Eating Disorder Treatment Often Excludes Transgender People

Trans people are much more likely to experience eating disorders, but current care systems overlook their unique needs and often do more harm. These advocates are working to change that.

Bee, a transgender, genderqueer person living in Portland, Oregon, once worked as a therapist serving trans, nonbinary, and intersex clients with eating disorders (EDs).

Now, they’re back in recovery from their own ED.

Bee, 36, was diagnosed with anorexia nervosa at 14 and entered recovery for the first time as a teen. They identified as recovered by their 20s, but during the COVID-19 pandemic, they said, they experienced “a full-blown relapse.”

Bee said their trans identity influences their ED, as it does for many people. Yet, they said that frontline ED treatment modalities often exclude, erase, or even harm trans folks in recovery.

Experts and advocates say that Bee is far from alone in feeling that way.

Trans people are more likely to experience eating disorders

Bee said their relationships with their body and food began to shift when puberty started.

“While I wasn’t necessarily cognizant of it at the time, looking back at it, there was definitely a lot of gender stuff at play,” they told Healthline. “I was just trying to take up as little space as possible.”

They said their gender dysphoria — extreme physical and emotional discomfort caused by perceiving your body as incongruent with your gender — continues to contribute to their ED.

Research suggests that trans people are much more likely to develop EDs and engage in disordered eating than cisgender people, and dysphoria likely plays a role (1Trusted Source2Trusted Source34).

A study including more than 289,000 college students, 479 of whom were transgender, found that rates of ED diagnoses and disordered eating behaviors were much higher among trans students (3).

More than 15% of the trans people surveyed reported ED diagnoses, compared with 0.55% of the cisgender, heterosexual men and 1.85% of the cisgender, heterosexual women (3).

Unpacking the disparity

While there are no clear causes of EDs in any population, several risk factors appear to contribute.

Trans people can contend with many of the same risk factors as cis people, such as trauma and food insecurity, but they may be more likely to experience them as a result of living in a transphobic society, according to Hannah Coakley, MS, RD.

Coakley is a nonbinary, queer dietitian who works with clients in ED recovery through their private practice, Pando Wellness, in New York. Nearly half their clients identify across the transgender spectrum.

Coakley said trans folks face additional social, environmental, and physical experiences that influence the rates of EDs. For example, while not all trans people experience gender dysphoria, many do — and they’re subjected to increased scrutiny of their bodies.

“There’s the felt sense of dysphoria, which makes being in your body very challenging, and I find a lot of eating disorders come from how the body is trying to adapt to overwhelming states of being,” Coakley told Healthline.

“You develop other methods of not being in the body, or blunting some sensations in the body, or blunting even physical development.”

— Hannah Coakley, MS, RD (they/them)

While cis people can experience body dissatisfaction, gender dysphoria is different. It’s often an “intolerable physical experience,” Coakley said — one that can make your body feel foreign, detached, or terrifying because it doesn’t align with your gender.

Gender dysphoria and body dissatisfaction can co-occur. The dysphoria element, though, is a trauma specific to trans and nonbinary people.

Many trans people lack social support to transition or access to the gender-affirming medical care — including puberty blockers, hormone replacement therapy (HRT), and surgery — that can help ease dysphoria.

As a result, disordered eating may emerge as an attempt to control a body’s gendered characteristics, according to Coakley.

For example, trans men and transmasculine people sometimes report restricting food intake in order to shrink body parts that induce dysphoria, such as hips or chests, or to stop menstruation (5).

It’s not just gender dysphoria itself: Transphobic discrimination and bullying may also affect EDs, especially among youth (67).

Where current eating disorder treatment may miss the mark

Although trans folks are disproportionately likely to experience EDs and disordered eating, they face prohibitive barriers to accessing treatment, ranging from financial obstacles to transphobia in care settings.

High costs and lack of insurance coverage

On average, the cost of inpatient ED treatment can range from $500–2,000 per day, and patients may need 3–6 months or more of care at that level. The cost of outpatient care may total more than $100,000 over time (8).

Bee is on Oregon’s state insurance, and they said there’s only one inpatient treatment facility in the state. However, Bee said the facility didn’t accept them as a patient.

When that treatment center didn’t pan out, Bee felt like they were out of options because their insurance wouldn’t cover alternatives.

“My parents actually ended up paying for my first month of residential treatment out of pocket, which is [ridiculous], and I was able to get private pay insurance that was helping me pay for it after that,” they said.

But Bee acknowledges that they come from an affluent family and have financial privilege that many people — especially many other trans folks — don’t.

Trans people are much more likely to live in poverty and much less likely to have adequate health insurance than cis people (9).

To help close these gaps, some advocates and organizations are working to provide free and reduced-cost options for LGBTQIA+ people seeking ED treatment.

Transphobia in treatment facilities

When trans people are able to access formal ED treatment, many report further issues that can impede healing.

It’s difficult to find trans-informed clinicians offering ED treatment. When clinicians don’t understand how gender dysphoria interacts with EDs, it can lead to a disconnect (7810).

