Exploring Food Security and Mental Health Among Street-Involved Canadian 2S/LGBTQI+ Youth: A Review of the Literature

Food insecurity and mental health affect and are affected by several complex and intersectional socio-political and economic factors including gender, sexual orientation, age, and income. Both are deeply tied to the other social determinants of health, and people who are part of one or multiple marginalized groups are at greater risk for experiencing food insecurity [1] and mental illness [2,3]. Research in adults also reveals potential relationships between mental illness and food insecurity [4].

The Canadian government defines food insecurity as the “inability to acquire or consume adequate diet quality or sufficient quantity of food” or “the uncertainty that one will be able to do so” [5]. In 2021, 1 in 6 Canadian households was food insecure, and 1 in 5 Canadian children lived in food insecure households [6], figures which do not include Indigenous reserves or the territories, places known to have higher levels of food insecurity [6]. Further, researchers report a strong correlation between reduced access to nutritious food and poor mental health [7]. Studies have found nutrition, mental health, and suicidality to be among the top reported concerns for Two-Spirit, lesbian, gay, bisexual, transgender, queer, and/or intersex (2S/LGBTQI+) youth, with transgender men experiencing especially pronounced risk for both food insecurity and depression [8,9]. A study of homeless or underhoused youth in Toronto revealed “disturbing levels of nutrient inadequacies and food deprivation despite the use of charitable meal programs,” [10(p. 846),11–13] a concern that has been noted Canada-wide [10–12,14–24]. Research reveals that meals provided through charitable sources such as food banks and faith-based organizations often do not meet users’ nutritional needs [10]. 2S/LGBTQI+ people are also at higher risk for poverty and homelessness [8,25]. Moreover, it has been found that food banks are one of the least commonly employed strategies for households experiencing severe food insecurity [26], something which is likely related to social stigmas [27].

The United Nations defines “street-involved” children as “any boy or girl… for whom the street in the widest sense of the word… has become his or her habitual abode and/or source of livelihood, and who is inadequately protected, supervised, or directed by responsible adults” [28,29,30(p. 15)]. We use the term in this paper to account for youth who are exposed to the “physical, mental, emotional and social risks of street culture,” but who may experience varying degrees of homelessness [31]. Notably, 2S/LGBTQI+ people are at higher risk for becoming unhoused [32] and 2S/LGBTQI+ youth comprise between 24% and 40% of homeless youth in Canada [33–36]. This elevated risk exerts detrimental effects on these youths’ mental well-being and 2S/LGBTQI+ youth reporting past or current homelessness have been found to experience three times greater odds for food insecurity within the preceding month [37].

Taking into consideration the known connections between poverty and food insecurity, it is reasonable to suspect that street-involved 2S/LGBTQI+ youth have especially precarious access to safe, nutritionally sufficient food and mental health resources. There is a need to more fully understand food insecurity and its relationship to mental health among street-involved 2S/LGBTQI+ youth in Canada. This research aims to identify more precisely the mechanisms by which food insecurity impacts the mental health of street-involved 2S/LGBTQI+ youth in Canada. The purpose of this work is, therefore, to review the extant literature, identify relevant information and gaps, and help inform dietitians about how they can collaborate within interdisciplinary teams to support safe, accessible, food systems and resources for this population. The dimensions of the research question, how does food insecurity influence the mental health among street-involved 2S/LGBTQI+ youth in Canada, are defined as the following: mental health, food security, 2S/LGBTQI+ population(s), youth, and Canadian context.

Searches were executed for academic and grey literature in academic databases (PubMed, CINAHL PLUS, Academic Search Premier, Medline, Gender Studies Database, PsychINFO, LGBTQ+ Source, PsycArticles, SocINDEX) and on Google and Google Scholar. Searches were undertaken using the search terms and Boolean operators found in Table 1. Please see Supplemental File 1¹ for search strategy details. Analysis of selected sources involved team members collaboratively reading and assessing each of the sources and identifying common factors addressed related to street-involved 2S/LGBTQI+ youths’ mental health and food insecurity. Repeatedly occurring elements among the web of factors that influence each dimension of the research question were then pulled out and synthesized.

Our search strategy identified 1770 papers, of which 28 were related to our research question and evaluated by our team. None of the papers examined food insecurity in connection with mental health among street-involved 2S/LGBTQI+ youth in Canada.

