Caring for Transgender Patients and Clients: Nutrition-Related Clinical and Psychosocial Considerations

      The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] . There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published.
      Disease prevention and health promotion in the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community has gained significant momentum in the past 3 decades. Prior research has demonstrated marked health disparities among the LGBTQ population, such as elevated rates of cancer, human immunodeficiency virus (HIV), acquired immunodeficiency syndrome, and mental health disorders, compounded by limited access to quality health care.

      Office of Disease Prevention and Health Promotion. Healthy People 2020: Lesbian, Gay, Bisexual, and Transgender Health. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health. Published 2014. Accessed November 20, 2017.

      Studies investigating cancer incidence specifically in the transgender population have been limited in size and scope, making it difficult to draw conclusions; however, increased incidence and mortality from cancer have been reported in LGBTQ communities.

      Pérez-Stable EJ. Director’s Message: Sexual and Gender Minorities Formally Designated as a Health Disparity Population for Research Purposes. https://www.nimhd.nih.gov/about/directors-corner/message.html. Published October 2016. Accessed November 21, 2017.

      Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. https://www.nap.edu/read/13128/chapter/1. Published 2011. Accessed November 20, 2017.

      • Gibson A.W.
      • Radix A.E.
      • Maingi S.
      • Patel S.
      Cancer care in lesbian, gay, bisexual, transgender and queer populations.
      • Mathews A.K.
      • Breen E.
      • Kittiteerasack P.
      Social determinants of LGBT cancer health inequities.
      As a result, in October 2016, the National Institutes of Health formally designated sexual and gender minorities as a health-disparate population.

      Pérez-Stable EJ. Director’s Message: Sexual and Gender Minorities Formally Designated as a Health Disparity Population for Research Purposes. https://www.nimhd.nih.gov/about/directors-corner/message.html. Published October 2016. Accessed November 21, 2017.

      In the nutrition and dietetics literature, differences in gender-specific diet- and nutrition-related considerations have traditionally been framed as occurring between cisgender, heterosexual males vs cisgender, heterosexual females. However, emerging research has indicated distinct nutrition-related considerations for sexual minorities of the LGBTQ population.

      Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. https://www.nap.edu/read/13128/chapter/1. Published 2011. Accessed November 20, 2017.

      A landmark study identified significant variations in health risk behaviors within each subcategory of sexual orientation, indicating a need to investigate the dietary considerations of sexual minorities that have historically been grouped into one category.
      • Smalley K.B.
      • Warren J.C.
      • Barefoot K.N.
      Differences in health risk behaviors across understudied LGBTQ subgroups.
      The transgender population is of particular importance to the nutrition profession, given the medical interventions undertaken to make the transition from one gender to another. An estimated 0.6% of adults in the United States, or 1.4 million, identify as transgender. This figure has approximately doubled in the last decade.
      • Flores A.R.
      • Herman J.L.
      • Gates G.J.
      • Brown T.N.
      How many adults identify as transgender in the United States?.
      Historic advancements in legal equality and increased cultural acceptance have likely contributed to an increasing number of individuals openly and more willingly describing themselves as transgender.

      Gay and Lesbian Alliance Against Defamation. Accelerating Acceptance 2017. https://www.glaad.org/files/aa/2017_GLAAD_Accelerating_Acceptance.pdf. Accessed February 10, 2018.

      Furthermore, increased media visibility, access to the internet, and greater support resources for this community have resulted in greater awareness of LGBTQ issues and a reduction in the stigma and some of the previously held stereotypes that often lead to discrimination.

      Gay and Lesbian Alliance Against Defamation. Accelerating Acceptance 2017. https://www.glaad.org/files/aa/2017_GLAAD_Accelerating_Acceptance.pdf. Accessed February 10, 2018.

      Literature on preventative and primary care of transgender individuals has focused primarily on HIV rates and risk behaviors, with a lesser focus on pelvic examinations, tobacco use, insurance coverage, and cholesterol screenings.
      • Edminston E.K.
      • Donald C.A.
      • Sattler A.R.
      • Peebles J.K.
      • Ehrenfeld J.M.
      • Eckstrand K.L.
      Opportunities and gaps in primary care preventative health services for transgender patients: A systematic review.
      However, no literature has focused solely on dietary concerns. Thus, the purpose of this paper is to discuss the nutrition-related clinical and psychosocial considerations of transgender individuals based on current evidence.

