[Skip to Content]
[Skip to Content Landing]

Should Clinicians Care About How Food Behaviors Express Gender Identity?

Learning Objectives
1. Explain a new or unfamiliar viewpoint on a topic of ethical or professional conduct
2. Evaluate the usefulness of this information for health care practice, teaching, or conduct
3. Decide whether and when to apply the new information to health care practice, teaching, or conduct
1 Credit CME

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.713Quiz Ref IDAlthough 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.7,1418

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

Quiz Ref IDHowever, 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.1,2Transmasculine 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.

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.23Quiz Ref IDMore 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


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.6,2628 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.7,8,1118 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

Quiz Ref IDQuiz Ref IDNutrition 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.


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.

Sign in to take quiz and track your certificates

Our websites may be periodically unavailable between 7:00pm CT December 9, 2023 and 1:00am CT December 10, 2023 for regularly scheduled maintenance.

The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Article Information

AMA Journal of Ethics

AMA J Ethics. 2023;25(4):E287-293.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Conflict of Interest Disclosure: The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information:

  • Whitney Riley Linsenmeyer, PhD, RD, LD, is an assistant professor of nutrition at Saint Louis University in St Louis, Missouri, and a spokesperson for the Academy of Nutrition and Dietetics. Her research and clinical practice center on nutrition care for the transgender population.

