Nutrition
What’s for dinner tonight? If you’re trans and taking hormones, figuring out what to put on your plate could be a surprisingly tricky process.
With a growing number of people seeking gender-affirming hormone therapy in the U.S., many could face unique nutritional considerations that researchers have only recently begun to explore, says Whitney Linsenmeyer, PhD, RD, an assistant professor of nutrition and dietetics at Saint Louis University who specializes in transgender nutrition. Adding to the challenge: Transgender identities aren’t reflected in standard dietary guidelines.
From daily energy requirements to how much calcium, iron, and other nutrients you really need, here’s a closer look at what the experts know—and are still investigating—about nutrition and gender-affirming hormone-replacement therapy (HRT) to help you understand what healthy eating might mean for you right now.
Beyond nutrition basics
Real talk: This isn’t the kind of article where you’ll find a handy chart outlining the ideal diet if, say, you’re getting a weekly testosterone injection or taking an estrogen tablet every day. Dietary recommendations that address the nuanced needs of the trans community don’t yet exist, says Dr. Linsenmeyer, who also serves as a spokesperson for the Academy of Nutrition and Dietetics.
While the broadest nutrition advice applies to basically all humans—eat a varied diet filled with whole veggies and fruits, lean protein, and whole grains, while limiting saturated fat, added sugars, and sodium—there’s still a lot to learn when it comes to supporting the health of trans folks on HRT specifically.
What the research says so far
Back in the day, scientists weren’t exactly pouring time and energy into understanding people of marginalized genders, Dr. Linsenmeyer explains. An overdue shift finally got under way in 2016, when the National Institutes of Health recognized transgender people (along with the LGBTQIA+ community as a whole) as an official health disparity population. This designation helps open the door for dedicated research funding aimed at closing gaps in health outcomes. “There has been a really dramatic uptick in research in the past five to seven years,” Dr. Linsenmeyer says. “Before that, there wasn’t very much at all.” Even so, a robust body of scientific evidence doesn’t just materialize overnight.
Thus far, at least one major positive takeaway has emerged: For many trans and nonbinary people, it’s clear that HRT can be a vital, lifesaving form of medical treatment that reduces anxiety and depression, and improves overall quality of life, in large part by inducing physical changes that ease gender dysphoria and improve social functioning. If you’re transmasculine, HRT might involve taking testosterone via injection, a topical gel, or a skin patch. HRT for transfeminine folks often includes oral estradiol (estrogen), commonly with progesterone and an androgen blocker such as spironolactone. (Important note: Not all trans people experience dysphoria, and not all trans people seek to medically or socially transition. The trans community is super diverse, and all trans identities are valid.)
As with pretty much every medication on the planet, HRT can have unwanted side effects even as it produces health-promoting outcomes, Dr. Linsenemyer says. Research to date has yielded some useful insights about the potential intermediate and long-term health impacts of gender-affirming HRT. Estradiol, for example, has been associated with reduced muscle mass, lowered resting energy expenditure that may set off weight gain, and elevated triglycerides, aka fats in the blood. Spironolactone may raise a person’s risk of developing high potassium levels, particularly in the presence of underlying conditions such as kidney or heart disease. Testosterone therapy has been linked to elevations in blood pressure, as well as increased blood levels of harmful LDL cholesterol and decreased levels of beneficial HDL cholesterol. These findings are valuable because they help patients and care providers understand which health markers to monitor along the way. But the work can’t stop there.
The science that’s still taking shape
Understanding potential side effects is just one piece of the puzzle. For patients to make informed choices about whether to start or continue a medication, they need to know how well they can avoid or manage those unwanted effects. With HRT, it’s totally possible that dietary adjustments could make a meaningful difference for managing cardiovascular risks and other concerns, Dr. Linsenmeyer says. But many of today’s patients are idling in trial-and-error mode.
