*Heather Schier (she/her/hers) is a cisgender Graduate Research Associate in Dr. Carolyn Gunther’s Community Nutrition Research Lab and a doctoral student in the Ohio State Interdisciplinary Ph.D. Program in Nutrition. Her research interests include nutrition-related issues among transgender youth and nutrition policy. She is currently an American Society for Nutrition Science Policy Fellow.
During the month of June, we celebrate the LGBTQIA+ community, recognize the contributions of individuals and honor the ongoing liberation movement since (and before) the Stonewall riots of 1969. Discrimination and health inequities continue to negatively impact sexual and gender minority groups. A recent survey indicated LGBTQIA+ young adults were at higher risk for experiencing nutrition insecurity, disordered eating patterns, and depression. These disparities were highest among transgender males (1).
A few years ago, as a graduate student, I attended a research talk on Transgender Care targeting an allied healthcare professional audience. I returned home and began furiously searching the scholarly databases for literature to understand the nutrition related considerations for transgender individuals. This search didn’t take long. The literature is rather limited for transgender adults and bare for transgender youth. We, as a scholarly community, ought to ask ourselves, why?
Nearly 1.4 million (0.6%) adults and 150,000 (0.7%) youth (ages 13 to 17) identify as transgender or gender non-binary (TGGNB) in the United States (2). These figures are comparable to the prevalence of Americans with Type 1 Diabetes (which we have strong nutrition guidelines for, right?). To date, there are no nutrition guidelines for TGGNB individuals published by the Academy of Nutrition and Dietetics, in large part due to the paucity of research required to develop nutrition recommendations. This deficiency of evidence hinders healthcare professionals’, including registered dietitians’ (RD), ability to best care for their TGGNB patients. Encouragingly, efforts to promote health equity and celebrate TGGNB health are emerging. Recent work published through the American Society for Nutrition journals have highlighted the benefits of brief educational modules to improve RDs knowledge in interacting with TGGNB individuals (3), protocols for screening disordered eating and food insecurity for TGGNB youth and adolescents (4), and a scoping review describing the extent, range and nature of current literature related to nutrition considerations for hormone therapy and health outcomes in transgender individuals (5). Research initiatives to elucidate the clinical nutrition and psychosocial implications for TGGNB youth and adults associated with medically transitioning (e.g., hormone therapy, gender affirming surgery, administration of puberty blockers and other supplementation) and approaches which celebrate TGGNB health are long overdue.
Are we asking the necessary questions to rigorously study dietary behaviors and nutritional status of LGBTQIA+ individuals? Sex and gender differences are often overlooked in research design, study implementation, and general scientific inquiry and reporting (6). TGGNB identification is grossly overlooked due to the conflation of sex and gender (male or female) in nutrition surveillance programs. This has partly contributed to a dearth of and limited ability to harmonize data (7). For example, the United States Census, the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey (NHIS) do not ask participants about their gender identity. The Sex and Gender Equity in Research (SAGER) guidelines offer recommendations for gender-sensitive approaches. This includes adopting the two-question method for distinctly assessing sex and gender (8). This change could yield multiple benefits. Importantly, it gives space for individuals to be seen and celebrated as they identify. Secondly, it is the first critical step to facilitate the pooling and harmonization of data. Dr. Whitney Linsenmeyer, assistant professor of nutrition and dietetics at Saint Louis University and spokesperson for the Academy of Nutrition and Dietetics, explains, “The development of clinical practice guidelines for nutrition professionals working with the transgender community is dependent on a robust body of research. We champion evidence-based practice, but until there is sufficient evidence, we are mostly using our clinical judgments or opinions. More research is truly the first step towards optimal gender-affirming nutrition care.”
Looking beyond how we collect data, who is involved in the research process? Diversity is more than race and ethnicity – but also sexual orientation, gender identity, class, ability-level, and the intersectionality of these identities. Representation of sexual and gender minority individuals across the nutrition sciences field (practitioners, academics, scientists, and students) will elevate the rigor and quality of research outcomes, moving the needle forward. One way to do this is by prioritizing community-based or engaged research which foster partnerships with LGBTQIA+ community members and stakeholders as equitable partners in solving complex health issues. Another is to foster sexual and gender inclusive cultures in spaces where research is conducted.
Bolstering the body of nutrition-related evidence specific to sexual and gender identities strengthens communities and the nutrition science field. Let’s do it with PRIDE.
- Language matters: Researchers, healthcare providers, and students can start by learning to practice gender-affirming communication
- As a research community, efforts to ubiquitously collect and report sexual and gender identities as a standard using SAGER guidelines are critically needed to pool and harmonize data and better represent individuals
- While the LGBTQIA+ term represents a greater community, it is critical to see each group separately as each presents with unique lived experiences and nutrition-related considerations
- Enabling scientists/scholars from the LGBTQIA+ community: representation across the nutrition sciences field is critical to move the needle forward
- Community based or engaged research approaches that foster equitable partnerships between LGBTQIA+ groups/individuals and researchers elevates voices, critical to solving complex issues
- Bolstering the body of nutrition-related evidence specific to sexual and gender identities strengthens communities and the nutrition science field
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- Arikawa, A. Y., Ross, J., Wright, L., Elmore, M., Gonzalez, A. M., & Wallace, T. C. (2020). Results of an Online Survey about Food Insecurity and Eating Disorder Behaviors Administered to a Volunteer Sample of Self-Described LGBTQ+ Young Adults Aged 18 to 35 Years. Journal of the Academy of Nutrition and Dietetics, S2212-2672(20)31341-1. Advance online publication. https://doi.org/10.1016/j.jand.2020.09.032
- Flores AR, Herman JL, Gates GJ, Brown TN. The Williams Institute. How many adults identify as transgender in the United States? https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf. Published June 2016. Accessed June 1 2021.
- Douglass, P., Kazaks, A., & Boutin, D. (2020). Three Populations Knowledge Regarding Nutrition and Health Care for Transgender and Gender Non-Binary (TGGNB) Individuals. Current Developments in Nutrition, 4(Suppl 2), 1363. https://doi.org/10.1093/cdn/nzaa060_001
- Linsenmeyer, W., Reed, J., Giedinghagen, A., Lewis, C., & Garwood, S. (2020). Nutrition Considerations for Transgender Adolescents and Young Adults: Screening for Disordered Eating and Food Insecurity at a Midwestern Transgender Center. Current Developments in Nutrition, 4(Suppl 2), 1130. https://doi.org/10.1093/cdn/nzaa055_015
- Rozga, M., Linsenmeyer, W., Cantwell Wood, J., Darst, V., & Gradwell, E. K. (2020). Hormone therapy, health outcomes and the role of nutrition in transgender individuals: A scoping review. Clinical nutrition ESPEN, 40, 42–56. https://doi.org/10.1016/j.clnesp.2020.08.011
- Heidari, S., Babor, T. F., De Castro, P., Tort, S., & Curno, M. (2016). Sex and Gender Equity in Research: rationale for the SAGER guidelines and recommended use. Research integrity and peer review, 1, 2. https://doi.org/10.1186/s41073-016-0007-6
- Linsenmeyer, W., Waters, J. Sex and gender differences in nutrition research: considerations with the transgender and gender nonconforming population. Nutr J 20, 6 (2021). https://doi.org/10.1186/s12937-021-00662-z
- Tate, C. C., Ledbetter, J. N., & Youssef, C. P. (2013). A two-question method for assessing gender categories in the social and medical sciences. Journal of sex research, 50(8), 767–776. https://doi.org/10.1080/00224499.2012.690110