While eating disorders disproportionately impact females in the United States, about 25% of people with anorexia are male, and transgender college students report experiencing eating disorders at about four times the rate of their cisgender classmates.
In this post, we look closely at the impact of eating disorders on under-represented transgender and nonbinary communities with Alyssa Goldenberg, LMSW, Senior Therapist and leader of The Dorm’s Body Image Group.
During a time when rates of eating disorders are at an all time high, we asked her to help us understand some common misconceptions about gender and eating disorders, and what clients and families can look for while seeking gender-affirming care for young adults.
What is the most common misconception about how gender comes into play when we talk about eating disorders?
In the media, females are so often positioned as “the face of eating disorders.” In my clinical experience however, male-identifying individuals struggle just as much with food and body, but they don’t fit in as clearly with the DSM descriptions of people with eating disorders.
As a mental health facility welcoming all genders, we see all groups of people opening up and saying, “food is a challenge for me.” Out in the real world there’s unfortunately stigma against being more open about this, especially for male clients. It’s harder for them to have a model of how to tell their friends or their parents about what they’re dealing with. That would apply to nonbinary or trans folks too.
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What do we need to know about clients who may be questioning their gender identity and also struggling with disordered eating?
Gender dysphoria is not a mental health disorder – it’s when someone is dissatisfied with their gender assigned at birth.
Body dysmorphia, on the other hand, is usually a very intense persistent negative feeling someone has about their body, typically related to feeling fat, or an intense preoccupation with negative thoughts such as “I look like a freak” or “I’m ugly.” Body dysmorphia is present in about a quarter of people with anorexia nervosa.
It’s so important to differentiate between these two camps because some folks are struggling with their body image, but it’s not necessarily due to being fat or a specific part of their body they don’t like. There’s usually an underbelly of very intense anxiety, anger, and frustration around being trapped in the wrong body for trans clients. That’s a very different experience than body dysmorphia.
How can we know if someone is struggling with gender dysphoria over body dysmorphia?
I think the first step is to figure out someone’s intention. What is their obsession with exercise, diet, or weight loss originating from?
Is it to have an ideal female or male body? Or is it that they’re so preoccupied or perseverating on the fact that they are “fat,” “ugly,” “weird,” or other negative self-labels? It’s the language that the client is using around these issues that we need to pay attention to.
With body dysphoria, you often hear a version of “I’m in the wrong body,” or, “I don’t feel like myself.” It’s important to know that there are folks that identify as nonbinary where gender dysphoria can also be present.
Transgender college students report experiencing disordered eating at approximately four times the rate of their cisgender classmates. Can you respond to why this might be happening for young adults?
I think that it’s layered. Eating disorder behaviors crop up when we’re under a tremendous amount of stress and we want to control something that we can’t control.
For folks struggling with their gender identity, there is so much that is incredibly stressful and anxiety-provoking. Particularly during adolescence and puberty when things are changing and are totally out of one’s control. For instance, if you identify as a male and are starting to get your period that is more than just upsetting – it’s a total out-of-body experience.
A lot of folks do resort to using food to manage and mitigate that level of anxiety and stress. For those who are either on estrogen or testosterone, that also can impact weight and create bloating, so it makes sense that some disordered eating behaviors arise as a response to trying to gain more control.
What are some common issues that transgender or nonbinary people can come up against while finding treatment for eating disorders?
The most common issue in my experience is in regards to residential treatment. The first question that clients face when seeking inpatient care is what “box” they fit into. It is also a delicate situation with many eating disorder residences because there is often a trauma lens to eating disorders, too. Someone that identifies as female or trans-feminine might feel unsafe living with someone that identifies as male.
In general, when it comes to residential treatment, there is a level of not having as many male beds or gender-affirming beds, so that can be a big barrier, and part of the reason why The Dorm’s affiliate recovery housing, dWELL, was launched in New York City: to fill a critical gap.
