For Trans People, Nutritional Guidelines Are Limiting

My confusion toward food, my gradually changing hormone dosage, and my feelings about my body begged me one collective question: When will I feel full, and when will I feel whole?

Nutrition guidelines ask us to consider the food we consume under the guidance of quantity, quality, and serving sizes generalized for the entire population.

Similarly, transgender people starting hormone replacement therapy (HRT) as part of our transitions are told to expect certain bodily changes in weight, measurements, and muscle mass. What, then, happens in the crossroads of nutrition and HRT?

Although there are general sets of expectations for trans people on HRT, results are individualistic based on genetics, dosage, age, and more.

But if HRT finds difficulty in providing a guideline for most people to follow, how can we expect nutrition — which in itself is more vast and extensive than taking hormones — to do the same for us?

Traditionally, methods of assessing nutrition are gender-specific, with one set of guidelines for men and one for women.

According to the National Academy of Medicine, the Dietary Reference Intake — which was released in 1977 and serves as a systemic guideline for recommended nutritional intake — also categorizes people as male and female.

In these cases, “male” and “female,” although “gender-specific,” refer to sex characteristics as opposed to gender.

A 2020 study by Dr. Whitney Linsenmeyer, Dr. Theresa Drallmeier, and Dr. Michael Thomure found that “no standards of care exist to inform clinicians on nutrition assessment methods for transgender and gender non-conforming patients.”

“Clinicians may opt to use the values related to a patient’s gender identity, may individualize nutrition care based on the patient’s stage of medical transition, or may utilize a range of values where appropriate,” the authors wrote.

My first nutrition lesson was in health class in eighth grade. I learned that the “appropriate” serving of poultry should be the size of a palm (whose palm, anyway?). I also learned to fear white rice, which conveniently was a household staple of our Indonesian family.

My first lesson on HRT was in tenth grade, watching Julie Vu and other brown trans women on YouTube document their transitions.

By the time I started HRT, I had learned to expect breast growth and curving of the hips — among other things solely based on cisnormative standards that not all cis women even attain.

Trans forums online even told me to expect bouts of what would be my occasional “period.” And although I saw how menstruating as a trans woman could feel validating in its proximity to most cisgender women (and therefore feel more legitimate), a voice in the back of my mind told me this was all wishful thinking.

Zachari Breeding’s “Nutrition Considerations for the Transgender Community” attests that “calorie, protein and fluid requirements are not significantly different than they are for cisgender individuals […] [And] because the time it takes for hormone therapy to produce results varies from person to person, it is sometimes difficult to tell where [a trans] individual is in the process.”

When I learned this, relief washed through me. I thought that if I had metrics and measurements of progress to base myself off of, then at least everyone else was held to the same bar too.

Nevertheless, I relied on the theoreticals, the maybes, the shoulds in order to keep going, but I ultimately had no comprehension of how to approach my nutrition — and if it would change at all.

Based on the research by Linsenmeyer, Drallmeier, and Thomure, not only are clinicians’ resources for nutrition solely based on binary sex organs, but clinicians don’t even have tools for nutritional care to give their trans patients — let alone trans patients who are on HRT.

Another study by Linsenmeyer, along with Dr. Rabia Rahman notes that because gender-affirming healthcare for trans and nonbinary people is limited, our communities often feel severely discouraged from speaking with healthcare professionals.

“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,” Linsenmeyer and Rahman note.

“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.”

College threw me into multiple crossroads — emotionally eating amid the daily throes of being a college student, overeating as a compensation tactic learned from being raised by parents who grew up poor and malnourished, and obsessing over morning workouts on campus as a way to feel reassured in my girlhood by needing myself to be small.

School put me on the edge, and being one of the few openly trans women at school pushed me over. My confusion toward food, my gradually changing hormone dosage, and my feelings about my body begged me one collective question:

When will I feel full, and when will I feel whole?

“People are given a moral value in terms of how we see food and how we see our weight. And we put that on people. [One of the] important things with an eating disorder is [the] connection of body size [and] the way a person evaluates their self-worth,” Sam Tryon, RD (they/them), tells me.

They are a registered dietitian based in Maryland who works with their clients — trans and nonbinary folks included — to challenge beliefs of inadequacy toward food and eating disorders.

“This isn’t about [a person’s] pants size, this is about whether or not they [feel] worthy enough to show up, whether it’s work, or dating, or general existing.”

— Sam Tryon, RD (they/them)

I thought about how lucky Sam’s clients must be to work with them, but Sam tells me that luck, for any client of theirs, starts much earlier.

“By nature of being able to see me, there’s a certain amount of health literacy [and privilege] because they would already have access to other healthcare providers, trans-affirming healthcare providers, and then found their way to me,” they say.

