Supporting Trans People with Eating Disorders: A Guide for Providers

In 2017, 37% of people said they knew someone who was transgender. By 2021, that number had increased to 42%.[1] We are currently seeing an increase in trans individuals seeking medical and mental health services. At the same time, we are seeing an increase in eating disorders, mental health concerns and suicidality in trans individuals. Bringing these issues to light and identifying ways to support the trans community may help to reduce some of the pain and challenges these individuals experience on a day-to-day basis.

Our hope today is to do justice to this incredibly important and time-sensitive topic by addressing the importance of providing gender-affirming care and support to transgender individuals with eating disorders. Whether we are treating patients with eating disorders or mental health issues, or both, we can only help our trans patients achieve the best outcomes when we provide gender-affirming care.

Gender-affirming eating disorder treatment

We firmly believe that transgender individuals have the right to be affirmed as their identified gender and to receive gender-affirming medical care and gender-affirming mental health care. Full stop. Throughout this piece, we will share stats and resources and offer support to eating disorder and mental health providers. We also hope that this piece helps to move the world closer to creating more safe spaces where people of all genders are welcomed and affirmed.

First, even though this might seem obvious to many of you, we want to clarify that being transgender is not a mental illness. We want to highlight the fact that being transgender is not a problem that needs to be fixed. Not all transgender people feel uncomfortable in their bodies, but many do.

Unfortunately, we live in a society where many people continue to deny, mock, and question the mere existence of trans individuals, creating distress, suffering, and gender dysphoria for millions of people who identify as trans.

Increased risk of eating disorders in trans folks

While all trans people will not struggle with their mental health or body image, the data are concerning. When compared to cisgender individuals (people who identify as the gender they were assigned at birth), transgender individuals are

• Four times more likely to experience a mental health condition (when compared to cisgender individuals) [2]
• Twice as likely to have depressive symptoms (when compared to cisgender lesbian, gay, bisexual, queer, and questioning youth) [2]
• Twice as likely to seriously consider suicide or attempt suicide (when compared to cisgender lesbian, gay, bisexual, queer, and questioning youth, who are all twice as likely to experience persistent sadness or hopelessness compared to heterosexual peers) [2]

While a genetic link (when a person in one’s immediate family has an eating disorder) is typically the primary risk factor for eating disorders, we see an increased risk of eating disorders in trans individuals due to multiple, additional, unique factors.

Eating disorders in transgender teens

First, let’s talk about trans youth. Adolescence is a time of blossoming gender identity and expression. All of us during this phase of life spend considerable time thinking about and crafting “who we are.” We work on (sometimes for many hours) our personal styles (hair, makeup, clothes, accessories), our voices, the ways we move our bodies, and the words we use to communicate.

During adolescence, we go through years of physical body changes while our hormones are also changing dramatically. During these years, we focus on the self, from time to time even asking, “Who am I?” This focus on our bodies and our identities can mean that we start to recognize that we have a body image. We can recognize that one’s body image is a construct.

For trans youth, when the body image doesn’t quite line up with who they want to portray in the world, like when a trans male begins to grow larger hips and breasts, gender dysphoria can arise. And it is extremely painful.

Gender dysphoria and eating disorders

Gender dysphoria is a clinical condition that is associated with high rates of discomfort or distress caused by a discrepancy between one’s gender identity and the sex they were assigned at birth. When a person has gender dysphoria, they may dislike certain parts of their bodies and have a strong desire to have been born and treated as their preferred/identified gender. This can cause a great deal of pain, stress, and anxiety because the world is imposing standards that negatively affect the way the individual feels about themselves. Should a trans youth experience bullying, gender dysphoria can worsen.

Yet the news is not all bleak. While we do see higher rates of depression, suicidality, and self-harm in trans individuals [3], the good news is that most trans people will not go on to develop serious eating disorders. More good news is that not all trans youth will develop feelings of low self-worth, depression, and anxiety. So, let’s explore both the risk factors that can increase mental health and eating disorder concerns and the protective factors that might reduce them.