The other limitation is, again, going back to the Body Image group: gender dysphoria and gender dysmorphia are two separate issues. So folks that do identify as transgender or nonbinary are experiencing different anxieties or struggles than those that are struggling with more typical symptoms of anorexia, binge eating, or bulimia. The two groups do feel very separate, and need to be treated with specific considerations.
What do therapists and clinicians need to take into consideration while treating transgender or nonbinary people struggling with eating disorders?
The thing that I’ve learned best is to always ask questions. I want to give respect and insight to the fact that I am a cisgender female, and I haven’t experienced what they’re feeling.
No matter who the client is, it’s all about trust and support. At the end of the day whatever they’re struggling with is a human feeling that we can all relate to. It’s important to validate the humanness of their experience and connect with them on that level instead of making everything so diagnostic and clinical.
Can you talk a little bit about The Dorm’s philosophy when it comes to treating eating disorders?
I like practicing the nutrition philosophy of The Dorm because we’re not a “typical’ eating disorder treatment center. Although I really believe in traditional eating disorder treatment, it can be more appropriate for people who fit the more common DSM-5 criteria for solely an eating disorder.
I think that our holistic approach takes away that “box” that a client has to fit into. We really tackle the food piece, the body image piece, but we also tackle the trauma, the OCD, depression, or borderline personality disorder that is a common dual diagnosis to eating disorders. We touch on every aspect through our group offerings so that a client isn’t only constantly focusing on food and body image.
I’m also a fan of our mindful movement group, and skills groups involving budgeting and grocery shopping. These are the steps to take towards a more holistic and sustainable experience of recovery. It’s not just about “three meals a day.” There’s so much more to it.
Lately there has been some controversy surrounding how clinicians use BMI in treatment, can you speak to this?
We typically don’t use BMI (Body Mass Index) at The Dorm. There’s controversy surrounding it right now because of the new pediatric guidelines for preventing obesity. It’s very boxing and stifling. At the end of the day, my philosophy is asking “what’s your body’s own trend?” You have to find each individual’s baseline and that’s where the therapeutic work comes in.
BMI can also be triggering because it’s another number. Those with eating disorders are prone to fixating on numbers. With that, there’s a level of “If I’m not under this number, then I don’t need help.”
It doesn’t let you engage in the intuitive eating philosophy of asking your body where it really does belong. It can translate into a similar situation of how the number on the scale can be traumatizing, as can counting calories, macros, fats, or other forms of biometrics.
When it comes to working with gender and eating disorders, which therapeutic modalities or groups do you find are most helpful?
I recommend as many Meal Group sessions as an individual’s schedule allows. Meal Group is a daily behavioral group centered in the community, and can get any client into a routine of learning about what’s an appropriate meal that helps them feel nourished.
For additional groups I would say if they’re able to participate in movement groups, that can be really helpful. Connection with the body is so valuable.
One of my other favorite groups is Food & Mood, which is a process group that looks at underlying origins of disordered eating behaviors and how those behaviors connect to other patterns in their life.
For more advanced clients, I’d recommend cooking groups like Essentials of Cooking or Advanced Cooking. I might also say RO-DBT for certain clients, which is shown to help over-controlled behaviors that correlate with anorexia and OCD.
When it comes to individual therapy – I typically recommend talk therapy, dynamic therapy, and skills-based therapy like ACT and CBT.
Can you recommend any resources, publications, Instagram accounts, or websites where people can learn more about gender and eating disorders?
Yes I’ve shared these with clients:
- FedUp Collective is a group of trans, intersex, and gender diverse people who believe eating disorders in marginalized communities are social justice issues. Their mission is to make visible, interrupt, and undermine the disproportionately high incidence of eating disorders in trans and gender diverse individuals through radical community healing, recovery institution reform, research, empowerment, and education.
- Resilient Fat Goddex is a writer covering all things body liberation, fat liberation, eating disorder, queer, trans, and body image issues.
- Sonya Renee Taylor is a great author and poet to follow. She wrote the bestseller The Body is Not an Apology: The Power of Radical Self Love.
Thank you Alyssa!
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