Eating disorders (EDs) have been identified as a significant health concern worldwide, as they are associated with the highest mortality rates of any mental health condition (Beat, 2021).
Emerging research has identified that the occurrence of EDs is higher amongst transgender and gender diverse individuals compared to cisgender individuals, yet research has largely focused on white cisgender girls and women (Coelho et al., 2019; Riddle & Safer, 2022). Gender diversity refers to when an individual’s gender identity differs from the gender they were assigned at birth. The stressors associated with gender diversity, such as gender dysphoria, may be independent or align with elevating the risk of EDs in gender diverse individuals (Hartman-Munick et al., 2021; Nagata et al., 2020).
Despite this increased risk, there is a lack of literature evidencing the experience in the screening, diagnosis, and treatment among this population (Hartman-Munick et al., 2021). Many gender diverse people seeking support for EDs regard their treatment from healthcare clinicians as lacking affirming and inclusive care (Delozier et al., 2020; Duffy et al., 2016).
Therefore, the current study by Ferrucci et al. (2023) qualitatively explored healthcare providers’ views around the access to care and treatment within eating disorders services for transgender and gender diverse individuals, with a focus on facilitators and barriers to care.
19 clinicians specialising in eating disorders (ED) services across the US were recruited to take part in individual semi-structured interviews over the telephone or Zoom. Eligibility included being licensed to provide mental health treatment and having at least one year’s experience in their role.
Interviews focused on the clinician’s familiarity with transgender and gender diverse populations, views around facilitators and barriers to care, and ways of improving intervention and delivery of ED treatment to these populations.
The researchers transcribed these interviews verbatim and used inductive thematic analysis to identify themes and patterns in the data.
From the data collected, the researchers identified two core overarching themes and several subthemes.
Theme 1: Factors affecting access to care
Participants perceived gender minority individuals to face difficulties which affected their access to care, reflected in six subthemes:
Fear of stigmatisation was identified as preventing individuals from seeking treatment. Participants reflected the role of themselves and others in contributing to gender minority patients’ hesitation to seek treatment, including shame and rejection.
2. Family support
Participants included a lack of family support networks as causing difficulties in accessing support and felt that unsupportive family members could delay help-seeking. Most participants perceived gender minority patients with supportive families to access care more easily.
3. Financial factors
Cost impacted individuals from seeking treatment, especially when trying to afford ED treatment alongside gender affirming medical intervention.
4. Gendered clinics
Participants noted gender minority patients may find mixed gender facilities preferable but unaffordable.
5. Scarcity of gender-competent care
Participants highlighted gender minority individuals struggle to access affirming and safe care, especially in areas where care is scarce or where US political ideology discriminates against gender minority individuals.
6. Religious communities
Religious family members or communities were identified as having a role in delaying help-seeking, with the potential personal conflict with religious beliefs also acting as a deterrent.
Theme 2: Factors affecting access to care while in treatment
Participants identified several factors impacting care for gender diverse patients whilst in ED treatment, which resulted in seven subthemes:
1. Discrimination and microaggressions
Clinicians perceived that specific religious and political beliefs, limited knowledge and stigma associated with gender identity facilitated a lack of acceptance and discrimination towards gender minority individuals from clinicians.
2. Provider lived experience and education
A selection of participants identified the burden on patients to provide education on their gender identity, and it was felt clinicians who reflected on the diversity of their patients were more confident in their ability to provide a safe space for treatment.
3. Other patients and parents
Group therapy was utilised by several participants; however, potential problems could arise in making treatment comfortable and accidentally exposing gender identities.
4. Institutions of higher education
The wider impact of higher education culture was noted by participants to restrict external support networks and reduce feelings of inclusivity.
5. Family-centred care
Participants spoke about their experience working with families, with the view that family-centred care was most effective when families were supportive and accepting of gender identity. Participants suggested engagement in treatment for EDs was partly driven by open and validating parental support.
6. Gendered-centred care
Participants expressed concern over inclusivity when gender diverse individuals were receiving treatment in care facilities for the gender they were assigned at birth.
7. Traditional therapeutic techniques
Feeling unprepared and lacking knowledge of therapies which support EDs in gender diverse populations was voiced by some participants as impacting treatment. Participants explained that patients often experience distress engaging in traditional therapeutic techniques, like body-positive talk.
The authors conclude that:
- The results highlighted clinicians’ awareness of the increased risk of EDs among gender diverse individuals, and were particularly focused on moderating the impact of puberty during adolescence.
- Participating clinicians demonstrated a good awareness of the barriers faced by gender minority patients in receiving treatment for eating disorders.