Risk factors for eating disorders

Trans individuals face an increased risk of having future psychiatric issues (eating disorders, anxiety, depression, substance abuse). Yet this doesn’t just stem from having a genetic predisposition to having mental health concerns. Rather, a number of risk factors can increase the likelihood of a trans individual developing mental health concerns.

Being discriminated against as a trans person is its own risk factor that can lead to mental health concerns, and discrimination against trans people can take many forms, such as

• Harassment (sexual or otherwise); verbal, mental, or physical abuse
• Denying one’s preferred or identified gender
• Using the wrong name or pronouns of a trans individual
• Bullying, labeling, or teasing
• Denial of opportunities that others are given

These risk factors put affected trans individuals at greater risk for all mental illnesses, including eating disorders.

How to reduce the risk of suicide in trans folks

In a recent study reviewed by the American Academy of Pediatrics (AAP), it was found that when transgender youth received gender-affirming treatment, their risk of suicide decreased by nearly 70% [4]. Gender-affirming homes, gender-affirming schools, gender-affirming sports leagues, and gender-affirming health care practitioners can go a long way in helping trans individuals be seen, heard, and valued for who they are.

Additional protective factors shown to reduce the risk of mental health concerns and eating disorders in trans individuals include

• Social support, being with friends, having ongoing peer support
• A sense of family connectedness
• A sense of school connectedness

To deny transgender children these protective factors and to deny them the gender affirmation they seek and need will directly harm their lives and well-being.

Trans individuals: Increased risk for suicide attempts

Nearly half of all transgender adults have attempted to take their own life. We’ll say it again: 40% of transgender adults have attempted suicide [5]. That is almost nine times the attempted suicide rate for individuals in the U.S. [5]. Across the board, transgender adolescents experience self-harm, suicidal ideation, suicide attempts, and suicide planning in far greater numbers than their cisgender peers [6]. These facts are highly alarming and illustrate the need for increased mental health support in the trans community.

Transgender eating disorder treatment

Now that we’ve discussed how hard it is to grow up and live as a transgender individual in today’s world, we want to turn our focus back to how we as providers can help transgender individuals presenting with eating disorders and mental health concerns.

Can an eating disorder be used to affirm one’s gender?

The first topic we want to address related to eating disorders in trans individuals may be surprising: Some transgender individuals engage in eating disorder behaviors as an attempt to both change their body and affirm their identified gender. And it is our responsibility to better understand this.

Trans individuals may use weight loss or manipulate their body to

• Suppress or accentuate certain characteristics associated with their identified gender
• Avoid gender-affirming surgery or having to undergo hormone replacement therapy
• Be seen as more androgynous
• Avoid being sexually objectified

Here are some examples of what this might look like in practice.

Trans masculine body image

The drive to change one’s body to look more masculine would include wanting to reduce curves, lose periods, and lose breasts. By engaging in eating disorder behaviors and modifying their bodies, their goal is to appear more masculine as an intent to reduce gender dysphoria and distress.

Trans feminine body image

The drive to look more feminine is often a quest for thinness. But it’s not always about being thin; we often see that the intent is to fit in socially with feminine peers. In these groups, eating disorder symptoms may be more likely to provide social reinforcement by saying words like, “Does this make me look fat?” or “That food has too many calories.”

Diagnosing eating disorders in trans individuals

As eating disorder professionals, we must ask ourselves if the person we see in our office has a true eating disorder or sub-threshold eating disorder behaviors that are intended to increase acceptance and affirmation as their identified gender. Is the eating disorder about losing weight or is it about aligning with one’s identified gender?

Additionally, if your patient presents with sub-threshold eating disorder behaviors, consider screening them to understand if they are using eating disorder behaviors to

• Avoid having to come out (thus avoiding rejection from community/friends/family)
• Deal with stress and ongoing microaggressions
• Feel more in control
• Express autonomy
• Deal with the oppression they feel as a marginalized person

While it’s important to tease out whether a trans individual is using eating disorder behaviors to seek gender affirmation or avoid gender dysphoria, we must always clinically act in a way that is best for our patients.

Benefits of gender-affirming treatment for trans individuals

Here’s one of our favorite data pieces to share.

