Towards Providing Culturally Aware Nutritional Care for Transgender People: Key Issues and Considerations

The impact of gender-affirming hormone therapy on nutrition-relevant biochemical measures

Gender-affirming hormone therapy carries the potential risk for shifts in biochemical markers that may impact cardiometabolic, hematologic, hepatic, and renal health. The critical evaluation of biochemical data is an integral part of a comprehensive nutrition assessment; therefore, nutrition professionals should be aware of shifts that are expected during the course of masculinizing and feminizing hormone therapy. Changes in important biochemical values along with binary sex-specific standards for interpreting laboratory data can pose significant challenges for nutrition professionals working with transgender and gender-diverse patients who receive gender-affirming hormone therapy. Overall, research on the biochemical impact of masculinizing and feminizing hormone therapy is nascent and limited. Methodologies and outcomes measured are heterogenous across studies, introducing complexities that impede researchers from drawing definitive conclusions. In light of these limitations, this narrative review aims to describe the potential implications of masculinizing and feminizing hormone therapy regimens on biochemical measures that may influence nutrition strategies and interventions to promote optimal health.

The Role of the Athletic Trainer in Providing Care to Transgender and Gender-Diverse Patients: Considerations for Medical Affirmation-Part II

Recently, with discriminatory legislation efforts and changing participation policies in organized sports, media attention surrounding transgender and gender-diverse (TGD) individuals has increased. These changes and the historical lack of competence and education regarding the transgender patient population have resulted in subpar patient care and a misunderstanding of the athletic trainer's (AT's) role within the health care and compliance systems. This literature review is the second part of a 2-paper series, and our objective was to educate ATs on the processes relevant to medical affirmation, including compliance considerations regarding medical eligibility, and to establish the AT's role. The gender affirmation framework includes social and legal components, which are discussed in part 1 of this literature, and the medical component is thoroughly discussed in part 2. All health care providers involved in the care of TGD individuals should work collaboratively on an interprofessional care team and have a general knowledge of the gender-affirmation process, including gender-affirming hormone therapy, surgical options, known risks and complications, and the general health needs of TGD patients. With this knowledge, ATs, as point-of-care providers and members of the interprofessional care team, are uniquely positioned to help reduce health and health care disparities. Furthermore, ATs can use their knowledge to facilitate medical compliance and eligibility in the evolving policies of sporting organizations.

Gender-Affirming Nutrition: An Overview of Eating Disorders in the Transgender Population

PURPOSE OF REVIEW

Transgender individuals are vulnerable to many nutrition-related conditions, especially eating disorders due to gender dysphoria. This review aims to summarize the current literature on eating disorders in transgender individuals. The issues that should be considered in nutrition care for the transgender population are discussed regarding public health.

RECENT FINDINGS

Transgender individuals can exhibit disordered eating behaviors to overcome the stress they experience due to stigma, discrimination, social exclusion, and abuse. Recent studies showed that disordered eating and clinical eating disorders are more prevalent among transgender than cisgender people. It is very important for a multidisciplinary team working in the clinic to understand the epidemiology, etiology, diagnostic criteria, and treatment of eating disorders in the transgender population. However, multidisciplinary nutritional care is limited due to the lack of transgender-specific nutrition guidelines. It is safe to say that adhering to a generally healthy nutritional pattern and using standardized nutrition guidelines. We recommend that health professionals working with patients/clients with eating disorders receive continuing education in transgender health, be empowering and inclusive, address patients/clients with their gender identity nouns and pronouns, and develop nutritional treatment plans that are not gender-specific. Eating disorders are a significant public health problem in the transgender population. Therefore, clinical screening and early intervention are necessary to identify and treat eating disorders in transgender people. Eating disorders in the transgender population should be monitored routinely, and gender-affirming care should be provided as well as treatment of eating disorders.

Not Just Checklists and Rainbows: Exploring Canadian Dietitians' Beliefs, Values, and Knowledge of Transgender Nutritional Care

Purpose

Many transgender (short form: trans) people are experiencing disparities within Canadian health care systems, including nutritional and dietetic health care systems. This research explores the views, beliefs, and experiences of Canadian dietitians about trans nutritional care and seeks to understand how dietitians can better address the nutritional needs of trans individuals.

