Celebrating Sexual and Gender Diversity – American Society for Nutrition

*Heather Schier is a PhD student at the Ohio State University and recently served as an ASN Science Policy Fellow. Her research employs community-engaged, mixed methods to elevate the voices of transgender and gender diverse youth.

As we celebrate sexual and gender diversity, sobering discriminatory legislation (240+) is being proposed (and passed) in states across the US. Policy impacts the social determinants of health and therefore has downstream nutrition implications. For example, insufficient anti-bullying policies in schools¹, school curriculum and topic censoring, and other bans and restrictions may further alienate LGBTQIA+ individuals and promote discrimination. Social rejection, discrimination, and stigma manifest as stress, compromised mental health, suicidality, food insecurity, disordered eating patterns, increased allostatic load, inflammation, overweight/obesity, and chronic disease².

This is concerning when we consider the known disparities experienced by the LGBTQIA+ community. For example elevated risk of overweight and obesity among lesbian and bisexual women^3,4, HIV among gay and bisexual men⁵, and mixed findings suggest elevated risk of some cancers^4,6 and cardiovascular disease^4,7 among LGB adults. Fewer studies have explored disparities among transgender individuals. Those that have been conducted indicate socioeconomic and health disparities persist among transgender individuals^8–11. This includes elevated rates of depression, anxiety, and psychological distress^10,12. Further, disproportionate rates of poor general health^10,13, food insecurity^14–16, and disordered eating patterns^1,14,16,17.

The disparities are stark and can’t be ignored. However, combatting health disparities does not stop at identifying prevalence. In alignment with the Health Equity Promotion Model¹⁸, identifying the strengths and pathways that promote health is equally important. The LGBTQIA+ communities have strength, resilience, persistence, adversity, and empathy. In working with LGBTQIA+ communities to leverage those strengths we begin to elevate solutions.

Research that applies this model of empowerment and celebration offers the community and advocates the tools to combat these disparities through interventions and policy change.

These articles summarize recently published research related to nutrition considerations for LGBTQIA+ communities:

Sexual orientation–based disparities in food security among adults in the United States: results from the 2003–2016 NHANES, The American Journal of Clinical Nutrition, December 2021

In the US, 10.5% of the general population experience food insecurity. These rates are disproportionately higher among sexual minority (e.g., lesbian, gay, bisexual, and otherwise non-heterosexual) individuals, likely a manifestation of discrimination and stigma. Data from NHANES revealed a statistically significant difference in household food security between sexual minority groups and their heterosexual counterparts. Rates and relative risk of moderate and severe food insecurity were 20-70% higher among all sexual minority groups compared to heterosexuals after adjusting for sex, race, ethnicity, and age. The highest rates were among bisexuals¹⁹.

An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients, Journal of the Academy of Nutrition and Dietetics, February 2022

The Nutrition Care Process (NCP) directs registered dietitians (RD) when conducting nutrition assessments. Many domains of the nutrition assessment are sex-specific, posing a unique question for those serving a transgender or gender diverse (TGGD) population. Applying clinical logic, Linsenmeyer et. al., offer suggested approaches for clinicians working with TGGD patients to deliver gender affirming care. Those suggestions include: use references consistent with sex assigned at birth if the patient has not medically transitioned (e.g., hormone therapy); individualize approach based on the patient’s medical transition status using the World Professional Association for Transgender Health Standards of Care; and report data as a range between male and female references. Additionally, clinicians can affirm patients by using correct names and preferred pronouns, updating medical records to reflect the patient’s gender identity, and using gender neutral terms (e.g., when describing the body). The article details hypothetical case studies for application²⁰.

Opportunities for Action

Regardless of your area of research, ASN members can take steps to celebrate and affirm sexual and gender diversity. A few opportunities for action are listed below:

• Gender affirming language improves mental health, sense of belonging, and reduces suicidality. This includes using preferred pronouns, gender neutral terms (e.g., when discussing the body), and refraining from deadnaming.
• Reference the National Academies of Science, Engineering, and Medicine’s report on measuring sex, gender identity, and sexual orientation. Ubiquitous adoption of these recommendations improves visibility of diverse sexual orientations and gender identities across data and is a critical step toward elucidating pathways to health disparities and promotion among LGBTQIA+ communities. 
• Support pathways to increase LGBTQIA+ representation across nutrition science professions.
• Empower LGBTQIA+ communities, elevating community-specific assets (e.g., size and strength of community, adversity, resilience) to identify effective solutions to address health inequities.
• Prioritize community-based participatory research methods if and when possible.
• Fund and evaluate interventions that prevent overweight/obesity, food insecurity, disordered eating behaviors, among other disparities.
• To learn more about ways to advocate for LGBTQIA+ communities, visit: The Trevor Project, UCLA Williams Institute, ACLU, or The National Center for Transgender Equality. 

