“Current guidelines are based on a very binary system for males and females in determining target weights and caloric needs,” says Kelly Davidson, RDN, Nutrition Therapist at Princeton Center for Eating Disorders. “It reinforces the fact that the nation’s health care system is not up to date on gender-affirming care.”
“We’re faced with navigating these complexities in a way that gender-diverse people navigate the world all the time: the system doesn’t quite fit,” adds Supervising Psychologist Rebecca Boswell, PhD. “That’s a system problem. So we work to mirror and be guided by the flexibility and resilience of our patients when providing care.”
The resulting approach is to individualize nutritional rehabilitation as much as possible – as the team would do for any patient. Davidson also fosters inclusive care in the following ways:
Building a rapport with patients. Gender identity can be a sensitive topic, but also an intricate part of an eating disorder that should be explored when a patient feels safe doing so. For providers, this means establishing trust, acting as an ally, and being continually open to education about gender-affirming care.
Discussing emotional aspects. Beyond meal-planning and nutrition calculations, Davidson works with patients to explore the history behind eating beliefs, the elements of adequate nutrition, and how thought distortion can create nutritional problems. She explains that nourishing the body does not validate or invalidate gender identity.
Planning with hormone therapy in mind. Because testosterone can impact bone density over time, Davidson ensures adequate calcium intake in individuals taking these hormones. She also monitors for a potential drop in phosphorus in patients taking estrogen. In addition, hormone therapy affects muscle mass and energy usage, altering caloric needs. Patients taking testosterone typically see an onset of muscle mass effects in six to 12 months, with a maximum effect at two to five years. Those taking estrogen and progesterone tend to experience an onset of decrease in muscle mass within three to six months, with a maximum effect at one to two years.
Considering weight history and lived experience. Davidson is honest with patients about the challenges of target weights for gender-diverse individuals. But she also factors in weight history and lived experience to identify the weight where patients thrived the most in the past, before being interrupted by eating disorder behaviors. For young patients, pediatric growth charts can assist in this assessment.
“Our goal for every patient is to help them achieve a healthy weight," adds Davidson. "This is the point where they are able to nourish the body adequately throughout the day, eat a variety of foods, engage in joyful movement in a way that honors the body, and have a healthy relationship with food. While this looks different for everyone, it’s where we all thrive.”