When trans individuals take part in gender-affirming gender reassignment and gender dysphoria treatment, there is often a reduction in eating disorder behaviors. When one’s gender is affirmed and gender dysphoria is reduced, eating disorder symptoms decrease [7-9].

Isn’t that amazing? Treating underlying gender dysphoria is critical to supporting the health of transgender individuals, and this is supported by the data [10, 11]. By starting hormone treatment and gender-affirming surgery, body dissatisfaction decreases along with eating disorder symptoms [12-14].

This is why we are so heartbroken that state governments around the U.S. are trying to create laws that would prohibit medical and mental health providers from providing gender-affirming treatment. But we will never lose hope. By becoming gender-affirming practitioners, we can help our trans patients grow and heal.

Family-based treatment for trans youth with eating disorders

Here at Eating Recovery Center, we believe, and research has indicated, that the core tenets of family-based treatment (FBT) are essential to helping people recover from eating disorders. When it comes to trans youth, however, we must be cautious. We cannot assume that trans teens are fully supported by their family. We cannot assume that families will affirm their child’s preferred gender, name, and pronouns. If the trans patient does not feel affirmed, respected, and seen, they may struggle to do hard work with their family of origin in a family therapy setting and eating disorder recovery may stall.

Creating a warm and accepting environment in treatment is an essential component to support recovery.

For FBT and Emotion-Focused Family Therapy (EFFT) to work, the family must be in a place where healing can occur. Keep the options open for trans patients to work with a “family of choice” if their “family of origin” is not affirming because, while we do put some individual life activities on hold during treatment, we don’t want to put a patient’s gender development on hold.

How to support trans individuals with eating disorders

As we wrap up today, we want to thank our patients who are willing and brave and vulnerable to share their lives with us. We thank the families and friends who support trans individuals. And we thank you for expressing interest in learning more about this topic. We can learn from each other with the ultimate goal of improving the quality of care for the transgender community.

While we share just a select few resources here, we invite you to learn more about how to implement best practices in treatment and to find even more resources to support your work with transgender individuals online at the live courses link shared below. In our online webinar on this topic, we share more screeners that you can use in your practice, along with specific strategies that can help you work more effectively with trans individuals with eating disorders. It's packed with information, so we encourage you to watch the webinar in full.

Screen all patients for gender and sexuality concerns

Our recommendation when working with patients who need help for eating disorders or mental health concerns is to screen every patient regarding issues related to gender identity and sexuality. Why? The information you get from this screening can help you apply more effective strategies for therapeutic intervention.

Screen all patients with gender dysphoria for eating disorders and vice versa

Further, every patient you talk to who has gender dysphoria should be screened for eating disorders. Every patient you see for an eating disorder should be asked about gender dysphoria.

An example of a question that you might consider asking would be, “From head to toe, what do you like/not like about your gender?”

Provide an LGBTQ+-affirming environment

Take time to create an affirming space. Wear pride flags on your clothing or as accessories. Put pride flags up in your office, outside, and on your website. Display photos or marketing materials that showcase diverse individuals, same-sex couples, and transgender individuals. It makes a difference!

Thank you for reading. We do all this amazing, rewarding work because the risk of not affirming our patients is just too high. And if your patients are looking for ongoing eating disorder or mental health support, please refer to our nationwide support groups.

From the Authors: We are not members of the trans community and not experts in all things LGBTQ+. We are allies and scientists who listen to data on health disparities and inequalities, and we are passionate about improving the state of mental health care.

We would like to acknowledge our transgender patients and their families, caregivers, other support humans and advocates who make their world peaceful, just and validating. With this blog, we hope to share some information and experience gleaned in order to increase our collective ability to learn and grow.

This blog was based on our continuing education course, “Gender Dysphoria and Eating Disorders: Understanding and Improving Care for Transgender Individuals with Eating Disorders,” presented by Anne Marie O’Melia, MD, MS, FAAP, CEDS-S (she/her). If you’d like to view this webinar along with many other behavioral health topics, we invite you to learn more about our accredited continuing education program and get free access to our entire continuing education library.

