Sam Sharpe, ORISE Fellow
Office of the Assistant Secretary for Health

While awareness of eating disorders in diverse populations is increasing, treatment programs and facilities sometimes struggle to provide appropriate and adequate care for all demographics. LGBTQIA+ individuals, in particular, often face barriers to receiving appropriate eating disorder treatment, including struggling to afford more intensive treatment options and sometimes going undiagnosed or misdiagnosed due to inadequate provider education. The second part of this blog post on eating disorders in LGBTQIA+ populations will further explore these issues in line with the 2024 NEDAW theme of “Let’s Talk about It: Eating Disorders, Stigma, and Empowered Recovery.”

Providing an Inclusive Environment for Treatment

LGBTQIA+ individuals who do access eating disorder treatment may encounter additional issues, such as body image interventions that focus on appearance ideals and pressures that impact heterosexual, cisgender women, which do not address the body-related pressures that people of other genders and sexualities face. There may also be assumptions about eating disorders being driven by the desire to be attractive to potential heterosexual partners, which is not a relevant factor for all individuals.

Some recovery-focused messages emphasize accepting one’s body exactly how it is without trying to change it, which can be exclusionary and harmful for transgender and nonbinary individuals who may need to access gender-affirming medical procedures such as hormones or surgeries as part of their comprehensive care needs. It may be more supportive for providers working with these populations to emphasize a more neutral and dynamic relationship with one’s body and body image, rather than using a one-size-fits all approach that demands unconditional acceptance of one’s body and appearance. This could include focusing on building skills and practices to enable meeting basic physical needs and maintaining positive habits, which can be more accessible to individuals experiencing gender dysphoria and while in any stage of pursuing gender-affirming care.

There may also be issues with some inpatient or residential treatment facilities not having inclusive roommate policies or bathroom facilities that accommodate transgender and nonbinary patients. It can also be alienating for LGBTQIA+ individuals in group-based treatment and therapeutic settings if most of the other patients and providers do not share their identities and do not understand or relate to their experiences of sexual orientation or gender identity. These challenges and feelings of alienation can be even more complex and difficult to navigate for individuals who are part of multiple groups underserved by eating disorder treatment, including LGBTQIA+ people of color, LGBTQIA+ individuals who live in larger bodies, and disabled LGBTQIA+ individuals.

Treatment Considerations for Healthcare Providers

Many providers who treat eating disorders frequently do not receive adequate education about working with LGBTQIA+ populations, which can result in reduced quality of care for these patients. Eating disorders can result in a variety of physical health risks, including some which are life-threatening.

Many of the metrics used to assess health status and severity of complications in eating disorder patients are based on reference ranges for cisgender, non-intersex men and women. This includes growth charts, laboratory values, menstrual status, bone density, and more. However, transgender, nonbinary, and intersex individuals may have different or unknown baseline values for these metrics due to congenital differences, gonadectomies, and/or hormone replacement therapy, and providers may be uncertain of which ranges and values to use for these populations in eating disorder treatment. For example, providers may not have received training on how to determine if a patient’s irregular menstrual cycle is due to their eating disorder or their intersex variation, whether a patient on hormone replacement therapy has nutritional needs closer to a cisgender man or a cisgender woman, or how to assess anemia if they do not know whether to compare a patient’s iron levels to the standard male or female range.

Another factor that may precipitate or maintain eating disorders for transgender and nonbinary individuals is the restriction of access to gender-affirming surgeries for individuals above a certain body mass index (BMI). There are no standardized guidelines for BMI cutoffs for gender-affirming surgeries, and some individual surgeons or surgery centers have established their own BMI criteria for these procedures, thus only operating on patients who are under a specified BMI cutoff. Access to these types of surgeries can be difficult for many transgender and nonbinary individuals for a variety of other reasons, including geographic location, cost, and insurance coverage, and the addition of BMI-based restrictions may significantly further restrict access for some individuals needing these procedures. Some transgender and nonbinary individuals begin or continue engaging in disordered eating behaviors or develop eating disorders or feel unable to pursue eating disorder recovery as a result of pressure to lose weight in order to access these surgeries. Overlooking these concerns and complexities can prevent these individuals from receiving appropriate, supportive, and comprehensive care.

Understanding and Avoiding Assumptions to Provide Quality Care

Some providers may be unfamiliar with the unique factors discussed above that may contribute to eating disorder development in LGBTQIA+ populations or may believe that they are not relevant. In contrast, other providers may assume that for every LGBTQIA+ individual with an eating disorder, their disorder must be related directly to aspects of their LGBTQIA+ status. This can be especially problematic for transgender and nonbinary individuals.

Some providers may believe that these individuals must fully recover from their eating disorders before they can begin to receive gender-affirming care, even if their eating disorder developed in response to issues of gender dysphoria, which cannot be resolved without access to this type of care. In other cases, providers may assume that gender-affirming care would eliminate the cause of a transgender or nonbinary person’s eating disorder and that no eating disorder-specific treatment would be needed once this care is accessed. Providers need to understand that eating disorders may interact with transgender and nonbinary individual’s experiences of gender dysphoria, transphobia, and pressures to achieve gendered body ideals in complex ways. Denying individuals access to gender-affirming care until they have recovered from an eating disorder can be very counterproductive, but it is also not helpful or accurate to assume that this type of care can replace the need for eating disorder treatment. Some trans and nonbinary individuals may also have eating disorders for reasons completely unrelated to their gender identity. It is always important to provide eating disorder care that is individualized and patient-centered rather than based on assumptions or stereotypes.

In order to increase awareness and access to competent care, it is vital for LGBQIA+ individuals with eating disorders, other individuals in their lives, and providers of eating disorder care to have a well-informed understanding of how these disorders can develop and what appropriate and supportive care for these populations can look like.

To learn more, check out the resources below. If you missed part 1 of this blog series, you can access it here.

Resources to Learn More

• Guidelines for research with transgender, gender diverse, and intersex individuals with eating disorders: recommendations from trans and intersex researchers
• Body Mass Index Requirements for Gender-Affirming Surgeries are not Empirically Based
• Nutritional considerations for gender-diverse people: a qualitative mini review
• Medical considerations in the care of transgender and gender diverse patients with eating disorders