Whitney Linsenmeyer, PhD, RD, LD, on Nutrition Care for Transgender Patients
Data have shown that increased health risks among transgender patients, such as food insecurity, cardiovascular disease (CVD), HIV, and body image issues may contribute to nutritional risks among this patient population.1 Though this year’s Pride Month is coming to a close, it is important for registered dietitian nutritionists (RDNs) to recognize and meet the unique nutritional needs of transgender patients year-round.
Nutrition411 spoke with Whitney Linsenmeyer, PhD, RD, LD, (pronouns: she, her, hers), spokesperson for the Academy of Nutrition and Dietetics and assistant professor of nutrition at Saint Louis University in Missouri.
N411: In your own practice, what have you found are the most important aspects of providing nutrition care to transgender patients?
Dr Linsenmeyer: I have found 2 approaches to be fundamental in working with the transgender community. The first is to hold unconditional positive regard, or complete support and acceptance, for every patient I meet. This is a mindset I was taught in my education and supervised practice, and it is especially important when working with a population that often experiences discrimination. According to the 2015 US Transgender Survey, 33% of transgender individuals had a negative experience, such as verbal harassment, with a health care provider in the past year; 23% did not seek healthcare in the past year due to fear of discrimination; and 33% did not go to a healthcare provider because they could not afford to do so.2 These numbers are staggering, and as a result it seems rather likely that our patients may have some initial trepidation in meeting with a new provider. Trust may need to be earned, not taken for granted. Unconditional positive regard is a good starting place to build that trust.
The second approach is to educate myself on the language, medical interventions, and nutrition-related needs unique to the transgender population. My formal education and supervised practice did not touch on the needs of transgender individuals or the greater LGBTQ population. I identify as cisgender (meaning my biological sex is the same as my gender identity), so I do not have my own personal experiences from which to draw. Instead, I learned through reading publications from reputable sources (I recommend the World Professional Association for Transgender Health (WPATH) Standards of Care and the University of California, San Francisco (UCSF) Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People), attending conferences such as the UCSF Transgender Health Summit, and listening closely to my patients. Educating ourselves as RDNs is especially critical, given the number of transgender individuals that have reported needing to educate their health care providers about appropriate care. We can do our due diligence as RDNs to self-educate and not expect our patients to carry that responsibility.
N411: How do some of the therapies prescribed to transgender patients affect nutrition status and care?
Dr Linsenmeyer: Feminizing or masculinizing hormone therapy (HT) is sought by most, but not all, transgender and nonbinary individuals. Feminizing and masculinizing HT are associated with modest weight gain and changes in body composition.3 Feminizing HT tends to increase fat mass and, masculinizing HT tends to increase lean body mass.3 The WPATH Standards of Care detail the clinical risks associated with both types of therapy on page 40.3 For example, feminizing HT is associated with a likely increased risk for hypertriglyceridemia and a possible increased risk for hypertension.3 Masculinizing HT is associated with a possible increase for hyperlipidemia and a possible risk for CVD, hypertension, and type 2 diabetes when other risk factors are present.3 As RDNs, we know the medical nutrition therapy strategies for each of these conditions, and we can work with our transgender patients to treat or prevent them from progressing.
N411: The risk for eating disorders is reported to be significantly higher among members of the LGBTQ+ community. What should RDNs keep in mind with respect to this?
Dr Linsenmeyer: The transgender population is disproportionately impacted by eating disorders and disordered eating compared to cisgender populations. Among high school students in Massachusetts, transgender adolescents were over twice as likely to report fasting for more than 24 hours, more than 8 times more likely to use diet pills, and more than 7 times more likely to report laxative use compared with cisgender males.4 Among college students in the United States, transgender students were more than 4 times more likely to self-report an eating disorder diagnosis within the past year and more than twice as likely to have used diet pills, laxatives, or vomiting within the past month compared with cisgender heterosexual women.5
This elevated risk may be due to a number of factors, such as the desire to attain or suppress attributes of body size and shape associated with one's gender identity (ie, breasts and hips), the desire to suppress pubertal development of secondary sex characteristics, or as a coping mechanism for gender-related stigma and discrimination.
As RDNs, we can be attuned to the complex relationship between body size, body shape, and one's gender identity. We are trained to help patients achieve a “normal” BMI, but this may be in conflict with the patient’s desired body size. For example, I worked with a transgender man who associated “stockiness” with masculinity and “having a presence.” We might be inclined to label him as obese, but his body size was in fact an expression of his masculinity. I appreciate the Health at Every Size model, as it takes the pressure off the numbers and promotes broad acceptance of body size and shape.
N411: What are some key areas where future research is needed for the field of nutrition care among transgender patients?
Dr Linsenmeyer: There is a lot of work to be done! Several questions remain, including:
- How can medical nutrition therapy mitigate the known clinical effects of feminizing or masculinizing HT?
- What are the nutrition-related implications for pubertal suppression therapy among adolescents?
- What does gender-affirming nutrition care look like for transgender and nonbinary patients with eating disorders or disordered eating?
- What is the best way to approach weight management, given the interplay between body size, body shape, and gender identity?
- What training should we include in a dietetics curriculum or internship program to equip future RDNs?
N411: This Pride Month, what key takeaways do you hope to leave with RDNs on this topic?
Dr Linsenmeyer: Although many in-person Pride events had to be altered this year due to the pandemic, June 2020 has been an active month. The Supreme Court delivered a historic decision in their interpretation of the 1964 Civil Rights Act as protecting LGBTQ employees from discrimination based on sex. A few days later, a group of LGBTQ clinics began the process of suing the current administration to block a rule aiming to remove sex discrimination protections from the Affordable Care Act. I hope our profession becomes increasingly attuned to the reality of sex and gender-based discrimination. As RDNs, we can be active and powerful voices in these conversations, especially with how we treat every patient that walks through our doors.
- Fergusson P, Greenspan N, Maitland L, Huberdeau R. Towards providing culturally aware nutritional care for transgender people: key issues and considerations. Can J Diet Pract Res. 2018 Jun 1;79(2):74-79. doi:10.3148/cjdpr-2018-001
- James, SE, Herman, JL, Rankin S, Keisling M, Mottet L, & Anafi M. The report of the 2015 U.S. Transgender Survey. National Center for Transgender Equality. Published December 2016. Accessed June 29, 2020. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
- Deutsch MB, Amato P, Courey M, et al. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people, 2nd ed. University of California, San Francisco Center of Excellence for Transgender Health. Published June 17, 2016. Accessed June 29, 2020. https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf
- Guss CE, Williams DN, Reisner SL, Austin SB, Katz-Wise SL. Disordered weight management behaviors, nonprescription steroid use, and weight perception in transgender youth. J Adolesc Health. 2017;60(1):17-22. doi:10.1016/j.jadohealth.2016.08.027
- Diemer EW, Grant JD, Munn-Chernoff MA, Patterson DA, Duncan AE. Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. J Adolesc Health. 2015;57(2):144-9. doi:10.1016/j.jadohealth.2015.03.003