RESEARCH ARTICLE Open Access

Food insecurity and food pantry use among transgender and gender non- conforming people in the Southeast United States Jennifer Russomanno* and Jennifer M. Jabson Tree

Abstract

Background: Transgender and gender non-conforming (TGNC) people face high rates of poverty, joblessness, and homelessness, rendering this population vulnerable to experiencing food insecurity. Yet, there is almost no empirical evidence concerning food insecurity and the use of local and federal food assistance resources in the TGNC community. Food insecurity, the use of local and Federal food assistance resources, and associations with gender-related minority stressors and resilience using the Gender Minority Stress and Resilience (GMSR) scale among TGNC individuals living in the Southeast United States (U.S.) were documented in this study.

Methods: A cross-sectional online survey was conducted with TGNC people living in the Southeast U.S. Participants were recruited via targeted Facebook advertisements.

Results: In total, 105 TGNC people completed the survey; 79% of survey participants experienced food insecurity, 19% utilized Federal, and 22% utilized local food assistance resources. High levels of minority stress and community resilience were reported. The GMSR resilience scale Pride (aOR = 1.09, 95% CI 1.00–1.19, p = .04) was significantly associated with the use of local food pantries, but minority stressors were not. No significant associations were found between GMSR and food security.

Conclusion: TGNC people living in the Southeast U.S. experienced food insecurity, unstable housing, low wages, and social stigma that were a barrier to using emergency food resources. Multi-level public health solutions that address discriminatory legislative policies and create linkages between TGNC people and local and federal food assistance are required to address issues of food insecurity in the TGNC population.

Keywords: Transgender, Food insecurity, Health disparities, Food pantries, LGBTQ

Background In the United States (U.S.), 1 in 9 people (11.1%) is food insecure [1]. Food security is defined as access by all people at all times to enough food for an active, healthy life and, at minimum, includes the availability of nutri- tionally adequate and safe foods, and the assured ability

to acquire food in a socially acceptable way [2]. People who are able to meet these standards on a daily basis are considered food secure, and those that cannot are con- sidered food insecure [2]. Federal organizations name food insecurity as a pressing public health challenge that contributes to hunger, obesity, chronic disease, and poor overall health [3–6]. Food insecurity disproportionately affects certain

groups of people, including those living in poverty,

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] The University of Tennessee Department of Public Health, 1924 Alcoa Highway, Knoxville, TN 37920, USA

Russomanno and Jabson Tree BMC Public Health (2020) 20:590 https://doi.org/10.1186/s12889-020-08684-8

people who are under or unemployed, and the homeless [3, 6, 7]. Transgender and gender non-conforming (TGNC) people (individuals whose gender identity is dif- ferent from their sex assigned at birth) are a diverse group of people who experience some of the highest risks for food insecurity. Based on the 2015 U.S. Trans- gender Survey (USTS), [8] TGNC people are 4 times more likely to have incomes below $10,000/year, are 3 times more likely to be unemployed, and 2.5 times more likely to experience homelessness in their lifetimes, com- pared to cisgender (gender identity is concurrent with sex assigned at birth) counterparts [8]. TGNC people also face the burden of minority

stressors in the form of discrimination, stigma, and marginalization as a result of their gender identities. Mi- nority stress is a chronic, cumulative, and institutional source of stress built into how organizations and soci- eties function and exists beyond the control of the indi- vidual or subgroup that it targets [9]. Minority stress affects TGNC people’s internal perceptions of them- selves, their relationships with peers, family members and community members, their integration and accept- ance into community groups, clubs or religious institu- tions, and their rights as dictated by governmental laws and legislation [9–11]. Although TGNC people are exposed to minority

stressors, this group is also resilient. Meyer [10] referred to this resilience as community resilience, or minority coping. Community resilience is a sense that individuals can overcome life challenges and obstacles with the as- sistance of close community networks and support. For TGNC people with strong community or social support, community resilience may be protective against minority stress [10]. Multi-level minority stressors and commu- nity resilience may contribute to or protect against the negative consequences of food insecurity in the TGNC population, however, these associations have not yet been empirically explored and documented. Where a person lives also influences their experiences

with and risk for food insecurity, minority stress, and community resilience. TGNC people living in states with high rates of food insecurity and sociopolitical contexts that produce discrimination and stigma, may be at espe- cially high risk for food insecurity. Of the 12 Southeast states (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia), 9 have food insecur- ity rates above the national average [12]. Additionally, the Southeast states, have, on average, very high levels of social stigma toward Lesbian, Gay, Bisexual & Transgender (LGBT) people, [11] evidenced by the ab- sence of employment or non-discrimination laws that protect this population [11]. High levels of social stigma combined with non-protective laws decrease the safety,

economic stability, and acceptance of the estimated 380, 000 TGNC people living in the Southeast U.S. [11, 13] In the general population, local food assistance pro-

grams, such as food pantries, are valuable resources to alleviate food insecurity [14]. A majority of U.S. food pantries (67%) are run by faith-based institutions, [15] which could pose a great threat to food insecure TGNC people. State Religious Freedom Restoration Acts (RFRA), or “religious freedom laws” allow institutions, including food pantries, to deny services to select com- munity members based on religious beliefs [16]. These laws allow food pantries to deny TGNC people support and thereby further jeopardize food access to this popu- lation [17].