Reference

1. Lessard LM, Wang EY, Watson RJ. School Safety Among Sexual and Gender Minority Adolescents: Implications for Eating and Weight Control Behaviors. J Sch Health. 2021;91(10):788-795. doi:10.1111/JOSH.13069
2. Tan KKH, Treharne GJ, Ellis SJ, Schmidt JM, Veale JF. Gender Minority Stress: A Critical Review. J Homosex. 2020;67(10):1471-1489. doi:10.1080/00918369.2019.1591789
3. Boehmer U, Bowen DJ, Bauer GR. Overweight and obesity in sexual-minority women: Evidence from population-based data. Am J Public Health. 2007;97(6):1134-1140. doi:10.2105/AJPH.2006.088419
4. Case P, Austin B, Hunter DJ, et al. Sexual Orientation, Health Risk Factors, and Physical Functioning in the Nurses’ Health Study II. https://home.liebertpub.com/jwh. 2004;13(9):1033-1047. doi:10.1089/JWH.2004.13.1033
5. CDC. HIV and Gay and Bisexual Men. Published online 2021. Accessed May 22, 2022. www.cdc.gov/hiv/group/msm.
6. Dibble SL, Roberts SA, Nussey B. Comparing breast cancer risk between lesbians and their heterosexual sisters. Women’s Heal Issues. 2004;14(2):60-68. doi:10.1016/J.WHI.2004.03.004
7. Fredriksen-Goldsen KI, Emlet CA, Kim HJ, et al. The Physical and Mental Health of Lesbian, Gay Male, and Bisexual (LGB) Older Adults: The Role of Key Health Indicators and Risk and Protective Factors. Gerontologist. 2013;53(4):664-675. doi:10.1093/GERONT/GNS123
8. Kenagy GP. Transgender Health: Findings from Two Needs Assessment Studies in Philadelphia. Health Soc Work. 2005;30(1):19-26. doi:10.1093/HSW/30.1.19
9. Xavier J, Jessica Xavier M, Julie Honnold MA, et al. Members of the Study Team. Published online 2007.
10. Fredriksen-Goldsen KI, Cook-Daniels L, Kim HJ, et al. Physical and Mental Health of Transgender Older Adults: An At-Risk and Underserved Population. Gerontologist. 2014;54(3):488-500. doi:10.1093/GERONT/GNT021
11. Grant, J.M., Mottet, L.A., Tanis J. Injustice at Every Turn : A Report of the National Transgender Discrimination Survey. Sociology. 2013;(May):120-198. Accessed May 22, 2022. https://www.semanticscholar.org/paper/Injustice-at-Every-Turn%3A-A-Report-of-the-National-Grant-Motter/0d2215528d2687e79db63a5381580de92d383090
12. Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103(5):943-951. doi:10.2105/AJPH.2013.301241
13. Fredriksen-Goldsen KI, Kim H-J, Emlet CA, et al. The Aging and Health Report The Aging and Health Report Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults.
14. Arikawa AY, Ross J, Wright L, Elmore M, Gonzalez AM, Wallace TC. 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. J Acad Nutr Diet. 2021;121(7):1231-1241. doi:10.1016/J.JAND.2020.09.032
15. Russomanno J, Patterson JG, Jabson JM. Food Insecurity Among Transgender and Gender Nonconforming Individuals in the Southeast United States: A Qualitative Study. Transgender Heal. 2019;4(1):89. doi:10.1089/TRGH.2018.0024
16. Linsenmeyer WR, Katz IM, Reed JL, Giedinghagen AM, Lewis CB, Garwood SK. Disordered Eating, Food Insecurity, and Weight Status among Transgender and Gender Nonbinary Youth and Young Adults: A Cross-Sectional Study Using a Nutrition Screening Protocol. LGBT Heal. 2021;8(5):359-366. doi:10.1089/LGBT.2020.0308/ASSET/IMAGES/LARGE/LGBT.2020.0308_FIGURE2.JPEG
17. Guss CE, Williams DN, Reisner SL, Austin SB, Katz-Wise SL. Disordered Weight Management Behaviors, Nonprescription Steroid Use, and Weight Perception in Transgender Youth. J Adolesc Heal. 2017;60(1):17-22. doi:10.1016/J.JADOHEALTH.2016.08.027
18. Fredriksen-Goldsen KI, Simoni JM, Kim HJ, et al. The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. Am J Orthopsychiatry. 2014;84(6):653. doi:10.1037/ORT0000030
19. Gibb JK, Shokoohi M, Salway T, Ross LE. Sexual orientation–based disparities in food security among adults in the United States: results from the 2003–2016 NHANES. Am J Clin Nutr. 2021;114(6):2006-2016. doi:10.1093/AJCN/NQAB290
20. Linsenmeyer W, Garwood S, Waters J. An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients. J Acad Nutr Diet. 2022;122(6):1081-1086. doi:10.1016/j.jand.2022.02.014

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