Stereotypes of eating disorders perpetuate common misconceptions regarding who may be at risk for their development. The stigma of disordered eating is that it only affects young, White, cisgender, high socioeconomic status (SES) women. As researchers and clinicians continue to challenge the stigmas associated with eating disorder pathology, it is increasingly evident eating disorders do not discriminate. In fact, underrepresented populations, such as sexual and gender minorities, are at higher risk eating disorder symptomatology. More specifically, transgender individuals have a higher prevalence rate of eating disorder diagnoses when compared to their cisgender peers, and higher rates of compensatory behaviors such as laxative use (Diemer et al., 2015).
According to the American Psychological Association (APA), transgender refers to “an umbrella term encompassing those whose gender identities or gender roles differ from those typically associated with the sex they were assigned at birth”. Transgender youths tend to have heightened challenges, such as anxiety and gender dysphoria, due to facing puberty. The development of secondary sexual characteristics that do not match their identified gender can contribute as well. Experiencing puberty is a key stressor among these youths. It serves as a risk factor with onsets of gender dysphoria and causes spikes in body dissatisfaction, which consequently corelates to eating disorder development (Coelho et al., 2019). Due to these factors, this puts transgendered adolescents at an increased risk for eating disorder development. They are also more likely to develop comorbid disorders such as depression, anxiety, substance use, risky sexual behaviors, and endorse suicidal thoughts/behaviors (Olson et al., 2011).
LGBTQIA+ youths meet criteria for eating disorders at greater rates than the general population, while transgender youths and young adults specifically report eating disorder diagnoses four times more frequently than cisgender individuals (Diemer et al., 2015; Mustanski et al., 2011). One study documented that around 15% of transgender youths had elevated scores on the Eating Disorder Examination Questionnaire (EDE-Q), with 63% reporting purposeful weight manipulation related to affirming their gender, putting them at elevated rates of eating disorders than cisgender youths (Avila et al., 2019). Despite these increased risk factors, transgender folks are extremely underserved both medically and psychologically. This calls the importance of reviewing relevant research and informing clinical considerations for those who work with this population. Components of potential risks, along with clinical implications will be discussed below.
Heightened Risks for Eating Disorders in Trans Folks
Gender dysphoria, which is the distress and impairment of functioning caused by an incongruence of one’s gender assigned at birth and gender identity, shows to be an imperative concern among transgender youths (Olson et al., 2014). Gender dysphoria addresses feelings of disconnection between one’s biological sex and gender identity. Moreover, body dissatisfaction rates are correlated and can be amplified from experiences of gender dysphoria. One of the strongest predictors of an eating disorder in the general population is higher levels of body dissatisfaction. A large number of individuals who are transgender experience gender dysphoria, which corelates to body dissatisfaction (Jones et al., 2018; Stice & Shaw, 2002). A notable finding is that transgender boys tend to report higher levels of gender dysphoria than transgender girls (Olson et al., 2014). Levels of body dissatisfaction is one of the strongest corelates to psychological distress, a central issue for transgender youths, shedding light to why eating disorders might be more common within this population (McGuire et al., 2016; Jones et al., 2015). This suggests that transgender individuals might engage in eating disorder behaviors to feel increased consistency between their body and their gender. Noting that when the EDE-Q was recently normed with transgender individuals, there was found to be significance in the shape concern subscale (Nagata et al., 2020). This subscale focuses on concerns regarding the bodies shape and feelings around seeing their own body, which could relate to discomfort of gender dysphoria. Another hypothesis is that eating disorder behaviors suppress the development of potential secondary sex characteristics of their gender assigned at birth. Among transgender girls and women, restricting or dieting is typically used to achieve a more stereotypical “feminine” or “thin” body shape, and to lose muscle mass. Among transgender boys and men, restricting is also common to avoid growth secondary sexual characteristics such as breasts, hips, or to stunt menstruation. Excessive exercise may be utilized to achieve larger muscle mass, since that would align with the societally accepted body type (Nagata et al., 2020).
Internalization of the many stereotypes that exist in Western culture about an “ideal” body, and ways to attain one, may open the door for many eating disorder thoughts and behaviors. The pressure to attain a certain “thinness” or “body type” is present in cis and trans people alike. Achieving the ideal body brings hope they will obtain acceptance from others. When we look at transgender folks in particular, this yearning for social acceptance can be amplified given their vulnerability to stigmatization. This might be in attempt to align more with a body they feel will be more accepted by society and how they are seen and understood by the world. It may also be to “blend in” more covertly to society to avoid discrimination or attention based on their gender identity (Rorty & Yager, 1996). This is an important consideration in adolescents, noting a staple concern in adolescent development being an increased desire to fit in into society and peer groups. The pressure from both the individual and society, in addition to being a marginalized community, can cause culturally “normal” behaviors like dieting and exercising to spiral into more severe patterns of behavior like restricting food, purging, using laxatives, excessive exercise, and other eating disorder behaviors (Jones et al., 2015; Griffiths & Yager, 2019).
Transgender individuals are at a heightened risk to experience trauma and discrimination due to the stigma associated with their gender identity. They report high rates of verbal, sexual, and physical abuse, which can affect health outcomes. Around half of transgender individuals reported being physically abused, one in 10 reported being verbally abused, around half reported sexual abuse, and more than half reported intimate partner violence (James et al., 2016). Even more concerning is that this population also reports discrimination in medical settings with encounters such as verbal harassment. Moreover, one third of transgender individuals in the last year reported having a negative experience with the healthcare system/a healthcare practitioner due to their gender identity (James et al., 2016). An interesting finding is that transgender individuals may also be stigmatized within the LGBTQIA+ community itself, which might lead to further social isolation (Mustanski et al., 2011). It is commonly discussed that many members of the trans community face frequent legal and ethical concerns related to discrimination of their rights as citizens yet have lower levels of legal protection. Some trans folks do not have an “invisible” LGBTQIA+ identity, especially during or after puberty. Therefore sometimes just existing means pushing Western norms related to gender and how sexuality is understood (Clements-Noelle et al., 2006). These are all reasons this population might be targeted for bullying and violence.