Study purpose The purpose of this study was two-fold. First, we aimed to describe TGNC peoples’ experiences with food inse- curity, including their use of Federal and local food as- sistance resources. Second, we sought to investigate possible associations between gender-related minority stressors and community resilience and the experience of food insecurity and use of local food assistance re- sources among TGNC people in the Southeast U.S.

Methods The University of Tennessee Institutional Review Board approved all study procedures (UTK IRB-18-04907-XP).

Pilot test To ensure survey quality and that questions were appro- priate and sensitive to the priority population, the survey was pilot tested with a person who self-identified as transgender male, and who resided in Tennessee. The pilot tester provided positive feedback about the survey questions and did not suggest modifications to the sur- vey protocol. The survey was not modified after the pilot test, prior to public dissemination.

Recruitment From January to February 2019, TGNC people living in the Southeast U.S. were recruited online via targeted Facebook advertisements to complete an online survey. This recruitment approach is an evidence-based method documented to successfully recruit stigmatized groups into research projects [18–21].

Eligibility Eligibility was determined with a 4-item online eligibility questionnaire. Determining eligibility required potential survey participants to: (1) agree to participate via in- formed consent, (2) live in 1 of the 12 Southeast U.S. states, (3) be over age 18, and (4) self-identify as TGNC. Responses were required for each item before it was

Russomanno and Jabson Tree BMC Public Health (2020) 20:590 Page 2 of 11

possible to advance to the full survey instrument. Upon clicking on the survey link embedded in the Facebook advertisement, potential respondents were directed to an online informed consent form with response options of “agree to participate” or “decline to participate.” Respon- dents who selected “decline to participate” were consid- ered ineligible to participate, and were directed to the end of the survey, thanking them for their time. Respon- dents who selected “agree to participate” were directed to the remaining items on the eligibility questionnaire. Survey participation was voluntary and confidential.

Participants could voluntarily provide a name and email address to be entered to win 1 of 4 randomly-selected $50 electronic gift cards. Names and email addresses were not associated with survey responses.

Participation Seven hundred and forty-two people clicked the survey link. Of those, 166 (22.4%) consented to participate. Nineteen participants (11.4%) either did not meet eligi- bility criteria (n = 16) or left the survey prior to the first question of the full survey (n = 3).

Measures The cross-sectional survey was conducted online via Qualtrics and measured: (1) food insecurity; (2) use of local and Federal food assistance resources; (3) gender- related stress and resilience; and (4) demographic char- acteristics. All “prefer not to answer” responses to any survey item were coded as missing.

Food insecurity Food insecurity was assessed using the USDA 6-item Short Form Food Security Module [22]. This measure identifies food insecure households [22] with Cronbach’s alpha (α) ranging from 0.74 to 0.93 [23]. USDA- recommended scoring guidelines [2] were used to calcu- late participant food security scores. Overall scores were summed, with a total possible score of 0–6. Final partici- pant scores were dichotomized: food secure (raw score 0–1) and food insecure (raw score 2–6) [22].

Local and federal food assistance programs Two survey items were used to assess participants’ expe- riences with the Federal Supplemental Nutrition Assist- ance Program (SNAP), and 6 items assessed participants’ experiences with local food pantries (Table 1). These items were designed by the research team specifically for this survey. Skip progressions were used for questions regarding federal food assistance and use of local food assistance programs. Regarding Federal food assistance, all participants were asked whether they had received SNAP benefits in the past 12 months. If a participant in- dicated they had received benefits during this period,

they were directed to an additional follow-up question assessing their average monthly SNAP allowance. Re- garding local food assistance programs, all participants were asked whether they had use local food assistance programs in the past 12 months. If a participant indi- cated they were not currently using food pantries, they were directed to a follow-up question regarding why they currently did not utilize these resources. All partici- pants were asked the remaining 4 questions regarding local food assistance resources capturing organizing agencies of their local pantries and assessing the wel- coming nature of pantries to TGNC people.

Gender-related stress and resilience Gender-related stress and resilience were assessed using the Gender Minority Stress and Resilience (GMSR) scale [24]. The Cronbach’s alphas reported in previous studies using the GMSR scale ranged from 0.61 (gender-related discrimination) to 0.93 (negative expectations for the fu- ture) [24, 25]. GMSR scoring guidelines [24] were used to calculate participant scores within each subscale. Higher scores indicated a higher minority stress and/or resilience depending on subscale.