My university gave each student a maximum of 10 therapy sessions over the course of their 4 years. My residential building’s director prohibited me from using the women’s restroom, even after a floor-wide survey to grant permission revealed that only two women were uncomfortable.

I was catching up to my changing body.

On top of my work-study job, classes were demanding enough. For students with meal plans, the unlimited access to our three dining halls thrilled us. We ate because we could, and it served as a meaningful time to express these feelings with each other over meals.

Nutrition was an afterthought, an extra-credit campus event to attend. Nutrition, in my experience, was made to be an option.

Jana Spindler (she/her), a licensed registered dietitian and online nutrition educator, works with Health Stand Nutrition, a practice based in Calgary, Canada. Health Stand Nutrition’s goal is to help people “live healthfully and soulfully,” according to Jana.

Her role, she says, is “to make food easier for the person, but [also] really to individualize nutrition. [My] approach is to look at where the person is right now, how [I] can make as few changes as possible, and make it the most livable as possible to get them to their goals.”

In reference to her trans and nonbinary clients, Jana says, “The risk of eating disorders is really, really high.”

In Sam’s experience, “Restricting is [seen as] really gender-affirming for both transmasculine and transfemme folks.”

“It’s really feminine in our society to be very tiny and waiflike,” Sam explains. “For transmasculine folks, restricting is going to decrease chest tissue. You’re going to have smaller hips. For transfemme folks, [restriction means] you’re not gonna have abdominal weight that [is seen as] really masculine.”

The insidious truth about being trans or nonbinary is that eating disorders, for some, minimize gender dysphoria, notwithstanding the bodily neglect that occurs in these situations.

When it comes to nutrition as a trans person, I found it disconcerting to understand whether it was the voice of gender euphoria or the voice of a soul-fulfilling approach to food I wanted to listen to.

After all, white supremacy and capitalism, in practice, value discipline, willpower, and control. In the realms of both nutrition and gender, I felt it was necessary not only to choose one over the other, but to choose one over the other like my livelihood depended on the obsession, the discipline, willpower, and control.

“[Trans or nonbinary people on HRT might say,] ‘OK, well, this energy that I have to show up as queer [and trans] is not the same energy of somebody who’s engaging in diet culture,’” Sam says.

“And at the same time, some people may be coming from another end of ‘I’m already counterculture in one way, right? [So] I need to really fit in in all of the other ways.’”

Giving in to the control and willpower of internalized fatphobia and transphobia declares white supremacy and capitalism victorious.

It becomes easy to see money and price tags in everything — in buying a new dress with the hopes of fitting into it one day. The expenses of hormones. Purchasing a meal plan guide. Yes, even consulting with registered dietitians and nutritionists.

The journey toward healing has a price to pay, and it looks different for everybody.

For Jana, building a “brag list” can alleviate tension between body and food.

“Every day, I want us to have something that we can name: I’m really proud of,” she says. “And that might be actually drinking all the water that was in my water bottle. That might be remembering to eat breakfast today. That might be walking by a mirror and fearing feeling neutral about my body instead of negative.”

To her, adding daily bragging points permits the addition of more quality into life.

According to Sam, we can alleviate tension by clarifying values. At the core of this practice is a nonjudgmental reminder: The ways people intentionally shape their bodies are not a testament to who they are but a testament to the people who influenced their ideas of what their bodies should look like.

At its most incendiary, clarifying values already happens within trans and nonbinary communities by default.

“Because by nature of being queer [and trans], if we’re lucky, we have a chance to really just break it all down,” Sam says.

“Crumble it all and pick and choose and DIY what’s important to us, what we want to be, how we want to live, what we want our community to look like, what our values are — which is really a privilege,” they continue. “And this goes along with that a lot when we’re looking at somebody being focused on food and their body, and how that actually doesn’t really fit the person who they want to be.”

I graduated from college and then graduate school more than a year later. The people who mean most to me still see me for who I am, no matter how big or small a role my gender plays in that.

I still inject estrogen intramuscularly on a weekly basis. My parents still pack me a bag of home-cooked dishes to bring home whenever I visit them.

Like the resident director of my dorm freshman year, like the fatphobic culture we are in, like my birth certificate, so much of showing up as myself has asked me to go against the current.

I don’t always need or want to eat the slice of the pie. But it helps to know I will always be worthy of one, regardless of who I am and what it has taken for me to be here — nutritionally and medically.

Denny is a writer, actor, and musician who has co-starred in “POSE” (FX) and “New Amsterdam” (NBC). Aside from Allure Magazine, SYFY Wire, PAPER, and more, her recent writing — “He Made Affection Feel Simple” — was published in The New York Times’ “Modern Love.” (Twitter/Instagram)