Bee, as a former clinician and current patient, said that clinicians in ED treatment facilities engage in both direct and indirect transphobia.

For example, they said that many facilities require trans patients to have had expensive, physically demanding surgeries before allowing them to use the appropriate single-gender spaces. Plus, not all treatment centers offer gender-neutral spaces or allow access to HRT.

Bee said clinicians at one residential treatment facility regularly misgendered them and other trans people, including trans staff members.

They had to ask staff repeatedly for access to the all-gender restroom, and they said they were often ignored or even punished for their self-advocacy. At the same time, a trans woman Bee met during treatment was denied access to the women’s restroom.

“My safety was not taken into consideration as a trans person.”

— Bee (they/them)

When treatment centers meant to help people heal replicate the oppressive systems that contribute to EDs in the first place, the effects can be serious.

In one study, many trans people said they wished they’d never gone to ED treatment — even though they acknowledged that it had been lifesaving — because of the transphobia they experienced (7).

Where body acceptance falls short

ED treatment often relies upon body acceptance or body positivity frameworks: helping patients learn to be OK with their bodies.

However, these frameworks may not be helpful for many trans people — and can even harm them, as these approaches can lead to trans patients being asked to accept characteristics of their bodies that induce dysphoria (7811).

That’s why research suggests that ED treatment professionals consider gender-affirming medical care part of recovery for trans people who want or need it. Access to HRT seems to lower the risk of EDs for youth and adults (5812Trusted Source).

How eating disorder treatment can become more trans-inclusive

Understanding trans patients’ unique needs should be a top priority in ED treatment, according to Coakley.

They emphasize gender affirmation in their practice, recognizing that trans clients’ discomfort with their bodies may require a different approach.

For example, when working with a transmasculine client whose ED stemmed in part from a desire to reduce the appearance of their chest, Coakley led conversations about top surgery as a potential element of their recovery.

When periods have caused dysphoria, Coakley has discussed HRT and healthcare options known to help slow menstruation, such as intrauterine devices.

“The question always being, ‘How can we affirm, validate, and address it without being in an eating disorder?’” Coakley said. “What are some other ways to achieve congruence?”

They work with most of their clients on sliding-scale or pro-bono bases, since costs often make treatment inaccessible.

“It’s just affirming the experiences and trying to create a space where someone feels like they can show themselves love.”

— Hannah Coakley, MS, RD (they/them)

Additionally, Bee said that clinicians should challenge the transphobia, fatphobia, ableism, racism, classism, and other systemic forms of oppression within healthcare systems to create more inclusive care settings.

How to find resources and get involved

Bee is a member of Fighting Eating Disorders in Underrepresented Populations (FEDUP), a trans and intersex collective supporting marginalized folks with EDs.

FEDUP facilitates trainings for clinicians, connects trans folks with treatment through a dietitian match program, leads virtual support groups, supplies grocery funds to trans and intersex Black, Indigenous, and People of Color, and more.

The group also maintains a scorecard rating residential treatment centers for accessibility and keeps a list of trans-identified and trans-allied ED treatment professionals.

Other resources include:

  • Project HEAL: a nonprofit offering financial assistance for ED treatment, including direct funding and help with navigating insurance, especially for marginalized people
  • Trans Lifeline: the only trans-led helpline for trans and nonbinary people — Trans Lifeline is divested from police (meaning nobody you talk to will contact law enforcement on your behalf) and also offers microgrants for HRT and name change costs
  • National Eating Disorders Association: a large national organization that manages a helpline and has compiled a list of free and low cost support resources here
  • National Center for Transgender Equality: a large nonprofit connecting trans people to resources, including a list of sources offering financial aid
  • Resilient Fat Goddex: a blog by SJ, a “super fat, trans, non-binary, poor, neurodivergent, and queer” coach, consultant, and writer who also offers peer support groups and trainings for care professionals
  • Let’s Queer Things Up: a blog by Sam Dylan Finch, a trans person writing about ED recovery, mental health, and other topics
  • ThirdwheelED: a blog by OJ and CJ, two people writing about ED recovery “through a queer lens and (documenting) the dual perspectives of patient and nontraditional caregiver”

If you need HRT, this map compiled by Erin Reed, a trans activist, may help you find local informed consent clinics (meaning they won’t require therapists’ letters or other gatekeeping measures).

There are also remote care organizations operating across the United States, such as Folx Health and Plume.

One last thing

Trying to “do it right” when it comes to nutrition may feel tempting, but it can backfire. If you are preoccupied with food or your weight, feeling guilt surrounding your food choices, or otherwise struggling with nourishing yourself, consider reaching out for support. These behaviors may indicate a disordered relationship with food or an eating disorder.

FEDUP maintains a list of trans-identified and trans-allied clinicians who may be able to help. Other organizations listed above may be able to connect you with affirming care as well.

You can also check out Healthline’s guide to finding a healthcare professional who is an LGBTQIA+ ally and explore other trans health resources here.

Remember that disordered eating and eating disorders can affect anyone, regardless of gender identity, race, age, socioeconomic status, or other identities.

And you — no matter who or where you are — deserve support and the opportunity to heal.

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