      Key Terms

      The following key terms are defined according to the American Psychological Association
      American Psychological Association
      Guidelines for psychological practice with transgender and gender nonconforming people.
      and will be used throughout this paper.
      • Transgender: an adjective that is an umbrella term to describe the full range of people whose gender identity and/or gender role do not conform to what is typically associated with their sex assigned at birth. Although the term transgender is common, not all transgender and gender-nonconforming people self-identify as transgender.
      • Cisgender: an adjective used to describe a person whose gender identity and gender expression align with sex assigned at birth; a person who is not transgender and gender-nonconforming.
      • Male to Female (MtF): individuals whose assigned sex at birth was male and who have changed, are changing, or wish to change their body and/or gender role to a more feminized body or gender role. MtF persons are also often referred to as transgender women, transwomen, or trans women.
      • Female to Male (FtM): individuals assigned a female sex at birth who have changed, are changing, or wish to change their body and/or gender identity to a more masculine body or gender identity. FtM persons are also often referred to as transgender men, transmen, or trans men.
      • Gender-nonconforming: an adjective used as an umbrella term to describe people whose gender expression or gender identity differs from gender norms associated with their assigned birth sex.
      • Genderqueer: a term used to describe a person whose gender identity does not align with a binary understanding of gender (ie, a person who does not identify fully as either a man or a woman).
      • Hormone therapy (gender-affirming hormone therapy, hormone replacement therapy): the use of hormones to masculinize or feminize a person’s body to better align that person’s physical characteristics with his or her gender identity. People wishing to feminize their bodies receive antiandrogens and/or estrogens; people wishing to masculinize their bodies receive testosterone. Hormone therapy may be an important part of medically necessary treatment to alleviate gender dysphoria.

      Dietary Considerations for Transgender Patients and Clients

      Based on the current evidence, dietary considerations for transgender patients and clients are both clinical and psychosocial in nature. Individuals seeking to medically transition may undergo gender-affirming medical interventions of masculinizing or feminizing hormone therapy, as well as surgical reassignment. In adolescents, treatment may also include suppression of puberty. Specific side effects of hormonal therapy may be within the scope of practice of registered dietitian nutritionists (RDNs). These side effects include weight gain, changes in body composition, altered lipid profiles, and changes in bone composition and other metabolic factors. As a result, the World Professional Association for Transgender Health has identified specific risks associated with hormone therapy.
      Specifically, transgender FtM individuals receiving testosterone therapy may exhibit weight gain, increased lean body mass, decreased fat mass, increased low-density lipoprotein levels, decreased high-density lipoprotein levels, delayed prothrombin time, increased hemoglobin and hematocrit, and increased creatinine levels.
      • Deutsch M.B.
      • Bhakri V.
      • Kubicek K.
      Effects of cross-sex hormone treatment on transgender men and women.
      • Fernandez J.D.
      • Tannock L.R.
      Metabolic effects of hormone therapy in transgender patients.
      • Klaver M.
      • Dekker M.J.H.J.
      • de Musert R.
      • Twisk J.W.R.
      • den Heijer M.
      Cross-sex hormone therapy in transgender persons affects total body weight, body fat and lean body mass: A meta-analysis.
      • Mail P.D.
      • Safford L.
      LGBT disease prevention and health promotion: Wellness for gay, lesbian, bisexual, and transgender individuals and communities.
      • Pelusi C.
      • Constantino A.
      • Martelli V.
      • et al.
      Effects of three different testosterone formulations in female-to-male transsexual persons.
      • Velho I.
      • Fighera T.M.
      • Ziegelmann P.K.
      • Spritzer P.M.
      Effects of testosterone therapy on BMI, blood pressure, and laboratory profile of transgender men: A systematic review.
      The World Professional Association for Transgender Health identifies transgender males as having a likely increased risk for polycythemia; a possible increased risk for hyperlipidemia; and a possible increased risk for cardiovascular disease, hypertension, and type 2 diabetes when other risk factors are present.