Dr. Linsenmeyer co-authored a December 2020 scoping review of 189 published studies on transgender nutrition and found that while 127 studies explored the health effects of HRT and 64 identified nutrition-related health disparaties in trans vs. cisgender people, only two studies explored nutrition interventions that might help. Many transgender people have distinct nutrition needs that warrant further investigation, the review concluded. Until science catches up, trans folks are left to workshop their diets in real time. “It’s like a theory right now,” Dr. Linsenmeyer says. “We need research to say these are evidence-based recommendations to provide to somebody.”
And honestly? Parsing nutrition info can be dicey even if you’re trans and not on HRT. Despite being 164 pages in length, the 2020–2025 Dietary Guidelines for Americans publication makes zero mention of trans identities or transgender-specific concerns popping up in the published literature. Daily intake recommendations for key nutrients, including calcium, fiber, iron, zinc, vitamin A, vitamin C, vitamin K, niacin, and more—not to mention calories in general—continue to be broken down by sex assigned at birth: one amount specified for “males,” another amount for “females.” If your identity doesn’t fit in one of these two boxes, healthy eating can feel downright inaccessible, Dr. Linsenmeyer says.
While eating a diet rich in a variety of whole foods is a good move for everyone, the particulars of trans nutrition may be tough to scale, acknowledges Jami Zamyad, RD, DCN, who is currently developing a clinic for trans patients in her role as director of clinical nutrition at Stanford Children’s Health. “It’s specific to the individual,” she says. If possible, Zamyad recommends working with a trans-sensitive dietitian or nutrition counselor as you navigate HRT. “Nutrition support [can] guide the patient in the right direction as far as what foods the person should focus on to feel better, feel healthier, and have a better transition,” she says.
Addressing other nutrition challenges
Research suggests that compared with cisgender people, trans people may disproportionately deal with certain dietary barriers that further affect nutrition status. For example, disordered eating behaviors may be more prevalent in the trans community—likely stemming from the complex relationship between gender identity and physical presentation, Dr. Linsenmeyer says. Soon, she hopes to see trans-specific data on how best to support patients who are looking to balance gender-affirming weight goals with overall health. For information on finding support for disordered eating in the meantime, visit WW’s Mental Health Resources page.
Access to affirming, high-quality health care may be another hindrance to healthy eating. Transgender people disproportionately lack access to insurance, and more than a quarter of trans respondents in the 2016 National Transgender Discrimination Survey said they had postponed necessary medical care due to concerns about anti-trans bias. If that sounds like you, read WW’s in-depth guide to advocating for yourself in healthcare settings, which includes info on finding a trans-sensitive provider and enlisting a third-party healthcare advocate, if needed.
Food insecurity is a concern for many trans people, as well, Zamyad notes. A small 2020 survey of trans and gender-nonconforming people in the Southeast U.S. found that 79% had experienced food insecurity in the prior year, compared with about 11% of the general U.S. population. The USDA National Hunger Hotline at 1-866-3-HUNGRY may be a good starting point for locating food resources near you. You can also search for a local food bank through Feeding America’s national directory.
The upshot: Leverage current knowledge and listen to your body
Although the research community is ramping up efforts to better understand diverse nutrition needs within the trans community, there’s still much to learn. Experts are working to develop evidence-based guidelines on how or whether a person’s diet should change when they start hormones, and how best to reconcile eating patterns with psychosocial needs around gender presentation.
As research continues, focus on things you can do today to support your health. Eating a diet rich in a variety of whole foods is a good move for everyone, as is regular physical activity. Understanding potential side effects of medications can help you respond promptly to issues that may arise. And if something feels off about your hormone regimen, nutrition status, relationship with food, or anything else? Connect with a qualified provider for a personalized assessment. You deserve care and support for all aspects of your wellbeing.
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Tara Santora is a freelance science journalist whose work has appeared in Popular Science, Scientific American, Business Insider, and more. Follow them on Twitter at @Tara_Santora.
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This article was reviewed for accuracy in July 2021 by Angela Goscilo, MS, RD, CDN, manager of nutrition at WW. The WW Science Team is a dedicated group of experts who ensure all our solutions are rooted in the best possible research.