Identifying & Treating Eating Disorders Among Transgender Clients - A Conversation with FEDUP Collective’s Emil Smith

Identifying & Treating Eating Disorders Among Transgender Clients – A Conversation with FEDUP Collective’s Emil Smith

Est. reading time: 6 mins
Posted Under: Interviews

Clinically Reviewed by: Amanda Fialk, PhD, LCSW, LICSW

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This post is based on a virtual roundtable event hosted by The Dorm and features a conversation with Emil K. Smith of FEDUP, a collective of trans+, intersex, and gender-diverse people who believe eating disorders in marginalized communities are social justice issues. 

Transgender and gender-diverse youth are uniquely at risk for eating disorders, and report experiencing eating disorders at about four times the rate of their cisgender classmates. Therapists attribute this to discrimination-based stress, the desire to suppress the body’s changes as they experience body dysmorphia, and even as a measure of control in the absence of gender-affirming medical care: for example, eating less to stop having their period. 

To learn more about how affirming mental healthcare can support TGD youth, we were honored to be joined by PhD candidate Emil K. Smith, whose experience as a behavioral health consultant led them to an enhanced understanding of trans-affirming medical and mental health practices. They are now a Ph.D. student focused on the treatment of transgender and gender diverse (TGD) individuals with eating disorders (EDs), with an emphasis on the barriers and facilitators to care.

Emil’s work with the FEDUP Collective, which stands for Fighting Eating Disorders in Underrepresented Populations, helps to expose and highlight the prevalence of eating disorders among the TGD community and provide support and a safe space for these individuals. 

Barriers to Care

As a precursor to understanding how care providers can support trans young adults, Emil describes several barriers to care that TGD young adults commonly face:

  • Many doctors have a BMI limit to perform gender-affirming surgery, which can lead a TGD individual to develop disordered eating behaviors. 
  • Eating disorders can be underdiagnosed if someone doesn’t look or feel “sick enough.” For example, an individual may experience many disordered eating behaviors but still have a healthy weight. For individuals who are seen as “not sick enough,” it can be much more difficult for them to get the care they need.
  • Eating disorders may go undiagnosed if they’re seen as a symptom of gender dysphoria, and “[Medical] transition is not necessarily a cure for eating disorders,” says Smith.

Prevention & Early Detection

Smith emphasized two keys to better TGD treatment: prevention and early detection. 

Prevention involves having open discussions around food that can help someone feel more comfortable talking about their own experiences, and help detect unhealthy behaviors before they can escalate further. 

When therapists or loved ones do approach food conversations with TGD young adults, it’s also important to talk about it in the context of transition-related goals, such as emphasizing the importance of nutrition when it comes to hormone treatments. Another supportive role they can take is to talk about and encourage healthy coping mechanisms that they can fall back on in times of stress instead of disordered eating. 

Supporting an individual is key in their treatment and therapeutic process. Building a support system (like connecting individuals to a community and peer support), harm reduction, and just listening to the person will help immensely. Keeping the person at the center and respecting their autonomy is essential to recovery.

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Finally, Emil notes that everyone’s recovery process is different. Gender-affirming care may indeed provide many benefits toward eating disorder recovery and the goal of treatment should be to meet the client where they’re at and continue to hold that change is possible.

Supportive Language

In terms of treatment, different languages can also be used to better support TGD individuals. The following language conventions are an important place for therapists and caregivers to start: 

Important Definitions

  • Gender dysphoria: distress from the incongruence between how a person’s gender is perceived and their internal experience of their gender.
  • Body dysmorphia: distress due to one’s distorted perceptions of flaws/defects of the body.
  • Body dissatisfaction: feeling worthless due to perception of body, hating body, etc.
  • Gender euphoria: distinct enjoyment or satisfaction caused by the correspondence between the person’s gender identity and gendered features that are affirming to their identity.

Gender is a Spectrum

Gender is currently understood as a spectrum, where many identities fall outside of the male-female binary, such as genderqueer, genderfluid, and intersex, and language around gender is always evolving, and will continue to evolve. It is important to try to always use language that is most comfortable for the individual. 

Body Neutrality > Body Positivity

Smith emphasizes that instead of “body positivity,” terms like “body neutrality” and “body liberation” may be more appropriate for transitioning clients. For example, instead of “you don’t need to change your body,” it could be more beneficial to use the phrases “bodily autonomy,” and “body change acceptance.”