      World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. file:///C:/Users/wkline/Downloads/WPATH%20Standards%20of%20Care.pdf. 2016. Accessed November 21, 2017.

      Transgender MtF individuals receiving estrogen therapy may exhibit changes in high-density lipoprotein and low-density lipoprotein levels, depending on the route of administration; an increase or decrease in blood pressure; an increase in bone mineral density, particularly if an individual undergoes gender reassignment surgery during which the testicles have been removed; and decreased creatinine levels.
      • Deutsch M.B.
      • Bhakri V.
      • Kubicek K.
      Effects of cross-sex hormone treatment on transgender men and women.
      • Fernandez J.D.
      • Tannock L.R.
      Metabolic effects of hormone therapy in transgender patients.
      • Klaver M.
      • Dekker M.J.H.J.
      • de Musert R.
      • Twisk J.W.R.
      • den Heijer M.
      Cross-sex hormone therapy in transgender persons affects total body weight, body fat and lean body mass: A meta-analysis.
      • Mail P.D.
      • Safford L.
      LGBT disease prevention and health promotion: Wellness for gay, lesbian, bisexual, and transgender individuals and communities.
      • Pelusi C.
      • Constantino A.
      • Martelli V.
      • et al.
      Effects of three different testosterone formulations in female-to-male transsexual persons.
      • Velho I.
      • Fighera T.M.
      • Ziegelmann P.K.
      • Spritzer P.M.
      Effects of testosterone therapy on BMI, blood pressure, and laboratory profile of transgender men: A systematic review.
      The World Professional Association for Transgender Health identifies transgender females as having a likely increased risk for venous thromboembolic disease and hypertriglyceridemia, a possible increased risk for hypertension, and a possible increased risk for type 2 diabetes when other risk factors are present.

      World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. file:///C:/Users/wkline/Downloads/WPATH%20Standards%20of%20Care.pdf. 2016. Accessed November 21, 2017.

      Dietary considerations for the transgender population are not only clinical but also psychosocial in nature. Existing research points to a higher prevalence of disordered eating, unhealthy weight control behaviors, weight misperception, and body dissatisfaction among sexual minorities.
      • Mail P.D.
      • Safford L.
      LGBT disease prevention and health promotion: Wellness for gay, lesbian, bisexual, and transgender individuals and communities.
      • Algars M.
      • Santtila P.
      • Sandnabba N.K.
      Conflicted gender identity, body dissatisfaction, and disordered eating in adult men and women.
      • Austin S.B.
      • Nelson L.A.
      • Birkett M.A.
      • Calzo J.P.
      • Everett B.
      Eating disorder symptoms and obesity and the intersections of gender, ethnicity and sexual orientation in U.S. high school students.
      • Conner M.
      • Johnson C.
      • Grogan S.
      Gender, sexuality, body image and eating behaviours.
      • Diemer E.W.
      • Grant J.D.
      • Munn-Chernoff M.A.
      • Patterson D.A.
      • Duncan A.E.
      Gender identity, sexual orientation, and eating-related pathology in a national sample of college student.
      • Matthews-Ewald M.R.
      • Zullig K.J.
      • Ward R.M.
      Sexual orientation and disordered eating behaviors among self-identified male and female college students.
      Within the adolescent population, heterosexual males with prior same-sex partners and bisexual males were more likely to consider themselves overweight, despite being at a healthy weight or underweight, whereas sexual-minority males and females were significantly more likely to engage in unhealthy weight control behaviors compared with exclusively heterosexual individuals.
      • Hadland S.E.
      • Austin S.B.
      • Goodenow C.S.
      • Calzo J.P.
      Weight misperception and unhealthy weight control behaviors among sexual minorities in the general adolescent population.
      Within the college student population, transgender and cisgender sexual minorities reported elevated rates of eating disorders and compensatory behaviors that included use of diet pills, use of laxatives, and induced vomiting.
      • Diemer E.W.
      • Grant J.D.
      • Munn-Chernoff M.A.
      • Patterson D.A.
      • Duncan A.E.
      Gender identity, sexual orientation, and eating-related pathology in a national sample of college student.

