Nutrition Considerations for Transgender PatientsJanuary 11, 2017 /
It is difficult to know how many people identify as transgender (those whose gender identity differs from the sex they were assigned at birth), but studies suggest the number may be around 0.3% of American adults. Although the visibility of the transgender population is increasing, this group still faces much discrimination and harassment and as a result, is subject to disparity in school, jobs, housing and even healthcare.
Healthcare providers are traditionally not trained in the unique health needs of transgender individuals, and because of barriers such as emotional discomfort on the part of both patient and clinician, or possibly a lack of preventive care insurance coverage for those who have changed their gender marker, many in this population do not seek routine healthcare. It is important for Registered Dietitian Nutritionists (RDNs) and other clinicians to be aware that certain lifestyle risks common to this group, as well as metabolic side effects from exogenous hormones, have nutritional implications and transgender patients should be screened and counseled about ways to maintain good health.
Weight and body image
Mental health disorders, especially anxiety and depression, are common in transgender individuals, and possibly related to this, are issues of overweight and concerns about body image. Transmen who have not had breast-removal surgery may be more likely to carry extra weight to mask their upper body appearance, while transwomen may intentionally restrict calories and protein to maintain a thinner, less muscular build. It is common for both groups to limit exercise, either because they are uncomfortable in a gym locker room or in athletic apparel, or for some, because they consider it to be a more masculine trait.
A study on weight in transgender college students found that compared to non-transgender students, this population is more likely to be either underweight or obese, and less physically active. They are also likely to spend more of their leisure time in front of a television or on the computer. Other research has found more alcohol abuse in this group, and all of these behaviors increase the risk for chronic diseases including hypertension, diabetes, heart disease, and some forms of cancer. Patients should be counseled about risk factors for chronic diseases, and ways to increase exercise and improve their diet, while being mindful of their personal concerns.
Diabetes and cardiovascular disease
Excess weight, especially abdominal obesity, along with a more sedentary lifestyle is known to contribute to impaired glucose tolerance, and to increase the risk of diabetes and cardiovascular disease. Additionally, cross-gender hormone therapy can further increase these risks. Exogenous estrogen reduces insulin sensitivity, while causing elevations in glucose and blood pressure, and an increase in both visceral and subcutaneous fat. Although estrogen increases high-density lipoprotein (HDL) cholesterol and decreases low-density lipoprotein (LDL) cholesterol, it can also decrease the LDL particle size, which is a risk factor for heart disease. Testosterone has also been shown to increase visceral fat, and reduce the LDL particle size, as well as reduce HDL cholesterol. Transgender patients undergoing cross-gender hormone therapy should be counseled on the importance of choosing a diet that is low in refined carbohydrates and saturated fats, and higher in fruits, vegetables, and cardio protective fats, as well as in ways to increase their physical activity to reduce the risk of developing diabetes and cardiovascular disease.
Cancer of the reproductive organs (e.g. breast, prostate) is still a concern for transgender individuals who have not had gender-affirming surgery. RDNs should encourage patients to consult with their primary care provider about undergoing regular cancer screenings, and educate patients regarding current research on diet and cancer risks. These include the relationship between alcohol intake and increased risk of breast cancer, and the benefits of consuming a diet rich in antioxidants from plant foods to reduce the risk of all cancers.
Sex hormones are important in regulating bone density, so both trans men and women who undergo cross-gender hormone therapy are at risk for osteoporosis because of the fluctuations in their hormone levels. Those who discontinue or reduce hormone therapy may be at increased risk, but further studies are necessary. Patients should be educated on lifestyle changes that can reduce their risk of osteoporosis, including increasing weight-bearing exercise, consuming a calcium-rich diet, and taking an additional calcium and vitamin D supplement if necessary.
Providing compassionate care
Lack of knowledge of the full range of health needs for the transgender population can lead to suboptimal health care. As with any minority population, it is important to provide culturally sensitive care by becoming more aware of the health risks for this population, as well as the risk of discrimination and victimization that many face.
To create a more culturally sensitive environment, be aware of any personal or professional biases that may exist among clinicians, staff, or yourself, and take steps to correct them. Also, to open the conversation, consider expanding the questions on your patient-intake form to allow patients to declare gender, sex assigned at birth, preferred pronouns, and instead of “married or single,” include an option to declare a partnership or significant-other. Research and locate community or internet-based resources that provide specialized information and support services for the transgender population. Finally, participate in or provide any necessary education to ensure that all staff uses culturally sensitive intake and interviewing skills, and correct terminology.
References and suggested readings
Elbers JM, Giltay EJ, Teerlink T, Scheffer PG, Asscheman H, Seidell JC, et al. Effects of sex steroids on components of the insulin resistance syndrome in transsexual subjects. Clin. Endocr. 2003;58(5):562-571. doi:10.1046/j.1365-2265.2003.01753.x.
Fredriksen-Goldsen KI, Hoy-Ellis CP, Goldsen J, et al. Creating a vision for the future: Key competencies and strategies for culturally competent practice with lesbian, gay, bisexual, and transgender (LGBT) older adults in the health and human services. J Gerontol Soc Work. 2014;57:80–107. doi:10.1080/01634372.2014.890690.
Gates GJ. How many people are lesbian, gay, bisexual, and transgender? The Williams Institute website. http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf. Published April 2011. Accessed July 9, 2015.
General prevention and screening. Center of Excellence for Transgender Health, University of California, San Francisco website. http://transhealth.ucsf.edu/trans?page=protocol-screening. Published April 2011. Accessed July 9, 2015.
Mayer KH, Bradford JB, Makadon HJ, Stall R, Goldhammer H, Landers S. (). Sexual and gender minority health: What we know and what needs to be done. Am J Public Health. 2008;98(6):989-995. doi:10.2105/AJPH.2007.127811.
Transsexual people and osteoporosis. National Osteoporosis Society website. https://www.nos.org.uk/document.doc?id=1369. Accessed July 9, 2015.
Vankim NA, Erickson DJ, Eisenberg ME, Lust, KE, Rosser B, Simon R, et al. Weight-related disparities for transgender college students. Health Behav Policy Rev. 2014;1(2):161-171. doi:http://dx.doi.org/10.14485/HBPR.1.2.8.