Eating Disorders in LGBTQIA+ People May Require More Focused Care
Popular media coverage might have you believe that the average eating disorder patient is a white woman, particularly a heterosexual one. But a wide array of studies, surveys and reviews have found that eating disorders are, in fact, more pervasive in the LGBTQIA+ population, affecting people of a wide variety of gender identities. These more vulnerable patients, however, are less likely to receive effective care.
"A social justice lens is necessary to understand the structural discrimination and unfit care these systems provide [as well as] the roots of diet culture and beauty standards and the need for trauma-informed care and harm reduction," explained Cody Esterle, a member of Fighting Eating Disorders in Underrepresented Populations: A Trans+ & Intersex Collective (FEDUP).
Factors such as race, class, gender, sexual orientation and ability influence access to care and treatment. They can also influence how likely someone is to have disordered eating habits, as suggested by the minority stress model, which posits that minorities face ongoing stressors such as discrimination that adversely impact health.
"Disordered eating behaviors are often a coping mechanism to manage living in a society that oppresses marginalized folks," Esterle continued.
Higher rates of eating disorders
A 2020 review of research on eating disorders and disordered eating behavior among the LGBTQIA+ population published in the Journal of Eating Disorders confirmed both clinical eating disorders and eating disorder behavior occur more frequently among LGBTQIA+ youth and adults than their heterosexual and cisgender (cis) counterparts.
According to the review, 54 percent of LGBTQIA+ adolescents have been diagnosed with a full-syndrome eating disorder during their lifetime, with 21 percent suspecting they had an eating disorder at some point. Trans youth were more likely to have eating disorders than cis youth.
For some LGBTQIA+ individuals with eating disorders, the behavior is related to the trauma of living in a society that oppresses them, said Emil Smith, a member of FEDUP and a clinical social worker in Pennsylvania who is pursuing a doctorate in social work at the University of Pittsburgh.
"Disordered eating is also a coping strategy for managing stress and trauma," Smith explained. "TGDI [trans, gender diverse and intersex] folks experience elevated levels of physical violence and sexual violence."
What eating disorder treatment misses
For some people, eating disorders and disordered behavior may stem from gender dysphoria, a sense of unease around the mismatch of assigned gender at birth and gender identity.
"Research has focused on how eating disorders are a strategy that trans folks use to make their body more in alignment with their gender and reduce gender dysphoria. This may be true for many trans folks, however, this is only part of the picture," Smith explained. "Living in invalidating environments exacerbates gender dysphoria."
Gender-affirming care is typically not provided in conjunction with eating disorder care, a major failure for TGDI patients.
"A common experience I hear about from clients is using eating disorder behaviors to find relief from gender dysphoria," said Hayden Kapalka, also a member of FEDUP and an eating disorder recovery coach at Body Roots in Bellingham, Washington. "This seems to show up frequently for clients that do not have access to gender-affirming resources, such as hormone therapy."
Eating disorder treatment centers, in turn, typically fail to care for TGDI patients adequately.
"One [failure] that I have often seen is providers who gatekeep letters of support, which helps clients gain access to gender-affirming surgeries and/or medications, because the provider believes that the desire for medical changes stems from the eating disorder," Kapalka noted.
'Living in invalidating environments exacerbates gender dysphoria.'
"In some cases, hormones and other gender-affirming needs will be inaccessible in treatment centers and treated as separate facets of someone's health," Esterle added.
A 2016 study, published in the Journal of LGBT Issues in Counseling, surveyed 84 transgender and gender-diverse people with eating disorders. None of the participants reported a positive experience with eating disorder care. Indeed, 40 percent of the participants did not disclose their transgender identity to clinicians. Participants who chose to disclose faced dismissal, stereotypes and bewilderment from clinicians. Study authors asserted that despite the prevalence of eating disorders among transgender individuals, clinicians and treatment centers may be ill-prepared to treat transgender patients.
"When trans individuals take part in gender dysphoria treatment, there is often a reduction in eating disorder behaviors," said Anne Marie O'Melia, M.D., chief medical and clinical officer for Eating Recovery Center, based in Denver.
Traditional eating disorder treatment commonly fails to consider the unique challenges LGBTQIA+ individuals face in relation to their bodies. For example, some eating disorder treatment centers include a body positivity or neutrality approach, enforcing body acceptance as a modality for eating disordered behavior. Body acceptance as a therapeutic tool fails to encompass the experiences of trans or gender-diverse individuals, or anyone with gender dysphoria.
Excluding LGBTQIA+ individuals
Eating disorder care is often unwelcoming to LGBTQIA+ individuals, even before they arrive at the front door.
"On a structural level, administrative processes consistently exclude LGBTQIA+ folks," Esterle explained. "The structural restrictions of healthcare and health insurance continuously use binary markers for sex [and] don't include options for genders, pronouns and name. As a part of that system, providers and healthcare systems put the burden on LGBTQIA+ folks to advocate for themselves while getting continuously misgendered, deadnamed and receiving improper care, rather than advocating for change and changing their policies, systems and trainings to include these populations."
Gender-based rooming policies create an obstacle, too, as TGDI people have a harder time finding a bed for treatment stays, Smith noted. Many trans people avoid medical care altogether because they are afraid they will experience discrimination.
Weight stigma keeps many people from receiving needed care, posing dangerous health consequences.
For example, Smith referred to conditions described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-4), which classifies disorders and defines diagnostic criteria.
"Atypical anorexia nervosa [AAN]—anorexia that doesn't meet the DSM-4 diagnostic criteria for anorexia because of the DSM-4's focus on low BMI [body mass index]—goes untreated for long periods of time, despite evidence that shows it is just as deadly as AN [anorexia nervosa] and causes long-term health consequences," Smith said.
While the DSM-5 now includes atypical anorexia, in practice, weight stigma in eating disorder care is still pervasive.
"People with AAN have described how their medical providers have praised their weight loss and told them that their eating disorder 'wasn't serious enough to need treatment,'" Smith continued.
Cost and insurance coverage also create access disparities.
"Many eating disorder treatment centers do not accept Medicaid, and it can even be expensive with the co-pays required of private insurance," Smith noted. "Often, services that support recovery—such as ongoing nutrition counseling, outpatient therapy and working with an eating disorder coach—are not covered by insurance."
What inclusive treatment looks like
Shifting healthcare to be inclusive and address eating disorders in LGBTQIA+ people involves an entire restructuring, Esterle explained. Eating disorder treatment centers often have no mandatory training to provide affirming care to LGBTQIA+ patients.
"In the current context of care, providers can start by educating themselves on trauma-informed care, harm reduction and fatphobia, and working with marginalized communities to address and understand how their systems and treatment exclude others—and how to start changing them," Esterle said.
"Taking steps towards understanding eating disorder medical knowledge, such as body dysmorphia, body image, relapse [and] nonlinear recovery through the lens of underrepresented and marginalized communities, is crucial in creating inclusive treatment plans," he added.
Developing an inclusive environment means more than adorning a treatment center's website with a rainbow flag.
"Inclusive care means creating care for all individuals, all identities and all backgrounds," Esterle continued. "This doesn't mean implementing one-time training and leaving the burden on marginalized communities to advocate for themselves and educate their providers on their own health, most of which never have the opportunity to."
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