Methods

Semistructured online interviews were conducted with 16 Canadian dietitians. Interviews were transcribed and the data were analyzed thematically.

Results

Three main themes were created; (1) There's an Unjust System, (2) We've Come a Long Way, and (3) Not Just Checklists and Rainbows. The participants explored the historic nature of the Canadian dietetic profession and noted the connection between cis-normativity and the erasure of trans identities. They also explored how dietitians could better address the health needs of trans people, including moving beyond the acknowledgement of trans identities to changing the way gender is viewed in the profession.

Conclusion

The dietetic profession must move beyond surface-level activities and rethink gender. Recommendations include adding trans-focused care training into the profession, creating safer spaces for trans individuals, advocacy and allyship, and recruiting trans people to the profession.

Registered Dietitian Nutritionists' Knowledge, Attitudes, and Beliefs Regarding Nutrition for the Transgender Population in Three New England States: A Cross-Sectional Study

This Study examined the knowledge, attitudes, and beliefs of Registered Dietitian Nutritionists (RDN's) practicing in Maine, New Hampshire, and Vermont, regarding the transgender population. 196 RDN's from the Commission of Dietetics Registration registry located in the tri-state area responded to an anonymous online survey. The survey used the Transgender Knowledge, Attitudes and Beliefs (T-KAB) Scale and nine true/false clinically-focused questions. Descriptive statistics and chi-square analysis were used to identify trends and associations in RDN's knowledge, attitudes, and beliefs regarding the transgender population. Political views (p < 0.0001), years practicing (p = 0.0454), and religious commitment (p = 0.0429) were negatively associated, and health disparities awareness (p < 0.0002) was positively associated, with total T-KAB Score. RDN's surveyed had positive attitudes and beliefs, but a low level of knowledge. Future research should focus on training and education of RDN's, and use of the T-KAB scale to evaluate pre/post-education modules regarding nutrition care for transgender patients.

Characterising body composition and bone health in transgender individuals receiving gender-affirming hormone therapy

BACKGROUND

Gender-affirming hormone therapy (GAHT) is prescribed to produce secondary sex characteristics aligning external anatomy with gender identity to mitigate gender dysphoria. Transgender women are generally treated with oestrogens and anti-androgens, whereas transgender men are treated with testosterone. The objective of this narrative review was to characterise the influence of GAHT on body composition and bone health in the transgender population to help address weight concerns and chronic disease risk.

METHODS

Studies were extracted from PubMed and Scopus and limited to only those utilising imaging technologies for precise adipose tissue, lean mass, and bone mineral density (BMD) quantification.

RESULTS

Although methodologies differed across the 20 investigations that qualified for inclusion, clear relationships emerged. Specifically, among transgender women, most studies supported associations between oestrogen therapy and decreases in lean mass and increases in both, fat mass and body mass index (BMI). Within transgender men, all studies reported associations between testosterone therapy and increases in lean mass, and although not as consistent, increases in BMI and decreases in fat mass. No consistent changes in BMD noted for either group.

CONCLUSIONS

Additional research is needed to appropriately assess and evaluate the implications of these body composition changes over time (beyond 1 year) in larger, more diverse groups across all BMI categories. Future studies should also seek to evaluate nutrient intake, energy expenditure and other important lifestyle habits to diminish health disparities within this vulnerable population. Policies are needed to help integrate registered dietitians into the routine care of transgender individuals.

Compassionate Discourses: A Qualitative Study Exploring How Compassion Can Transform Healthcare for 2SLGBTQ+ People

Compassion can be seen as a necessary, but often lacking, concept and practice in healthcare. Due to the cis-heteronormative nature of societies, people who identify as Two-Spirit, lesbian, gay, bisexual, transgender, queer (2SLGBTQ+) often experience health disparities and disparities in accessing compassionate healthcare. We aimed to explore the meanings of compassion in healthcare for Canadian 2SLGBTQ+ people. Using a poststructuralist framework, 20 self-identifying 2SLGBTQ+ participants were interviewed. Data was analyzed through discourse analysis. Three main discursive considerations are discussed, including (1) meanings and expectations of compassion in healthcare, (2) compassionate healthcare is not guaranteed, and (3) prescription for care: self-compassion for healing and health. The results provide insights into how compassionate healthcare is framed for 2SLGBTQ+ participants and how compassion is often lacking for them due to discourses of cis-heteronormativity and healthism.