      The Role of the RDN

      The increased demand for medical treatment by transgender individuals, in conjunction with evidence that this population is health disparate and underserved, supports the need for highly trained health care providers with expertise in this area.
      • Unger C.A.
      Hormone therapy for transgender patients.
      • Colebunders B.
      • Brondeel S.
      • D’Arpa S.
      • Hoebeke P.
      • Monstrey S.
      An update on the surgical treatment for transgender patients.
      RDNs are in a position to provide appropriate, patient-centered, and compassionate care for this health-disparate population.

      Eating Disorders

      Although the precise etiology of eating disorders in the transgender population has not been clearly explicated, it is evident that the relationships among sexuality, gender identity, body image, and eating disorders are complex. The higher incidence and multifactorial nature of eating disorders in this population requires a collaborative treatment approach by an interdisciplinary team of experts, including an RDN. Nutrition interventions provided by an RDN have demonstrated improvements in behaviors related to binge eating, increased caloric intake, and purging and significant increases in weight and the amount and variety of foods consumed.
      • Laessle R.G.
      • Beaumont P.J.
      • Butow P.
      • et al.
      A comparison of nutritional management with stress management in the treatment of bulimia nervosa.
      • O’Connor M.A.
      • Touyz S.W.
      • Beumont P.J.V.
      Nutritional management and dietary counseling in bulimia: Some preliminary observations.
      • Waisberg J.L.
      • Woods M.T.
      A nutrition and behaviour change group for patients with anorexia nervosa.

      Weight Gain

      Weight gain is a documented side effect in the transgender population among those undergoing hormone therapy. Although weight gain has been noted in both MtF and FtM individuals, the composition of the gained weight varies. Typically, in MtF transitions, body weight changes reflect an increase in body fat and decrease in lean body mass owing to feminizing hormones, whereas masculinizing hormones in FtM transitions appear to have the opposite effect.
      • Klaver M.
      Cross-sex hormone therapy in transgender persons affects total body weight, body fat and lean body mass: A meta-analysis.
      Within the literature, there exists a dearth of evidence identifying best practices to estimate nutrient needs in the transgender population. Further research investigating the impact of hormone therapy on the calorie needs of transitioning individuals would allow RDNs to work effectively on weight management strategies with their clients. Further research in this area is needed to optimize weight loss efforts and weight management strategies within this specific population. Although successful and lasting treatment interventions for overweight and obesity remain somewhat elusive, evidence suggests that incremental, discrete, and practical lifestyle changes that are implemented with the support of a multidisciplinary team can be sustainable and effective.
      National Institutes of Health; National Heart, Lung, and Blood Institute; North American Association for the Study of Obesity
      The Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults.
      In addition, existing research has established the effectiveness of nutrition counseling by an RDN on weight loss when compared with counseling provided by other health care professionals.
      • Croft P.R.
      • Brigg D.
      • Smith S.
      • Harrison C.B.
      • Branthwaite A.
      • Collins M.F.
      How useful is weight reduction in the management of hypertension?.
      • Delahanty L.M.
      • Sonnenber L.M.
      • Hayden D.
      • Nathan D.M.
      Clinical and cost outcomes of medical nutrition therapy for hypercholesterolemia: A controlled trial.
      • Willaing I.
      • Ladelund S.
      • Jorgensen T.
      • Simonsen T.
      • Nielsen L.M.
      Nutritional counseling in primary health care: A randomized comparison of an intervention by general practitioner or dietician.
      • Diaz R.
      • Esparza-Romero J.
      • Moya-Camarena S.
      • Robles-Sardin A.
      • Valencia M.
      Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth.
      • Nybacka A.
      • Carlstrom K.
      • Stahle A.
      • Nyren S.
      • Hellstrom P.M.
      • Hirschberg A.L.
      Randomized comparison of the influence of the dietary management and/or physical exercise on ovarian function and metabolic parameters in overweight women with polycystic ovary syndrome.