Demographics Demographic variables included: state of residence, gen- der identity, [26] age, [27] geographic location (urban, suburban, rural), marital status, [27] race, [27] ethnicity, [27] education, [27] employment status, [27] household income, [27] housing stability, [28] and number of chil- dren in the household [27].

Statistical analyses Food insecurity and local and federal food assistance Summary statistics were calculated for food insecurity and receipt of SNAP benefits and use of local food pan- tries. Open-ended questions concerning experiences with local food assistance resources were analyzed quali- tatively by categorizing and sorting the responses into overarching themes.

Gender-related minority stress Mean GMSR subscale scores were calculated.

Demographics Frequencies and percentages for all demographic vari- ables were calculated.

Associations between GMSR and food insecurity/local and federal food assistance Logistic regression models were calculated with adjust- ment for demographic characteristics, to test for associa- tions between GMSR subscales and (1) food pantry usage and (2) food security. All adjustment variables

Russomanno and Jabson Tree BMC Public Health (2020) 20:590 Page 3 of 11

were selected based on associations in bivariate analyses. Per published guidelines [29], variables that were signifi- cant at < 0.15 in the bivariate analyses were included as adjustment variables in the multivariable regression

models. The six regression models calculated were: (1) food pantry usage regressed on the 7 full-sample GMSR subscales; (2 & 3) food pantry usage regressed on the 2 partial-sample GMSR subscales (negative expectations

Table 1 Local and Federal food assistance program survey questions

Question Potential Responses

1. Do you currently, or have you in the past 12 months, received assistance through the Supplemental Nutrition Assistance Program (SNAP) (formerly known as food stamps)? [all participants]

1. Yes, I/We currently receive SNAP assistance

2. Yes, I/We have received SNAP assistance in the past 12 months, but do not currently receive assistance

3. No, I/We have not received SNAP assistance in the past 12 months

4. Prefer not to answer

2. On average, how much in SNAP assistance did/do you receive monthly? [participants who responded Yes in Q1]

1. Less than $50

2. $50 – $99

3. $100 – $149

4. $150 – $199

5. $200 or more

3. Do you currently, or have you in the past 12 months, use local food assistance programs such as food pantries? [all participants]

1. Yes, I/We currently use them

2. Yes, I/We have used them in the past 12 months, but do not currently

3. No, I/We do not use them and have not used them in the past 12 months

4. Prefer not to answer

4. Why do you not currently use local food pantries? (select all that apply) [participants who responded no current food pantry use in Q3]

1. I do not need to use these resources at this time

2. I do not feel these resources are meant for me

3. I do not feel comfortable using these resources

4. I do not have transportation to these resources

5. I do not feel welcome at these resources

6. I did not know these resources existed

7. None of these resources are available to me in my community

8. Other, please describe

9. Prefer not to answer

5. Who is the organizer of your local food pantry? (if more than one pantry exists in your community, select all that apply) [all participants]

1. Church or faith-based organization

2. Charitable, non-profit organization (such as Second Harvest)

3. A local college or university

4. I am not aware of any food pantries in my community

5. I do not know who organizes my local food pantry

6. Prefer not to answer

6. Overall, how welcoming do you feel your local food pantry is to transgender or gender non-conforming people? [all participants]

1. Extremely welcoming

2. Somewhat welcoming

3. Neither welcoming nor unwelcoming

4. Somewhat unwelcoming

5. Extremely unwelcoming

7. In your own words, please describe how your local food pantry is welcoming to transgender or gender non-conforming people. [all participants]

Open ended

8. In your own words, please describe how your local food pantry is unwelcoming to transgender or gender non-conforming people. [all participants]

Open ended

Russomanno and Jabson Tree BMC Public Health (2020) 20:590 Page 4 of 11

for the future and nondisclosure) for the “gender history” and “gender identity” participant subgroups; (4) food se- curity regressed on the 7 full-sample GMSR subscales; and (5 & 6) food security regressed on the 2 partial- sample GMSR subscales for the “gender history” and “gender identity” participant subgroups. Logistic regression models testing the associations be-

tween GMSR and food security and use of food pantries were calculated as nested models, with demographic covari- ates included in Block 1, and GMSR subscales in Block 2.

Missing data As recommended [30, 31], respondents were excluded from analyses if they were missing more than 20% of survey items. In our tests of missingness according to recommended guidelines [31, 32], there were no obvious patterns of missingness within excluded cases χ 2 (18, N = 147) 17.11, p = .52. Therefore, cases were considered missing completely at random (MCAR). According to Peng [31], MCAR assumes the “probability of a response depends on neither the observed nor the missing value that could have been collected or recorded” among cases with 20% missing data. Under conditions where data are MCAR, complete removal of cases with 20% or more missing data will not produce biased estimates to the remaining data [31]. For this project, 42 MCAR cases were excluded, leaving 105 cases in the final analyses. Respondents who were missing fewer than 20% of sur-

vey items had item-level missing

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