Eating disorders don’t discriminate. They affect people across race, socioeconomic status, body size, sexual orientation, and gender identity—but the reality is that certain of these groups are more likely than others to develop an eating disorder. In particular, transgender and nonbinary folks face a mountain of risk factors, and eating disorder rates are significantly higher among these populations.
Consider just some of these stats: Transgender college students report experiencing disordered eating at about four times the rate of their cisgender counterparts; transgender high school students are nearly three times as likely to restrict eating, nine times as likely to use diet pills, and seven times as likely to use laxatives to control their weight as their cisgender peers. And 32% of transgender people report using their eating disorder to modify their body without hormone replacement therapy.
Given all this, it’s important for healthcare providers to be informed about eating disorders in transgender patients: how they might show up, the unique challenges trans patients face, their specific treatment needs, and more. Jessie Menzel (she/her), PhD, Equip’s VP of Program Development, answered some of the common questions providers have about eating disorders in transgender patients.
Do eating disorders look different in transgender patients than they do in cisgender patients? If so, how? Are there particular signs to look out for?
Eating disorder signs and symptoms are generally the same regardless of a person’s gender identity. However, eating disorders occur more frequently in transgender people.
What’s different about eating disorders in trans folx is that often the eating disorder serves a very specific purpose for them: many trans folx use extreme weight- and shape-control behaviors out of a desire to achieve a physical state that’s more in line with their gender identity. For example, by losing weight to maintain a more boyish frame or to suppress puberty and the development of secondary sex characteristics.
What are the risk factors that put transgender folks at increased risk of developing an eating disorder?
Trans people are at increased risk for developing an eating disorder for many reasons. The first is because these individuals are the subject of a considerable amount of stigma and discrimination in our society. The increased stress that trans folx experience from living in communities that are non-accepting, non-affirming, and—at times—outright hostile or violent towards them places them at increased risk for developing mental health issues in general.
Eating disorders, though, are a unique risk in this community because of the gender dysphoria that trans folx may experience. Gender dysphoria is the term used to describe the very significant stress that results from a discrepancy between a person’s gender identity and their assigned sex at birth. It should be noted, though, that not all transgender individuals experience gender dysphoria.
Often, a patient may not be out yet or may not be open about struggling with their gender identity. Figuring out that piece—that the eating disorder may be a person's way of responding to their extreme discomfort with their body because of their gender identity—can be crucial for successful treatment.
Are there certain questions I should ask if I’m concerned a transgender patient might be struggling with an eating disorder?
All transgender patients should be screened for eating disorders. While not perfect, we can still use our current screening tools—like the SCOFF or the NIAS—to quickly assess for the presence of an eating disorder. In particular, if your patient experiences gender dysphoria, be curious and inquire about any attempts the patient has made to alter their body or resolve their gender dysphoria.
Note that body image is an extremely complex issue in this community because of the double stress of living in a body that may not match one’s gender identity and the added stress of then having to live up to or match societal appearance standards for one’s gender identity.
What barriers and challenges do transgender patients face when it comes to getting eating disorder diagnoses and treatment?
Like many other marginalized communities, transgender individuals have faced significant hurdles and barriers to accessing care. Many of these people may be wary of seeking out help due to prior traumatic or stigmatizing encounters in healthcare and other settings. And more recently, legislative bans aimed at gender-affirming medical care may make it more difficult for trans folx to trust in healthcare establishments and seek out care.
While not outwardly related to eating disorder care, research has shown that inability to access gender-affirming medical care—either as the result of legislative bans or lack of parental consent—is a major risk factor for development of an eating disorder in transgender individuals. Lack of access to this care may then significantly hinder successful treatment. Access to gender-affirming care is so important for trans folx because it provides an affirming and safe way for them to address their gender dysphoria (if present), embrace their identity, and live authentically.
What kind of unique treatment needs do transgender patients have? What should I look out for when referring them to an eating disorder provider or program?
It is incredibly important that both potential providers and treatment centers be inclusive of transgender individuals with respect to representation, training, and programming. If you’re seeking in-person treatment, look out for clinics and treatment settings that are gender-inclusive in terms of their restrooms, rooming policies, and program offerings.
Some questions to ask: Does the provider or program have specific treatment approaches or programs for the trans community? Do they have providers or staff that have received specialized training in working with transgender patients or do they consult with outside specialists in gender affirming care? Significant experience with, knowledge of, or access to specialized supervision or training from folx who work with or are a part of this community will go a long way toward ensuring safe and effective treatment.
- Mary E. Duffy, Kristin E. Henkel & Valerie A. Earnshaw (2016) Transgender Clients’ Experiences of Eating Disorder Treatment, Journal of LGBT Issues in Counseling, 10:3, 136-149, DOI: 10.1080/15538605.2016.1177806
- Guss, Carly E. et al. “Disordered Weight Management Behaviors, Nonprescription Steroid Use, and Weight Perception in Transgender Youth.” Journal of Adolescent Health, Volume 60, Issue 1, p. 17-22, January 2017
- Duffy, M. E., Henkel, K. E., & Earnshaw, V. A. (2016). Transgender Clients’ Experiences of Eating Disorder Treatment. Journal of LGBT Issues in Counseling, 10(3), 136-149.
- Morgan, J F et al. “The SCOFF questionnaire: assessment of a new screening tool for eating disorders.” BMJ (Clinical research ed.) vol. 319,7223 (1999): 1467-8. doi:10.1136/bmj.319.7223.1467
- Zickgraf, Hana F, and Jordan M Ellis. “Initial validation of the Nine Item Avoidant/Restrictive Food Intake disorder screen (NIAS): A measure of three restrictive eating patterns.” Appetite vol. 123 (2018): 32-42. doi:10.1016/j.appet.2017.11.111
- Jones, Bethany Alice et al. “Risk Factors for Eating Disorder Psychopathology within the Treatment Seeking Transgender Population: The Role of Cross-Sex Hormone Treatment.” European eating disorders review : the journal of the Eating Disorders Association vol. 26,2 (2018): 120-128. doi:10.1002/erv.2576