      Chronic Conditions

      Although limited, evidence suggests that transgender adults are more likely to have chronic conditions such as cardiovascular disease, type 2 diabetes mellitus, HIV, cancer, obesity, depression, asthma, chronic obstructive pulmonary disease, and chronic kidney disease.
      • Dragon C.N.
      • Guerino P.
      • Ewald E.
      • Laffan A.M.
      Transgender Medicare beneficiaries and chronic conditions: Exploring fee-for-service claims data.
      • White Hughto J.M.
      • Reisner S.L.
      • Pachankis J.E.
      Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions.
      Substantial evidence links dietary factors to increased risk and incidence of chronic disease. However, the elevated prevalence of chronic conditions among the transgender population cannot be attributed to nutrition-related factors alone. The etiology of chronic conditions among the transgender population is multifactorial and complex. Stigmatization of transgender individuals has been implicated as an underlying contributor to adverse health outcomes in this population.
      • White Hughto J.M.
      • Reisner S.L.
      • Pachankis J.E.
      Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions.
      Although limited research exists on the effects of stigmatization on health outcomes in the transgender population specifically, studies from other stigmatized groups show links between stigma, stress, and negative health effects such as hypertension, diabetes, and cardiometabolic disturbances.
      • White Hughto J.M.
      • Reisner S.L.
      • Pachankis J.E.
      Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions.
      Furthermore, limitations in access to and utilization of health care services remain a substantial impediment to transgender individuals receiving the care they need, further increasing their risk for chronic disease.

      World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, 7th version. file:///C:/Users/wkline/Downloads/WPATH%20Standards%20of%20Care.pdf. 2016. Accessed November 21, 2017.

      Regardless of the etiology of chronic disease in this population, dietary modifications, implemented with the guidance of an RDN, have been shown to improve biomarkers of chronic disease.
      • Mitchell L.J.
      • Ball L.E.
      • Ross L.J.
      • Barnes K.A.
      • Williams L.T.
      Effectiveness of dietetic consultations in primary health care: A systematic review of randomized controlled trials.
      Nutrition counseling in the adult population has been effective in improving overall diet quality, blood glucose levels and glycated hemoglobin values, blood pressure, and lipid levels and in reducing weight and waist circumference,
      • Mitchell L.J.
      • Ball L.E.
      • Ross L.J.
      • Barnes K.A.
      • Williams L.T.
      Effectiveness of dietetic consultations in primary health care: A systematic review of randomized controlled trials.
      thereby reducing overall risk of chronic disease.

      Appropriate Affirmative Patient Care for Transgender Individuals

      Although some strides have been made in societal understanding and acceptance of transgender individuals, access to culturally competent, gender-affirming health care remains limited and contributes to troubling health inequities.

      Public Religion Research Institute, Jones RP, Cox D. Most Americans favor rights and legal protections for transgender people. http://www.prri.org/research/american-attitudes-towards-transgender-people/. Accessed November 28, 2017.

