Background:
When diving into the nutrition sphere in the trans community it can be helpful to explain the terminology.
What is Trans.
Trans people are those who identify with and/or present as a gender other than the one assigned to them at birth.
Trans people are a large part of the LGBTQ+ community. Nearly 1.6 million people identify as trans or are under the trans umbrella –about 300,000 being youths (1). Some trans people undergo medical intervention surgeries, HRT or hormone replacement therapy, vocal lessons, or simply social transition. Social transition can look different for many but it consists of expressing gender identity through changes to appearance, name, pronouns, and behavior. Each person's journey and goals may look different but all are equally trans.
Mental Strain:
Trans people often face increased discrimination, mental anguish, lowered self-esteem, a plethora of physiological concerns–including disordered eating patterns, and eating disorders.
Often many people face the same issue of disliking their appearance or feeling some kind of body dysmorphia.
Eating Disorders and Disordered Eating Patterns:
Disordered patterns or eating disorders that include restricting foods, excessive working out, and desire for “perfection” are common. These can stem from years of poor mental health and self-esteem.
When it comes to how we are meant to be eating, it is different for everyone. But the one thing that stays consistent is that we shouldn't ever be feeling bad about what we choose to eat, or feel the need to hyperfocus on meal patterns. Eating disorders and disordered patterns usually stem from long-term stress responses and a need for control. In order to help reduce the effects these conditions have over you, you need to first find the root cause or potential triggers. Working with a medical health team–including dietitians–can help bring this to light. Having support is key, and being able to connect with like-minded professionals who provide individualized care is often the best way to go.
Once you identify possible causes, we now need to work towards a solution. This can look different for everyone. Each person may be dealing with layers of concerns that need to be addressed, but a great first step is simply acknowledging there is a problem, and that the way you view food and your body is not beneficial.
Medical Transitioning:
Trans people seeking medical transition will undergo Hormone Replacement Therapy (HRT) to help their body develop and change the way they wish to see themselves. The hormones naturally found in our body are how your body “speaks” to itself, and how it sends signals to activate or deactivate activities. When looking at the sex hormones of estrogen, testosterone, and progesterone; these influence our secondary sex characteristics, varying based on their amounts. When speaking about medical transitioning it may be helpful to split it up between the typical distinct physical aspects of male and female sexes as start positions.
For a trans man who is pursuing medical transition, it begins with an injection of Testosterone, or “T” for short. A person given T will typically develop a deeper voice, grow greater amounts of facial and body hair, and increase in muscle mass (2). There is a big role T can play in body composition, appetite, and what the person may need to be consuming. There are also inherent risks. Conditions like type 2 diabetes, hypertension, and heart disease become more likely.
For a trans woman who is pursuing medical transition, care begins with the introduction of a cocktail of estrogens and utilizing anti-androgenic therapy. When on this HRT program increases in body fat and changes to its distribution occur. Decreases in muscle mass and strength typically occur at the same time(3).
For cis-women starting at puberty age, we usually pay extra attention to nutrients like iron and folate at reproductive age; as during menstruation, a loss of blood can result in a decrease in iron in blood (4). The folate is usually for the prevention of serious birth defects like neural tube defects, and the production of DNA and RNA (5). But for trans women, this isn't a major concern since menstruation and giving birth can't occur.
For cis-men starting at puberty age, a focus on increased calories when compared to cis-women and nutrients like zinc for hormone balancing and fertility. Because of hormone changes in trans men and increased predispositions for nutrition-related health conditions like heart disease and diabetes; changes to dietary patterns are an important area to adjust.
Meal patterns/Lifestyle goals to focus on:
When working with lifestyle changes there are a few key parts to focus on: Stress, Sleep, Hydration, Activity, and Nutrition.
Stress:
When working with stress, it is important to differentiate which kind of stress you are dealing with first. Acute–or short-term stress that comes and goes quickly, Episodic Acute Stress or acute stress that occurs often, and Chronic Stress that can last for weeks or months at a time.
As stress responses can be different in each situation or per person; it can sometimes be hidden. Physical symptoms of exhaustion, headaches, high blood pressure, digestive issues like IBS, muscle tension, and even a weakened immune system. We also have emotional or mental symptoms like anxiety, depression, and panic attacks (8).
Since there are so many different reactions that can occur, getting to the root cause of the stress is the best method to fix the symptoms. Yes, we should always make sure to work with a mental health professional to help set up healthy “in-the-moment” stress responses that may be helpful. Grounding techniques, attainable goal setting, and talk therapy can be great ways to help start the stress recovery process.
Sleep:
Sleeping well and being able to get enough sleep is so important to stay physically and mentally healthy. Good sleep can help repair cells, combat infections, store energy and strengthen the immune system. It can also be a great resource for stress reduction and mood improvement. Many trans and cis people alike should be getting on average 8 hours of sleep each night. So switching up your nighttime routine may be a great place to start getting more productive sleep (9).
Hydration:
Something to note about hydration and HRT is that with the change in body composition and hormones in the body, the amount of hydration needed can change. Many trans people can see changes in skin dryness. Increased dehydration, and water retention (10). So making sure that urine is a pale yellow color with little string smells is a surefire way to ensure the right level of hydration.
Activity:
With changes to hormone balance, exercise becomes crucial to maintaining a healthy physique. Reducing poor body image, reducing cortisol levels, and combating changes to physical needs all come into account. Increasing activity to about 60 minutes per day of low to moderate intensity with a variety of muscle groups will help achieve this (11,12). It can also help enhance the effectiveness of the HRT, as secondary sex characteristics may become more pronounced with continued work.
Nutrition:
When it comes to what we put in our bodies, there are variations from person to person in terms of effectiveness. Our goals for the future, if we have any disordered eating patterns or ED, and possible restrictions all influence what we eat each day.
With the increased risks of heart disease, obesity, DM2, and hypertension medical nutrition therapy can play an important role. With the changes in hormones, there are a few parts that we need to pay attention to (13).
Bone Health
As our hormones change, it can modify bone density putting some people at risk for osteopenia or osteoporosis down the line. In order to prevent this, getting enough vitamin D and calcium to maintain mineralization is key.
Heart Health
Helping with heart health by reducing higher saturated fat foods and including more unsaturated foods; while also increasing fiber as tolerated to reduce the effects of high blood pressure and lower low-density lipoprotein (LDL), or "bad," cholesterol levels.
Protein
Protein intake can be distressing to some. Since there tends to be a really big focus on how much protein we are getting each day and the fear that “if I don't get enough protein in, I will lose all my progress”. Protein intake can be simple, depending on activity level we can estimate between .8g/kg to 2g/kg of protein, such that the more active you are the more protein you should be getting each day.
Conclusion:
Trans people are a small community within an even smaller community which can result in lowered media presence and representation. Medical studies and journals don't get published as often with a direct focus on these groups as they only benefit a small subset of individuals. Nutrition especially can play a very important role for not only trans people but everyone as we all need to eat to survive.
-None of this information is meant to be direct medical advice and you should always see our health providers that can work with you and give you an individualized plan.-
Sources:
https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/
https://www.center4research.org/what-to-know-about-transgender-medical-transitioning-female-to-male/
https://www.uclahealth.org/news/article/why-every-woman-needs-folic-acid
https://screening.mhanational.org/content/why-it-so-hard-recover-eating-disorder/
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