Bates  N, Chin  M, Becker  T, eds;  National Academies of Sciences, Engineering, and Medicine.  Measuring Sex, Gender Identity, and Sexual Orientation. National Academies Press; 2022:chap 1. Google Scholar
Deutsch  MB, ed.  Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. 2nd ed. Center of Excellence for Transgender Health, University of California San Francisco; 2016. Accessed May 20, 2022. https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf
Swan  WI, Vivanti  A, Hakel-Smith  NA,  et al.  Nutrition care process and model update: toward realizing people-centered care and outcomes management.  J Acad Nutr Diet. 2017;117(12):2003–2014. Google ScholarCrossref
Swan  WI, Pertel  DG, Hotson  B,  et al.  Nutrition care process (NCP) update part 2: developing and using the NCP terminology to demonstrate efficacy of nutrition care and related outcomes.  J Acad Nutr Diet. 2019;119(5):840–855. Google ScholarCrossref
Academy of Nutrition and Dietetics.  Nutrition Care Process Terminology (NCPT) Reference Manual: Dietetics Language for Nutrition Care. Academy of Nutrition and Dietetics; 2017.
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. Google ScholarCrossref
Rosenfeld  DL, Tomiyama  AJ.  Gender differences in meat consumption and openness to vegetarianism.  Appetite. 2021;166:105475. Google ScholarCrossref
Ruby  MB.  Vegetarianism. A blossoming field of study.  Appetite. 2012;58(1):141–150. Google ScholarCrossref
Andersen  SS.  The legacy of marriage: using food to challenge traditional gender norms in widowhood.  J Aging Stud. 2021;59:100966. Google ScholarCrossref
Contois  EJH.  Real men don't eat quiche, do they? Food, fitness and masculinity crisis in 1980s America.  Eur J Am Cult. 2021;40(3):183–199. Google ScholarCrossref
De Backer  C, Erreygers  S, De Cort  C,  et al.  Meat and masculinities.  Can differences in masculinity predict meat consumption, intentions to reduce meat and attitudes towards vegetarians?  Appetite. 2020;147:104559. Google ScholarCrossref
Rothgerber  H.  Real men don't eat (vegetable) quiche: masculinity and the justification of meat consumption.  Psychol Men Masc. 2013;14(4):363–375. Google ScholarCrossref
Schösler  H, de Boer  J, Boersema  JJ, Aiking  H.  Meat and masculinity among young Chinese, Turkish and Dutch adults in the Netherlands.  Appetite. 2015;89:152–159. Google ScholarCrossref
de Boer  J, Schösler  H, Aiking  H.  Towards a reduced meat diet: mindset and motivation of young vegetarians, low, medium and high meat-eaters.  Appetite. 2017;113:387–397. Google ScholarCrossref
Rosenfeld  DL.  The psychology of vegetarianism: recent advances and future directions.  Appetite. 2018;131:125–138. Google ScholarCrossref
Keller  C, Siegrist  M.  Does personality influence eating styles and food choices? Direct and indirect effects.  Appetite. 2015;84:128–138. Google ScholarCrossref
Love  HJ, Sulikowski  D.  Of meat and men: sex differences in implicit and explicit attitudes toward meat.  Front Psychol. 2018;9:559. Google ScholarCrossref
Mesler  RM, Leary  RB, Montford  WJ.  The impact of masculinity stress on preferences and willingness-to-pay for red meat.  Appetite. 2022;171:105729. Google ScholarCrossref
Aavik  K, Velgan  M.  Vegan men's food and health practices: a recipe for a more health-conscious masculinity?  Am J Mens Health. 2021;15(5):15579883211044323. Google ScholarCrossref
Brady  J, Ventresca  M.  “Officially a vegan now:” on meat and renaissance masculinity in pro football.  Food Foodways. 2014;22(4):300–321. Google ScholarCrossref
Greenebaum  J, Dexter  B.  Vegan men and hybrid masculinity.  J Gend Stud. 2018;27(6):637–648. Google ScholarCrossref
Nagoshi  JL, Brzuzy  S.  Transgender theory: embodying research and practice.  Affilia. 2010;25(4):431–443. Google ScholarCrossref
Linsenmeyer  W, Rahman  R, Stewart  DB.  The evolution of a transgender male's relationship with food and exercise: a narrative inquiry.  J Creat Ment Health. 2022;17(1):2–14. Google ScholarCrossref
Coelho  JS, Suen  J, Clark  BA,  et al.  Eating disorder diagnoses and symptom presentation in transgender youth: a scoping review.  Curr Psychiatry Rep. 2019;21(11):107. Google ScholarCrossref
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 Health. 2021;8(5):359–366. Google ScholarCrossref
Coleman  E, Bockting  W, Botzer  M,  et al.  Standards of care for the health of transsexual, transgender, and gender nonconforming people, version 7.  Int J Transgend. 2012;13(4):165–232. Google ScholarCrossref
Rahman  R, Linsenmeyer  WR.  Caring for transgender patients and clients: nutrition-related clinical and psychosocial considerations.  J Acad Nutr Diet. 2019;119(5):727–732. Google ScholarCrossref
Waters  J, Linsenmeyer  W.  Transgender health and nutrition.  In: Raymond  JL, Morrow  K, eds.  Krause and Mahan's Food and the Nutrition Care Process. 16th ed. Forthcoming 2023. Google Scholar
Linsenmeyer  W, Drallmeier  T, Thomure  M.  Towards gender-affirming nutrition assessment: a case series of adult transgender men with distinct nutrition considerations.  Nutr J. 2020;19(1):74. Google ScholarCrossref
Conron  KJ, O'Neil  KK.  Food insufficiency among transgender adults during the COVID-19 pandemic.  Williams Institute; 2022. Accessed May 20, 2022. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Food-Insufficiency-Update-Apr-2022.pdf
James  SE, Herman  JL, Rankin  S, Keisling  M, Mottet  L, Anafi  M.  The Report of the 2015 US Transgender Survey. National Center for Transgender Equality; 2016. Accessed May 20, 2022. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf
US Department of Agriculture; US Department of Health and Human Services.  Dietary Guidelines for Americans 2020-2025. 9th ed. US Department of Agriculture; US Department of Health and Human Services; 2020. Accessed May 21, 2022. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf
Masson-Delmonte  V, Pörtner  HO, Skea  J,  et al, eds.  Climate Change and Land: An IPCC Special Report on Climate Change, Desertification, Land Degradation, Sustainable Land Management, Food Security, and Greenhouse Gas Fluxes in Terrestrial Ecosystems. Intergovernmental Panel on Climate Change; 2019. Accessed May 21, 2022. https://www.ipcc.ch/site/assets/uploads/2019/11/SRCCL-Full-Report-Compiled-191128.pdf
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


Name Your Search

Save Search

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.