"It Literally Can Save Lives": How Challenging Structural Inequities in Sexual Orientation and Gender Priorities Can Create Change in the Canadian Dietetic Profession

Purpose: Our aim was to explore Canadian dietitians' knowledge, beliefs, and values relating to the nutritional care of Two-Spirit, lesbian, gay, bisexual, trans, and other queer groups (2SLGBTQ+).Methods: The research was qualitative and used a poststructural theoretical lens. Interviews were conducted with 16 Canadian dietitians. Data were analyzed using thematic analysis.Results: Three themes were noted: (i) moving away from the binary; (ii) systemic discrimination and 2SLGBTQ+ experiences; and (iii) professional organizations and advocacy. The participants discussed structural, professional, and cultural barriers that affect the nutrition and health experiences of sexual and gender diverse groups.Conclusion: Dietetic institutions and regulatory bodies must provide sexual and gender diversity resources and engage in activities that acknowledge the lives and nutritional concerns of sexual and gender diverse people. Such advocacy is a means to provide more inclusive and equitable care. Key recommendations for structural changes within the profession include using an intersectional lens and a critical dietetic approach to nutritional care.

Trans-affirming care: An integrative review and concept analysis

BACKGROUND

Contemporary healthcare exists within a cisnormative landscape which underpins the erasure of trans persons in healthcare, health research, and health education, and results in negative experiences and poorer outcomes. Further, nurses report feeling inadequately prepared to provide affirming care to trans patients, with little guidance available to inform their practice.

OBJECTIVE

To explore the conceptual understanding of trans-affirming care as it pertains to nursing, and to provide recommendations for trans-affirming nursing care at the systemic, organizational, and individual level.

METHODS

A systematic search of the literature was completed using standard review processes. Two reviewers independently applied a two-step study selection procedure to identify eligible citations. Walker and Avant's concept analysis method was used to analyze the extracted data to determine antecedents, defining attributes, empirical referents, and consequences.

RESULTS

Of the 5914 studies, 136 met criteria, representing a variety of clinical settings. The antecedents identified were depathologization of gender variance and cultural humility. The defining attributes were patient-led care, trans-affirming culture, and trans-competent providers. The consequences were improved psychological and physical health outcomes.

CONCLUSIONS

Trans persons and communities are becoming more visible in society, as are their testimonials about their substandard treatment within healthcare systems. Nurses need to respond to these health inequities with self-reflection, advocacy, and education. At the center of this work is the concept of trans-affirming care, which is a philosophy of care specific to trans persons. Tweetable abstract: This article offers an evidence-informed definition of trans-affirming care and recommendations for how it can be operationalized by nurses.

Being in a queer time: Exploring the influence of the COVID-19 pandemic on LGBTQ+ body image

Aim

The isolating public health measures mandated during the COVID‐19 pandemic had complex influences on the lives and body image of lesbian, gay, bisexual, trans, and queer individuals (LGBTQ+) in Canada. The aim of this study was to explore the impact the COVID‐19 pandemic had on body image for LGBTQ+ Canadians.

Methods

The qualitative research process was guided by queer theory and poststructuralism and consisted of an online survey with open‐ended questions and semi‐structured virtual interviews. A total of 70 self‐identifying LGBTQ+ individuals completed the survey, and eight individuals partook in the interviews. Responses were analysed using Foucauldian discourse analysis.

Results

Four major discursive considerations were found to shape participants' experiences, including, (a) time for reflection, (b) time away from social surveillance, (c) time to work on oneself, and (d) time to (dis)connect. Woven through these considerations were social discourses of hetero‐cis‐normativity, healthism, and resistance.