      Research has demonstrated that these disparities are made evident in the prevalence of physical and mental health conditions and are exacerbated by stigma and the inexperience and insensitivity of health care providers. In a follow-up to the 2011 National Transgender Discrimination Survey, the National Center for Transgender Equality, conducted the National Transgender Discrimination Survey and found that discrimination and disparities were evident in the workplace, educational system, community, family structures, and the health care system.
      • James S.E.
      • Herman J.L.
      • Rankin S.
      • Keisling M.
      • Mottet L.
      • Anafi M.
      The Report of the 2015 U.S. Transgender Survey.
      The Joint Commission
      Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide.
      Social and economic marginalization have devastating effects on health outcomes for the transgender population. One-third of respondents to the US Transgender Survey reported having at least one negative experience with a health care provider in the past year, including denial of care; verbal, physical, or sexual harassment; and the need to educate the provider about transgender health issues in order to receive appropriate care. In addition, 23% of respondents avoided necessary medical care because of fear of discrimination and mistreatment, as compared with 28% of respondents to the National Transgender Discrimination Survey.
      The Joint Commission
      Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide.
      • Lim F.A.
      • Brown D.V.
      • Justin Kim S.M.
      Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices.
      With the staggering consequences of inadequate treatment, it is incumbent upon health care providers and agencies to adopt culturally competent, gender-affirming practices to ensure optimal health care access and provision. Health care providers can take a number of positive steps to eliminate barriers that compromise access to and provision of culturally sensitive care. The Joint Commission has outlined best practices guidelines designed to promote patient-centered and inclusive care for the LGBTQ community (Figure).
      The Joint Commission
      Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide.
      • Lim F.A.
      • Brown D.V.
      • Justin Kim S.M.
      Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices.
      FigureStrategies to promote inclusive patient- and family-centered care.
      Reprinted with permission from reference 42: Lim FA, Brown DV, Justin Kim SM. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: A review of best practices. Am J Nurs. 2014;114(6):24-34. https://journals.lww.com/ajnonline.
      Strategies for Provision of Care, Treatment and ServicesImplementation
      Create a welcoming environment that is inclusive of LGBT
      LGBT= lesbian, gay, bisexual, transgender.
      patients.
      • Prominently post the hospital’s nondiscrimination policy or patient bill of rights.
      • Waiting rooms and other common areas should reflect and be inclusive of LGBT patients and families. (For example, LGBT-relevant magazines and posters and information about local LGBT resources should be available.)
      • Décor and images depicting couples and families should include same-sex partners, same-sex patients, and LGBT families.
      • LGBT-friendly symbols such as the rainbow flag can be displayed in waiting areas, on placards and forms, and on staff badges. This can immediately signal a culture of acceptance.
      • Create or designate unisex or single-stall restrooms. (Although making a unisex restroom is an important signal of acceptance, patients should be permitted to use restrooms that comport with their gender identity and should not be required to use the unisex restroom.)
      Foster an environment that supports and nurtures all patients and families.
      • Ensure that visitation policies are implemented in a fair and nondiscriminatory manner.
      • Refrain from making assumptions about a person’s sexual orientation or gender identity based on appearance. (For example, a patient wearing a wedding ring may be partnered with another man or woman; someone whose appearance is typically masculine or feminine may have transitioned from another gender.)
      • Be aware of misconceptions, biases, stereotypes, and other communication barriers.
      • Be aware that visible discomfort on the part of staff or other patients in the presence of displays of affection or support can exacerbate an already difficulty situation for LGBT families.
      • Determine mechanisms for handling patient-to-patient discrimination while preserving the dignity of all involved.
      Facilitate disclosure of sexual orientation and gender identity while remaining aware that such disclosure (“coming out”) is an individual process.
      • Honor and respect the patient’s decision and timing with regard to coming out.
      • Ensure that all forms contain inclusive, gender-neutral language that allows for self-identification. (For example, under “relationship status”, provide options such as “partnered”. For parents, use terminology such as “parent/guardian” that is inclusive of same-sex parents who may or may not be biologically related to the child.)
      Advance effective communication.
      • Keep in mind that patient information is protected by privacy and confidentiality laws.
      • Use neutral and inclusive language in interviews and when talking with all patients.
      • Listen to and reflect patients’ choice of language when describing their sexual orientation and how a patient refers to his or her relationship or partner.
      • If you are unsure of a person’s gender identity, ask gender-neutral questions for clarification (such as “How would you like to be addressed?” or “What name would you like to be called?”).
      • Be aware of language or questions that assume heterosexuality (such as “Are you married?”). When asking about family relationships ask “Who are the important people in your life?” or “Who is family to you?”
      Promote community involvement and advocacy.
      • Provide information and guidance about specific health concerns faced by various LGBT subgroups.
      • Become familiar with online and local resources available for LGBT health topics.
      • Be prepared with appropriate information and referrals, and help patients find respectful providers.
      • Be an advocate for vulnerable LGBT subgroups such as the frail elderly, disenfranchised youth, those who are homeless or uninsured, those who have been victims of violence or bullying, and those with no legal status.
      a LGBT= lesbian, gay, bisexual, transgender.