- There are improvements to be made to advancing treatment outcomes and inclusivity for gender minority patients receiving eating disorder treatment, including better provider knowledge and tailored approaches.
Strengths and limitations
Overall, the study complements findings from the existing literature and expands on the understanding and knowledge clinicians have about how transgender and gender minority populations engage within eating disorders (ED) services. Other strengths of the study were seen in:
- The inclusion of a diverse set of participants, with the recruited sample representing a breadth of experiences across the US, thus making it relevant to this population
- Attempts to reduce bias by including a second author during analysis and questionnaires pre-interview, thus improving validity
- Clear, open research aims, which were reflected in the established themes
- Subthemes that were clearly outlined and explored in the results section, with sufficient evidence provided from within the interview data to consolidate these points.
However, there were also some limitations:
- Whilst the methodology was clear in providing a clear description of participant and data collection, there is an absence of example questions and prompts that were included in the interviews. Additional information in the methodology about interview structure would be insightful in understanding exactly how the findings were generated
- The study’s findings included a considerable list of subthemes categorised under two generalised core themes. Without concise themes, it is challenging to balance the level of significance each theme holds for participants and whether some themes were more prominent than others
- Additionally, as identified by the authors, there were concerns about the pool of participants being volunteer-based, who may have had preconceptions or certain views on the topic prior to being involved in the study
- Finally, a requirement to be included in this study was to be working in an eating disorders (ED) service. I wonder if an alternative tale would have been told regarding understanding and awareness, if healthcare professionals and services working alongside (but not directly in) ED services had been recruited, as this might have provided even more insight to the systemic difficulties in accessing care. I query how generalisable the results of this study are to the wider healthcare system.
Implications for practice
Overall, these findings shed light on the barriers faced by transgender and gender diverse service users in receiving care for eating disorders (EDs), from the perspective of providers. The study has important implications for clinical practice, particularly regarding potential areas for improvement in the attitudes of healthcare professionals towards gender minority individuals receiving treatment within ED services.
The study raises questions about the contributors to distrust and dissatisfaction towards healthcare providers in transgender and gender diverse populations, which has implications for screening and treatment for EDs. Reading about how clinicians in this paper manage and cope with these barriers highlights the need for future research to explore more effective training strategies that target the improvement towards treatment pathways. Future research should explore the changes and training within clinical practice needed to address the remaining disconnect in awareness and understanding of gender diversity amongst healthcare populations (for more, read Siobhan D’Almeida’s recent blog).
Overall, the paper reinforces the need to reflect patient-centred care and implement further training and understanding in supporting gender minority eating disorders patients. Future research could explore the ways in which we can improve gender affirmation and inclusivity within services; informed by the perspectives of stakeholders. It would also be interesting to expand on the challenges to improving education and changing practices in clinical settings. For me, it is good to see that research is shifting its focus towards understanding a broader range of gender and sexual minority experiences.
Statement of interests
Ferrucci, K. A., McPhillips, E., Lapane, K. L., Jesdale, B. M., & Dubé, C. E. (2023). Provider perceptions of barriers and facilitators to care in eating disorder treatment for transgender and gender diverse patients: a qualitative study. Journal of Eating Disorders, 11(1), 1-12.
Beat (2021). How many people have an eating disorder in the UK?. Beat.
Coelho, J. S., Suen, J., Clark, B. A., Marshall, S. K., Geller, J., & Lam, P. Y. (2019). Eating disorder diagnoses and symptom presentation in transgender youth: a scoping review. Current Psychiatry Reports, 21, 1-10.
D’Almeida, S. (2023). Mental health services for sexual minorities: experiences of discrimination, barriers to services and priorities for improvement. The Mental Elf.
Delozier, A. M., Kamody, R. C., Rodgers, S., & Chen, D. (2020). Health disparities in transgender and gender expansive adolescents: A topical review from a minority stress framework. Journal of Pediatric Psychology, 45(8), 842-847.
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.
Hartman-Munick, S. M., Silverstein, S., Guss, C. E., Lopez, E., Calzo, J. P., & Gordon, A. R. (2021). Eating disorder screening and treatment experiences in transgender and gender diverse young adults. Eating Behaviors, 41, 101517.
Nagata, J. M., Murray, S. B., Compte, E. J., Pak, E. H., Schauer, R., Flentje, A., … & Obedin-Maliver, J. (2020). Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among transgender men and women. Eating Behaviors, 37, 101381.
Riddle, M. C., & Safer, J. D. (2022). Medical considerations in the care of transgender and gender diverse patients with eating disorders. Journal of Eating Disorders, 10(1), 1-10.