How is eating disorder treatment different for transgender and nonbinary clients?
Considering treatment for your eating disorder at any level of care – inpatient, PHP/IOP, or outpatient, can be scary, and it can be even more terrifying as a transgender or nonbinary person. You have a sense that eating disorder care that is gender affirming is important to your recovery, but perhaps you also sense that truly affirming care is hard to come by. And what does gender affirming eating disorder care actually look like in practice? Is finding that kind of care even possible?
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Eating disorder treatment that centers transgender and nonbinary clients focuses on identifying and then addressing aspects of the eating disorder that are related to gender or gender dysphoria. Eating disorders are often best understood as coping skills that people rely on in moments of loss of control, stress, and emotional dysregulation in order to regain a sense of control and stability. Eating disorders are especially prevalent coping skills among marginalized communities due to minority stress – in other words, racism, homophobia, and transphobia heighten stress and thus increase the likelihood folks impacted by these forms of oppression will develop an eating disorder to cope. And at the same time, eating disorders are often underdiagnosed in people who are not cisgender, heterosexual white women because they may not fit the traditional narrative of what an eating disorder “looks like”. Many people, even some therapists, still think of eating disorders as conditions of vanity. They picture a thin cis white woman who attempts through restriction to be even thinner so she can fit a certain idea of beauty. But eating disorders are much more varied and complicated than that, especially for transgender and nonbinary people.
Someone who is transgender or nonbinary might struggle with gender dysphoria and a persistent sense of lack of control over how others perceive their gender, and they might turn to their eating disorder to lend that sense of control. If someone is trans and/or nonbinary and bothered by how their body distributes fat in a way that produces dysphoria, it may feel to them that their eating disorder offers the perfect solution – simply restrict or purge to eliminate fat and thus eliminate the dysphoria. To make matters worse, we exist in a world where gender-affirming care is becoming increasingly difficult to access due to political and legal attacks, as well as threats to the safety of transgender and gender non-conforming people. So for many, turning to an eating disorder may feel like a much more accessible tool to manage dysphoria than accessing the healthcare that transgender and nonbinary people deserve. And a lot of the time, trans and nonbinary folks may be turning to their eating disorder due to the stress of navigating a transphobic world without even being consciously aware of the role their eating disorder plays.
So, gender-affirming treatment focuses on exploring the way that gender is intertwined with disordered eating. A gender-affirming eating disorder therapist helps the transgender or nonbinary client explore their sense of their gender, their values around gender, and how they want to present their gender. We help the person answer questions like “what have I internalized about what my gender ‘should’ be or look like vs. what does gender actually mean to me?” and “what helps me feel safe in my body and in my expression?”. We explore the reality of living in a transphobic and fatphobic world and help the person identify how they can balance physical and emotional safety with being able to live in line with their values and desires as a transgender person. And then, if gender-affirming care is part of the equation for the person, we focus on helping them access gender-affirming care, whether it be HRT, FFS, top surgery, or another form of care.
While we are doing this, gender-affirming eating disorder therapists also treat the eating disorder through helping the transgender or nonbinary client learn to recognize the eating disorder’s function and build alternative coping skills, just as in any other eating disorder case. And as treatment progresses, we help the client note the impact of addressing gender dysphoria on the eating disorder. Many times, simply unpacking internalized transphobia and beginning to shift gender presentation in ways that align with the client’s values can reduce eating disorder symptoms and behaviors. If we can address the very issue the eating disorder is helping us cope with by minimizing gender dysphoria, internalized transphobia, and a lack of safety, that lessens the need for the eating disorder in the first place.
Looking for a gender-affirming eating disorder therapist? My name is Gabby Collins, LCSW, and I am both a nonbinary lesbian and a licensed therapist in Los Angeles, California that specializes in treating eating disorders in transgender and gender diverse tweens, teens, and adults. I see folks in-person in Los Angeles and virtually throughout the state of California. If you’re curious about working together, click the button below to schedule a free consultation with me.
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