      Education of Health Care Students

      The best practices identified in the Figure are important strategies for providing appropriate affirmative care for transgender individuals. However, increasing transgender cultural competence during health care training may provide an opportunity to reduce these biases before health care practitioners are working in their respective fields. Although there is evidence that explicit bias against the transgender population is on the decline, implicit bias within the health care system remains pervasive and creates barriers to individuals seeking and receiving appropriate care.
      • Fallin B.
      Implicit bias against sexual minorities in medicine: Cycles of professional influence and the role of the hidden curriculum.
      • Dovidio J.F.
      • Fiske S.T.
      Under the radar: How unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities.
      In addition to barriers to access to and utilization of health care created by stigmatization and discrimination, transgender individuals often cite providers’ lack of knowledge about trans health and health care issues as an obstacle.
      • McPhail D.
      • Rountree-James M.
      • Whetter I.
      Addressing gaps in physician knowledge regarding transgender health and healthcare through medical education.
      The Institute of Medicine, the US Department of Health and Human Services, the American Association of Medical Colleges, and the American College of Physicians have all described gaps in training and education related to LGBTQ issues among health care students and practitioners.

      Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. https://www.nap.edu/read/13128/chapter/1. Published 2011. Accessed November 20, 2017.

      US Department of Health and Human Services. Healthy People 2020 Topics and Objectives: Lesbian, Gay, Bisexual, and Transgender Health. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25. Published 2013. Accessed November 28, 2017.

      American Association of Medical Colleges
      Implementing Curricular and Institutional Climate Changes to Improve Health Care for Individuals Who Are LGBT, Gender Nonconforming, or Born with DSD: A Resource for Medical Educators.
      • Daniel H.
      • Butkus R.
      Lesbian, gay, bisexual and transgender health disparities: Executive summary of a policy position paper from the American College of Physicians.
      The widespread prevalence of bias against sexual minorities among health care providers suggests that health care curricula are inadequately addressing stigmatization, if at all. Research suggests that medical school curricula and residency training rarely include LGBTQ health issues.
      • Moll J.
      • Krieger P.
      • Moreno-Walton L.
      • et al.
      The prevalence of lesbian, gay, bisexual, and transgender health education training in emergency medicine residency programs: What do we know?.
      • Obedin-Maliver J.
      • Goldsmith E.S.
      • Stewart L.
      • et al.
      Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education.
      More germane to the field of nutrition is the lack of research on the inclusion of LGBTQ health issues in nutrition and dietetics curricula. Although there is a dearth of research regarding LGBTQ health and transgender cultural competence training in nutrition and dietetics curricula, there is some evidence from other health care disciplines that introducing trans-specific curricula into students’ training improves their knowledge regarding transgender health issues.
      • McPhail D.
      • Rountree-James M.
      • Whetter I.
      Addressing gaps in physician knowledge regarding transgender health and healthcare through medical education.
      However, an increase in knowledge does not always translate into fewer transphobic attitudes and behaviors.
      • McPhail D.
      • Rountree-James M.
      • Whetter I.
      Addressing gaps in physician knowledge regarding transgender health and healthcare through medical education.
      Therefore it is crucial for health care curricula to include bias reduction interventions in conjunction with teaching students how to address the specific health care needs of transgender individuals.
      Although the full scope of the role of an RDN in treating transgender individuals has yet to be elucidated, it is clear that an RDN can play an important part in reducing health disparities and providing appropriate and inclusive care. Educational endeavors to increase health care providers’ cultural and clinical competence in providing care to the transgender population is a critical first step in addressing these health inequities.

      Future Needs

      Although certain dietary considerations for the transgender population are known, a marked gap exists in both research and nutrition care guidelines for this health-disparate population. A sound body of literature is needed to identify the nutritional considerations of transgender individuals during and after a medical transition. Given the lack of existing research in this area, exploratory studies may investigate the impact of diet on mitigating known effects of hormonal therapies, the psychosocial concerns of transgender patients and clients as they relate to food intake and behaviors, best practices for applying the nutrition care process to transgender individuals, and the role of the RDN in the health care team providing care to transgender patients and clients.

      Author Contributions

      Both authors contributed to the literature review and writing of this manuscript.

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