AMA Journal of Ethics^®

Abstract

The nutrition care process (NCP) accounts for a person’s biological sex characteristics but does not adequately address their gender. Yet dietary choices express one’s social identity in ethically and clinically relevant ways. Persons identifying as men tend to eat meat more frequently, consume more meat, and are less likely to be vegetarian than persons identifying as women, for example. Research on transgender persons’ diets suggests that food is one means of expressing gender identity; this article argues that an inclusive sex- and gender-informed approach can likely improve the NCP’s usefulness to clinicians caring for transgender patients.

Sex and Gender in Nutrition

Sex and gender are often conflated and reduced to a male-female binary within clinical, research, and administrative settings. However, sex and gender are separate constructs; sex is assigned as male or female based on assessment of genitalia at birth, and gender is one’s internal sense of self and place in the world as man, woman, or nonbinary, among other gender identities.^1,2 Both sex and gender have meaningful implications for a person’s overall health, nutrition, food choices, and eating behaviors.

The nutrition care process (NCP) is the standardized process by which nutrition practitioners deliver care in 4 steps: assessment, diagnosis, intervention, and monitoring and evaluation.^3,4 Nutrition assessment involves not only an evaluation of patients’ food and nutrient intake but also an evaluation of their knowledge, beliefs, attitudes, and food-related behaviors.⁵ The NCP utilizes biological sex to inform nutrition assessment with respect to energy needs calculated using predictive energy equations, dietary reference intake values (DRIs), body fat and waist circumference, growth (for children), and complete blood count (ie, hemoglobin, hematocrit, red blood cell count, ferritin levels).⁶ Gender, however, is either erroneously conflated with sex or largely unaddressed in the NCP.^1,6 Thus, the NCP is sex informed but rarely gender informed.

Dietary Gender Norms

Gender has meaningful implications for dietary intake when food choices and eating behaviors reflect a core component of a person’s social identity.^7,8  Dated and hegemonic gender norms suggest that men hunt, kill, and grill (“real men eat meat”), whereas women shop, cook, and serve.^{7,8,9,10,11,12,13} Although these gender norms are oversimplified, existing research supports that men are less likely to be vegetarian than women and tend to consume larger portion sizes of meat, eat meat more frequently, and view meat as an essential part of a proper diet.^{7,14,15,16,17,18}

The degree of internalization of gender norms—not limited to male or female gender identity—may also meaningfully influence dietary intake. In particular, red meat intake can enhance one’s self-perception of masculinity, especially for those with a higher degree of masculinity stress or feelings of not living up to male gender norms.¹⁸ Hence, among men, greater conformity to traditional male gender roles predicts more frequent beef and chicken intake and lower openness to vegetarianism.⁷ Conversely, lower traditional gender role conformity among men is associated with openness to becoming vegetarian for environmental reasons. Among women, greater conformity to traditional gender roles is associated with openness to becoming vegetarian for health reasons.⁷

However, emerging research challenges the “real men eat meat” aphorism. Aavik and Velgan describe the emergence of a “health-conscious masculinity,” which values physical and mental well-being among men following a vegan diet.¹⁹ Brady and Ventresca use the language of “renaissance masculinity” in describing the case of a professional football player who publicly adopted a vegan diet and the media coverage that followed.²⁰ Greenebaum and Dexter suggest that men following a vegan diet engage in “hybrid masculinity” by modifying the values typically associated with veganism and femininity to better align with traditional masculine values.²¹ Thus, just as expressions of meat and masculinity are numerous, so, too, are emerging examples that contradict and redefine masculinity with regard to diet.

Food and Transgender Patients

Dietary discourse holds special meaning for the transgender population, for whom sex and gender may differ. For the purposes of this article, the term transgender describes a person whose current gender identity is different from the sex they were assigned at birth. The term nonbinary describes a transgender or gender-nonconforming person who identifies as neither male or female.^1,2 Transmasculine and transfeminine describe gender-nonconforming or nonbinary persons based on the directionality of their gender identity that differs from sex assigned at birth; a transmasculine person has a masculine spectrum gender identity with a female sex assigned at birth, and a transfeminine person has a feminine spectrum gender identity with a male sex assigned at birth. A person’s gender expression refers to how an individual signals their gender to others through appearance, clothing, hairstyle, speech, mannerisms, or behaviors,¹ which may include dietary and eating behaviors.

Questions arise concerning gender norms and diet. Do transgender and nonbinary individuals use food to express their affirmed gender identity? In other words, do transmasculine individuals seek to adopt the dietary gender norms associated with traditional masculinity (ie, eating meat, especially red meat)? Do transfeminine individuals seek to adopt the dietary gender norms associated with traditional femininity (eg, vegetarianism, health consciousness)? How do nonbinary individuals negotiate existing dietary gender norms? Evidence to address these questions is largely lacking and presents an opportunity for future research.

Nutrition practitioners can help patients define for themselves what food means to their gender identity. 