Discussion

The COVID‐19 pandemic was a ‘queer time’ for LGBTQ+ people. Competing social discourses created complex and often contradictory meanings of bodies and body image. COVID‐19‐related self‐isolation was for some participants a reprieve from constant body monitoring while for others it was a time of continued pressure to embody body ideals. Participants suggested that nutritional messages during such times be ones of compassion and non‐judgement of bodies.

Ethical and culturally competent care of transgender patients: A scoping review

BACKGROUND

Transgender individuals experience discrimination, stigmatization, and unethical and insensitive attitudes in healthcare settings. Therefore, healthcare professionals must be knowledgeable about the ways to deliver ethical and culturally competent care.

ETHICAL CONSIDERATIONS

No formal ethical approval was required.

AIM

To synthesize the literature and identify gaps about approaches to the provision of ethical and culturally competent care to transgender populations.

DESIGN

A Scoping Review.

LITERATURE SEARCH

Literature was searched within CINAHL, Science Direct, PubMed, Google Scholar, EMBASE, and Scopus databases using indexed keywords such as "transgender," "gender non-conforming," "ethically sensitive care," and "culturally sensitive care." In total, 30 articles, which included transgender patients and their families and nurses, doctors, and health professionals who provided care to transgender patients, were selected for review. Data were extracted and synthesized using tabular and narrative summaries and thematic synthesis.

FINDINGS

Of 30 articles, 23 were discussion papers, 5 research articles, and 1 each case study and an integrative review. This indicates an apparent dearth of literature about ethical and culturally sensitive care of transgender individuals. The review identified that healthcare professionals should educate themselves about sensitive issues, become more self-aware, put transgender individual in charge during care interactions, and adhere to the principles of advocacy, confidentiality, autonomy, respect, and disclosure.

CONCLUSIONS

The review identified broad approaches for the provision of ethical and culturally competent care. The identified approaches could be used as the baseline, and further research is warranted to develop and assess organizational and individual-level approaches.

Sex and gender differences in nutrition research: considerations with the transgender and gender nonconforming population

A sex- and gender-informed approach to study design, analysis and reporting has particular relevance to the transgender and gender nonconforming population (TGNC) where sex and gender identity differ. Notable research gaps persist related to dietary intake, validity and reliability of nutrition assessment methods, and nutrition interventions with TGNC populations. This is due in part to the conflation of sex and gender into one binary category (male or female) in many nutrition surveillance programs worldwide. Adoption of the Sex and Gender Equity In Research (SAGER) guidelines and the two-step method of querying sex and gender has the potential to exponentially increase the body of research related to TGNC health.

Cultural Competency Training and Evaluation Methods Across Dietetics Education: A Narrative Review

Developing cultural competence among credentialed nutrition and dietetics practitioners is critical to move toward eliminating disparities in health care. Despite emphasis put forth on culturally competent care by credentialed nutrition and dietetics practitioners, the types, methods, and outcomes of cultural competency training are lacking or inconsistent. In this narrative review, we evaluated studies detailing cultural competency training for content, modes of delivery, and learner outcomes. Main inclusion criteria were students in dietetics or credentialed nutrition and dietetics practitioners engaging in an educational intervention. Exclusion criteria were studies published before 2000 and not published in the English language. Ten studies were reviewed from four health science databases. Our aims were to quantify the literature on cultural competence training in dietetics education and describe the interventions to identify gaps within the field; thus, a quality assessment tool was not utilized. Data were extracted on learner type, number of participants, curriculum content, intervention type, learning outcomes, and outcome evaluation tool. Most studies employed interprofessional education (n=7) and/or service learning (n=6) as interventions types. Quantitative evaluation of learners in the studies reviewed indicated increased knowledge and skill (statistically significant; n=2), whereas qualitative evaluation of learners indicated themes, including curriculum satisfaction, gains in competence, and comfort working with diverse people. Methods of evaluation and delivery were inconsistent, making it difficult to draw larger conclusions about cultural competency training in dietetics. Cultural competence creates opportunities for growth and development of health professionals to serve diverse communities and work environments; future work should include standardizing evaluations of training, specifically to include both qualitative and quantitative methods.