Mirroring Language

This involves using the language that someone uses to self-identify. If they identify as a “trans person,” it is appropriate for people to also use the term “trans person” when talking about them. And, of course, use their pronouns!

Person-centered Language: 

Instead of saying “She is a transgender” or “She is transgendered,” it is more respectful to say “She is a transgender/trans person.” 

Specific Language Around Transitions

Transitioning may look different for each individual and there are several types of transitions, including social transition, medical transition, or legal transition. No matter how a person transitions or where they are in their process, there is no such thing as “not trans enough.” 

Supportive Resource for Trans Clients Facing Eating Disorders

Many of the resources available for eating disorder treatment were not made specifically for trans people. For example, the EDE-Q and EDE-QS are validated tools for measuring eating disorder symptoms, but may not encompass the issues unique to TGD individuals, such as dysphoria or dysmorphia. These resources can be very helpful in the recovery process, but it is vital to take into account that they may not have fully considered trans people during their creation.

Emil outlines several resources they’ve found supportive of trans clients and other underrepresented groups:

  • Fighting Eating Disorders in Underrepresented Populations (FEDUP) Collective: a collective of trans+, intersex, and gender-diverse people working to bring attention to the disproportionate amount of EDs among the TGD population. 
  • Association for Size Diversity and Health (ASDAH): a nonprofit organization dedicated to celebrating bodies of all shapes and sizes, helping oppressed communities have equal access to health and well-being. 
  • Nalgona Positivity Pride (NPP): an organization focused on meeting the needs of BIPOC individuals affected by eating disorders, supporting communities through art, education, and activism. 
  • Project HEAL: an organization featuring programs that address and break systemic, healthcare, and financial barriers to eating disorder care, providing support to those who do not have access to treatment. 
  • Body Reborn: an intersectional healing community for people of color with disordered eating, joining Project HEAL to expand access to equity-focused care.

How The Dorm Approaches and Provides Affirming Eating Disorder Treatment and Care

Our Holistic Model of Care

At The Dorm we provide young adults with an affirming and inclusive community model that supports clients struggling with disordered eating with a multi-pronged approach, which includes comprehensive assessment and an individualized treatment plan including individual therapy, clinical coaching, and group therapy. 

All of our therapists and clinical coaches are well-versed in working with clients struggling with food and identity, and are kept aware of evolving language and therapies available for trans young adults through our ongoing DEI trainings and initiatives. Today, about 5% clients in our care are transgender and 44% who are LGBTQ+. 

In addition to clinical work, our dedicated Health & Wellness team is well versed in treating eating disorders and collaborates with each client’s clinical team to focus on food, movement, and body image. 

Our Nutrition Philosophy

Our nutrition policy utilizes three main models: Health at Every Size, Intuitive Eating, and Freedom From Diet Culture, which align with affirming care principles for young adults transitioning or exploring their identity.  Our team is also attuned to gender and eating disorders, and recommends the following paradigms for our diverse community when it comes to helping clients find peace with food:

The Health at Every Size model is an evidence-based framework of care that celebrates body diversity, challenges cultural norms, and rejects stigmas around weight, which can allow our clients to feel further at peace with their bodies. Research consistently demonstrates that weight and BMI are an inaccurate measure of health; HAES believes that instead of BMI other indicators of well-being, such as behaviors and mindset, are better ways to measure health. 

Intuitive Eating allows for an individualized look into a client’s relationship with food and their body. Through this model, clients will learn to identify obstacles of body respect, address and improve negative thought patterns, and respond to hunger and fullness cues. 

Freedom From Diet Culture encourages clients to step away from the rigid expectations associated with dieting and diet culture, such as values of thinness over health. Diet culture is shown to be harmful to a person’s relationship with their body and food, increasing body dysmorphia, disordered eating, eating disorders, and other mental health issues. Therefore, we at The Dorm work to ensure that we are a diet-culture-free environment to help clients feel safe in our community. 

With our registered dietitians and clinicians, we strive to help clients find freedom from issues of body image, food rules, disordered eating, and eating disorders. We intend to reduce clients’s stress about food and their bodies through respectful, individualized, and stigma-free care.

In Conclusion

We were so pleased to have Emil Smith and the FEDUP Collective speak with and educate us further about eating disorders in transgender and gender diverse people. Many of our own clients have benefited greatly from the resources the FEDUP Collective offers, and we’re so grateful for their time and for having been able to hear about their work.

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