightest hesitation in confidence during a session can make a patient feel uncomfortable and uneasy about the abilities of the clinician. RDNs with advanced training in nutrition interventions in the treatment of eating disorders find there is little difference between transgender and cisgender individuals when it comes to eating pathology. Because the etiology of the eating disorder can assist in the determination of nutrition recommendations, understanding the overall struggles of the transgender community can be a useful tool in the development of quality dialogue and patient goals.