However, a single report touched briefly upon each dimension of the research question but did not formally examine connections between mental health and food insecurity. The report was an evaluation of the 2015–2017 RainCity LGBTQ2S Housing First Project [38] which assisted 2S/LGBTQI+ youth in Vancouver with housing. The mixed-method evaluation consisted of 2 surveys (13 participants completed the intake and 15 the follow-up) and 7 focus groups. All participants had experienced housing precarity and mental health concerns at the time of their admittance to the program. At the conclusion of the program, participants reported improvements in their housing stability, substance use behaviours, skills, knowledge of supports, and how to access them. Program staff reported that they were unable to meet participants’ food needs, but nevertheless saw a reduction in reports of “going to bed hungry” [38(p. 31)] and 60% of participants reported an improvement in access to healthy food items which they credited to their participation in the program.

Despite a social epidemic of homelessness and street-involvement in 2S/LGBTQI+ youth [55] that impacts their access to nutritious food, our literature review did not identify any studies directly addressing this important issue. In Canada, youth are one of the fastest growing segments of the unhoused population [56], and 2S/LGBTQI+ homeless youth are at increased risk for poorer outcomes overall [57]. Street-involved 2S/LGBTQI+ youth are polymarginalized and must cope with stigma, discrimination, and prejudice from several sources. When 2S/LGBTQI+ youth experience overt acts of discrimination in multiple locations and/or multiple times, their risk for experiencing proximal stressors leading to emotional distress is increased [58]. American data showed that 54% of 2S/LGBTQI+ adults reported food insecurity, with 64.8% of transgender men surveyed reporting food insecurity [8]. Despite these alarming numbers, there remains little empirical research describing food insecurity among transgender people [59] or the wider 2S/LGBTQI+ communities, particularly youth [8]. Further, the research is clear that 2S/LGBTQI+ youth experience higher risk for poorer mental health outcomes [39] due to systemic cis-heterosexist attitudes and discrimination [60], and housing precarity increases this risk yet again [61].

Our review highlights the challenges street-involved 2S/LGBTQI+ youth face accessing nutritious food, as well as the impact food insecurity exerts on their mental health is under recognized and under-researched. This awareness, including acknowledging the impact of cis-heteronormativity, can positively influence dietitians’ practice with 2S/LGBTQI+ clients. Dietitians in Canada can play an important role in supporting the mental health and well-being of street-involved 2S/LGBTQI+ youth experiencing food insecurity. Building relationships within the 2S/LGBTQI+ community is critical in understanding how dietitians can help. This can be done by volunteering with applicable community groups and establishing partnerships with applicable social services and mental health professionals in practice. As noted by Davison et al., “nutritional interventions as part of collaborative and integrative programs aimed at mental health promotion as well as prevention contribute to positive health outcomes” [63(p. iv)]. While serving on interdisciplinary teams, dietitians can advocate for 2S/LGBTQI+ youth by bringing their concerns to the fore. They can assist in development of appropriate resources, including such things as language used, communication with, and education for food banks and other resources to reduce stigmas.

The training and professional development in dietetics must incorporate comprehensive education to enhance effectiveness when working with 2S/LGBTQI+ clients. This should encompass a deep understanding of the social determinants of health, the specific mental health challenges faced by the 2S/LGBTQI+ community, and issues around food insecurity. Furthermore, it is crucial for practitioners to master the use of inclusive language, develop refined communication and counseling skills, and adopt a compassionate approach to care. Dietitians can acquire these competencies through engagement in educational sessions and workshops focused on these critical topics, staying abreast of the latest research, and conducting introspective evaluations of their personal prejudices and assumptions. Dietitians of Canada have recently launched a PEN: Practice-based Evidence in Nutrition pathway, entitled “Food, Nutrition, and Eating Issues of Transgender and Gender-diverse Individuals Background” and are designed as a self-educational tool for dietitians and students to further their knowledge and expertise in this area [64].

The extant literature on this topic is scant, fragmented, and has not addressed these topics in conjunction. The need for further targeted research is evident based on the gaps located in the literature because there is not yet a clear picture of how these interconnected elements influence one another. We call for further research that will help produce a deeper understanding of the situation. Such research would help dietitians participate collaboratively with other clinicians such as social workers and nurses, policymakers, and community organizations to design and implement safe, accessible, nutritionally sound programs and supporting policy for 2S/LGBTQI+ youth experiencing food insecurity.