View all of our upcoming live courses here.

Glossary

Gender nonconformity — The extent to which a person’s gender identity, role, or expression differs from cultural norms for people of that same sex. Gender nonconformity does not equal gender dysphoria. Many who are gender nonconforming do not have gender dysphoria.

Sex – Said to be chromosomal yet sex is assigned at birth based on outward genital appearance (female, male, intersex, or other)

Gender – A social construct based on cultural roles, behaviors, and external pressures; changes over time (one identifies as female, male, nonbinary)

Gender identity – An inward sense of self; cis or trans (female, male, nonbinary, gender queer, gender fluid, agender, gender expansive)

Gender expression – One’s outward presentation to others, often dependent on cultural and societal norms; varies depending on culture and community (feminine, masculine, other)

This piece was updated on June 23, 2023 and clinically reviewed by Allison Chase, PhD, CEDS-S, regional clinical director at Eating Recovery Center on June 16, 2023.

Read These Next

• The ERC LGBTQ+ Resource Guide
• Body Dysmorphia in Gay Men
• The Journey of Transgender Recovery

Sources

1. Minkin, R., & Brown, A. (2021). Rising shares of U.S. adults know someone who is transgender or goes by gender-neutral pronouns. Pew Research Center, July 27. https://www.pewresearch.org/fact-tank/2021/07/27/rising-shares-of-u-s-adults-know-someone-who-is-transgender-or-goes-by-gender-neutral-pronouns/.

2. National Alliance on Mental Illness: LGBTQI: https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI.

3. Connolly, M.D., Zervos, M.J., Barone, C.J., Johnson, C.C., & Joseph, C.L. (2016). The mental health of transgender youth: Advances in understanding. Journal of Adolescent Health, 59(5), 489-495.

4. Turban, J.L., King, D., Carswell, J.M., & Keuroghlian, A.S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).

5. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC, National Center for Transgender Equality.

6. Thoma, B.C., Salk, R.H., Choukas-Bradley, S., Goldstein, T.R., Levine, M.D., & Marshal, M.P. (2019). Suicidality disparities between transgender and cisgender adolescents. Pediatrics, 144(5), e20191183.

7. McClain, Z., & Pebbles, R. (2016). Body image and eating disorders among lesbian, gay, bisexual and transgender youth. Pediatric Clinics of North America, 63(6), 1079-1090.

8. Nagata, J.M., Ganson, K.T., & Austin, S.B. (2020). Emerging trends in eating disorders among sexual and gender minorities. Current Opinions in Psychiatry, 33(6), 562-567.

9. Avila, J.T., Golden, N.H., & Aye, T. (2019). Eating disorder screenings in transgender youth. J of Adolescent Health, 65(6), 815-817.

10. Milano, W., Ambrosio, P., Carizzone, F., De Biasio, V., Foggia, G., & Capasso, A. (2020). Eating disorders and body image: An overview. Endocrine, Metabolic & Immune Disorders Drug Targets, 20(4), 518-524.

11. Testa, R.J., Rider, G.N., Haug, N.A., & Balsam, K.F. (2017). Gender confirming medical interventions and eating disorder symptoms among transgender individuals. Health Psychology, 36(10), 927-936.

12. de Vries, A.L.C, Doreleijers, T.A.H., Steensma, T.D., & Cohen-Kettenis, P.T. (2011). Psychiatric comorbidity in gender dysphoric adolescents. Journal of Child Psychology and Psychiatry, 52(11), 1195-1202.

13. de Vries, A.L., McGuire, J.K., Steensma, T.D., Wagenaar, E.C., Doreleijers, T.A., & Cohen-Kettenis, P.T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.

14. Jones, B.A., Haycraft, E., Bouman, W.P., Brewin, N., Claes, L., & Arcelus, J. (2018). Risk factors for eating disorder psychopathology within the treatment seeking transgender population: The role of cross-sex hormone treatment. European Eating Disorders Review, 26(2), 120-128.

This page was updated and clinically reviewed by Allison Chase, PhD, CEDS-S, regional clinical director at Eating Recovery Center on June 16, 2023.