Further, it has been found that transgender youths that experience higher rates of harassment also show higher rates of eating disorder symptomology, such as restricting, purging, and binging (Watson et al., 2016). Ultimately, societal issues impact pathology within trans folks.
Given the complexity of stressors a trans individual may encounter causing various comorbidities, a variety of approaches must be considered while working with this community. (Connolly et al. 2016; Jones et al., 2018). So, what can help?
Screening and Protocols
Clinicians and medical providers working with transgender individuals and youths should be assessing for eating disorders. Additionally, eating disorder facilities and treatment programs should be inquiring about gender identity and its potential impact on the individual and how that may relate to their eating disorder (Jones et al., 2018). Protocols must be updated to the needs of our transgender community when treating eating disorders. Growth charts utilized for nutritional planning and weight considerations for the youths should be changed and updated to take into account this populations specific and unique needs (Nagata et al., 2020).
Medical Interventions and Referrals
Research has documented that transgender individuals are aware of the discrepancy between their gender assigned at birth and their gender identity at a young age in childhood. This calls into importance early interventions and the psychological benefit of social gender transitions and gender-affirming medical treatment for those that desire it, as those who receive these treatments show lower levels of eating disorder symptomology (Connolly et al. 2016; Mattila et al., 2015; Testa et al., 2017). Consideration of referring out for consulting on cross-sex hormones can be utilized. These hormone treatments have been shown to decrease levels of body dissatisfaction, one of the largest predictors for eating disorders in transgender adults and youths (Jones et al., 2018). Thus, these treatments might lower the risk for developing eating disorder pathology in this population, which is imperative when considering the lethal nature of the disorders.
It is recommended that clinicians have visible items of support in their office, such as a rainbow flag or a safe space sticker and integrate activities that focus on accepting and enhancing the youth’s identity. These techniques help in the journey of a corrective relational experience through the therapeutic relationship, noting many having had negative social experiences (Davey et al., 2011; Lytle et al., 2015). Other clinical considerations therapists can utilize is to guide affirmation of identity with the youth, help reduce symptoms of gender dysphoria, and be supportive in the transition process when appropriate while considering specific needs (Spivey & Edwards-Leeper, 2019). This is especially important when noting that early medical and psychological interventions help the child fare best over time. Advocating for transgender youths in the broader contexts of their families and the community overall is also recommended.
Given the high levels of social isolation and eating disorder symptomology, many transgender individuals, especially girls and women, feel like they lack social support (Davey et al., 2011). Additionally, with high levels of gender dysphoria, social support/interpersonal connections, and self-esteem should be considered and integrated into care and treatment planning (Davey et al., 2011; Bouman et al., 2016). Positive psychology interventions have been shown to increase social connectedness while working with transgender folks, especially those who have had negative social experiences before coming into therapy (Lytle et al., 2015). Positive psychology interventions include activities such as gratitude exercises, assessing values, enhancing strengths, among others.
Considering family rejections are related to worse outcomes in the youths, intersectional family therapy can be utilized to assist in strengthen family understanding, connection, and support for the youths with their overall functioning and any comorbid diagnoses (Golden & Oransky, 2019). Supportive family therapy for transgender youths and their families might also be utilized. This consists of psychoeducation, community resources, advocating for any legal or educational needs, and assisting with setting familial boundaries (Bernal & Coolhart, 2012). A final consideration on the microsystem level when working with this population is school based interventions, as they have been shown to lower levels of victimization and absenteeism from school (Greytak et al., 2013).
Finally, noting the prevalence of technology in youths as well as the need for such technology with the COVID-19 pandemic, and the online community can act as a powerful tool for building connections and support for transgender individuals (Prinsloo, 2011; Shapiro, 2004). However, misinformation should be considered as many transgender youths and their parents reported going to the internet as their first stop for information. Thus, clinicians should be assessing for their client’s accurate knowledge of gender identity and information they get regarding health. Limiting access any gender non-affirming content online while providing appropriate resources and psychoeducation is necessary as well (Evans et al., 2017).
Although all of the above should be considered throughout working with this population, it is imperative that one does not generalize, and remember that the needs of this population are complex and can vary greatly on the individual level. Areas of intersectionality must be explored. This includes other identities existing within the individual, and concerns regarding the spectrum of sexual orientation and how all of these coexist and interact with, or are unrelated to, the eating disorder or other area of concern (Nagata et al., 2016). It is important to note that the scope of this review and current literature seems to focus on transgender boys/men and transgender girls/women, and there shows to be a gap in the literature related to nonbinary transgender folks. This should be considered when acknowledging clinical suggestions and areas for future research exploration.
Protective factors of transgender youth affected by eating disorders include family and school connectedness, a strong support system, and other social supports such as peers, so integrating this in treatment will be important (Watson et al., 2017). Despite the many challenges and obstacles this population faces on a day-to-day basis, resiliency is a common protective factor among trans folks. Ultimately, fostering connectivity to one’s gender identity and improving relational interactions may help in alleviating their diagnosis symptomology, increase experiential awareness, and facilitate unconditional acceptance of the self (McGuire et al., 2016).
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