Relatedly, Nagoshi and Brzuzy encourage clinicians working with the transgender community²² to identify “source[s] of empowerment,” which can be applied to dietary gender norms. Food may be a potential source of empowerment for transgender individuals seeking to express their gender identity through food choices and eating behaviors. For example, the narrative of one transgender man’s relation to food throughout his transition revealed specific functions of food and nutrition: support of his physical transition, promotion of his overall health, and a source of self-care.²³ More generally, transgender individuals may adopt eating behaviors that are distinct from nontransgender or cisgender individuals, such as reducing caloric intake to induce pubertal or menstrual suppression or adjusting caloric intake to augment body features that are aligned with one’s affirmed gender, although these behaviors might be characterized as disordered when they result in adverse health outcomes.^24,25

Research

Future research on food choices and eating behaviors as expressions of gender identity should be grounded in relevant clinical and psychosocial considerations and take into account the context of current dietary guidelines.

Hormone therapy and food insecurity. Among those who medically transition, masculinizing and feminizing hormone therapy (HT) typically results in changes in body size and composition, which in turn will affect energy needs.^6,26,27,28 Masculinizing HT in particular may result in increased appetite.²⁹ Moreover, transgender people are at heightened risk for food insecurity due to poverty, homelessness, and joblessness and may face transgender-specific barriers to accessing food assistance resources, such as gender-based discrimination or needing to use an identification card with a name, gender marker, or photo that doesn’t match their current gender expression.^30,31 Therefore, future research on food and eating behaviors as an expression of one’s gender identity or as a source of empowerment must take into account the metabolic effects of HT and the nutrition-related health disparities that impact the transgender population.

Dietary guidelines. The US Department of Agriculture 2020-2025 Dietary Guidelines for Americans recommend limiting saturated fat and sodium intake—2 nutrients found in relatively high levels in red and processed meats (eg, beef, bacon)—and encourage intake of protein sources from a mix of animal- and plant-based foods.³² The United Nations 2019 report on climate change not only recommends reducing meat consumption but also frames plant-based diets as an approach to mitigating climate change.³³ Research and dialogue on reducing meat intake for health and environmental purposes, however, largely explore strategies to decrease men’s meat intake.^{7,8,11,12,13,14,15,16,17,18} Overlooked is how transgender and nonbinary individuals reconcile dietary gender norms with health and environment-driven recommendations to consume less meat. Does discouraging meat intake disempower transmasculine individuals from using traditionally masculine food choices to express their gender identity?

Inclusion and NCP Usefulness

Nutrition practitioners can improve the accuracy of nutrition assessment and the inclusiveness of the NCP by taking a sex- and gender-informed approach that includes the following steps.

Acknowledge sex and gender as separate and relevant constructs. Collection of both sex and gender identity information during a clinical intake will improve the accuracy of a patient’s demographic data. The National Academies of Science, Engineering, and Medicine recommends a 2-step method to query patients about their sex and gender¹:

1. “What sex were you assigned at birth, on your original birth certificate?
   • Female
   • Male

        (Don’t know)
        (Prefer not to answer)”

2. “What is your current gender? [Mark only one]
   • Female
   • Male
   • Transgender
   • [If respondent is AIAN [American Indian or Alaska Native]]: Two-Spirit
   • I use a different term: [free text]

        (Don’t know)
        (Prefer not to answer)”

Use of transgender response options improves the inclusiveness of the NCP by inviting patients to share their authentic gender identity (vs selecting from male-female response options only). Collection of gender identity data may foster further dialogue regarding the patient’s food choices and eating behaviors.

Recognize gender as a fluid (rather than binary) concept. Conceptualization of gender as a fluid and dynamic element of a patient’s identity not only can ensure that transgender and nonbinary identities are included in the NCP, but also might help to liberate all patients (including cisgender individuals) from the constraints of perceived dietary gender norms. Conversely, failure to recognize gender as a fluid concept may perpetuate dietary gender norms and resulting masculinity stress (“real men eat meat.”)¹⁸

Seek to empower patients by encouraging food and eating behaviors that express their gender identity. Gender is both socially and self-constructed²²; nutrition practitioners can help their patients explore having power and control over their own lives by defining for themselves what food means in the context of their gender identity.

Conclusion

Although sex and gender have meaningful implications for a patient’s health and nutrition, sex informs multiple elements of the NCP but gender is rarely considered. Yet food and eating behaviors are, in part, an expression of a patient’s gender identity and may reflect internalized dietary gender norms concerning meat intake, vegetarianism, or veganism. The flawed conflation of sex and gender in the NCP compromises the accuracy of nutrition assessment and contributes to the erasure of transgender identities when sex and gender are reduced to a male-female binary. A sex- and gender-informed approach to the NCP has the potential to improve its accuracy and inclusiveness, liberate patients from destructive dietary gender norms, and harness food and eating behaviors as a source of empowerment.