This is the first excerpt of a two-part interview. Read the second excerpt here.
- Statistically, young gender-expansive people (people who don’t adhere to gender stereotypes) are more likely to develop eating disorders. Young gender-expansive people are also more likely to experience sexual abuse, assault, and harassment. In what ways do these two issues overlap?
Both of these issues are deeply rooted and connected to people’s bodies and how they are impacted by systems of oppression. They are connected to agency and control over one’s body, and the restrictions put on it by others, whether that be systems, people of authority, or loved ones. Trans and gender-expansive youth are often not given the right to bodily autonomy. This includes the language and understanding of it, as well as access to knowing that your identity exists and connecting with that identity. Every single transgender and gender-expansive youth relates to and has needs around their body that are different, but there’s an overarching lack of representation, understanding, and acceptance that these bodies exist. Feeling disjointed and disconnected from your body is a reality that these youth experience. Despite the undeniable existence of transgender and gender-expansive individuals, their realities and embodied experiences are considered a “debate” and something that kids supposedly should not be exposed to, and that creates a lot more confusion and lack of understanding over one’s body, which further affects bodily autonomy.
The culture of consent is also important to consider in relation to transgender, gender diverse, and intersex (TGDI) youth, sexual violence, and eating disorders. We often discuss consent solely in relationship to sexual violence, and that is more than important, but we also need to consider consent in relation to youth more generally. The consent to be touched by adults. The consent of how to say “hi” or be hugged. The absence of consent when gender roles are being forced and reinforced on you. Many aspects of youth’s bodies and connections are not seen as basic rights. Bodily autonomy and consent related to access to affirming and medically necessary care, as well as preventing non-consensual, non-medically necessary surgeries done on intersex children, are another important facet of this.
Eating disorders, sexual trauma, and transphobia/ gender policing also create intersectional and complex experiences of Post Traumatic Stress Disorder (PTSD). Youth with those experiences and identities are more prone to having complex feelings around their body. Too often, they are not given proper validation, the tools to understand, or informed and appropriate mental health help. This aggravates the already existing loss of control over their body and their trauma, whether that be connected to gender, eating disorders, sexual violence, or any other aspect of their body.
- Eating disorders, similar to sexual assault, are perceived to be a “feminine issue” despite the fact that they occur in every community, regardless of gender identity, sex, background, or other demographics. How has that perception prevented or alienated members of the gender-expansive population from seeking eating disorder treatment?
When it comes to accessing support, resources, and recognition for eating disorders (which is misunderstood in similar ways to sexual assault), there is an assumption that it does not happen to people who are not white, cisgender, able-bodied, endosex* (non-intersex) women. Eating disorders are not easy to recognize and address as realities, especially within a wider context of how normalized disordered eating and disordered exercise behaviors are. That also intertwines with body size. There is a highly pervasive stereotype that eating disorders (particularly restrictive eating disorders) only impact people who are very thin. People who are fat or live in larger bodies are often assumed not to experience restrictive eating disorders and frequently experience stigma in medical settings where their body size is treated as a pathology. They commonly experience false assertions being made about their eating and exercise habits, and they may be prescribed or recommended disordered behaviors by medical professionals. So, all of these compiling factors have multiple consequences at internal, social, and medical levels.
On an internal level, stereotypes about eating disorders can make it difficult for some people whose bodies and lived experiences do not align with these stereotypes to accept that they have an eating disorder or take seriously the accompanying risks. There are also existing dismissive attitudes in social environments. If someone can’t be considered as someone who can have an eating disorder, then others in their social environments are likely to miss warning signs. Eating disorder behaviors, especially those that are socially reinforced such as seeming to be “in control” or “disciplined” around food and exercise, may be ignored or even encouraged for individuals who are not seen as at risk for developing these disorders. That person will not be able to engage in that conversation, however it’s brought up. That person is going to be dismissed or disregarded. Whatever dismissive attitudes around eating disorders only applying to white, cisgender, thin, able-bodied women, are going to be compounded and aggravated by the lack of visibility around experiences that fall outside of that model.
On the medical level, not only are there barriers to access, levels of microaggressions, and assumptions for anyone who doesn’t fall into that stereotype of femininity (and all the other compiled factors of race, disability, and body size), but there is going to be a variety of interpersonal assumptions that medical providers are going to have. Whether it be the belief someone in a larger body “can’t” have an eating disorder because they’re above a certain Body Mass Index (BMI) (the medical system treats BMI as a substantial factor in diagnosing eating disorders and assessing perceived eating disorder severity), or that they only see eating disorder behaviors within the bodies and identities of that standard. We already see this through the weight stigma ingrained in the classification of “atypical anorexia,” the clinical description of anorexia nervosa when it occurs in someone who is above the weight criteria outlined in the DSM-5-TR), as atypical based on not being at an extremely low weight, when it is actually more common than low weight anorexia nervosa. The medical basis of how eating disorders are treated, identified, and understood is made to treat them as a white, cisgender, thin, able-bodied, feminine issue. One contributing factor is that many providers approach eating disorders as conditions through the framework of, “Everything you feel about your body is in your head.”
When you talk about body image in transgender and gender expansive populations, it is not something that you are only going to experience internally. This challenges the expectations of many medical treatment approaches. There’s no understanding of, “how I experience my body is also going to be experienced by other people and institutions. This might lead to increased policing and criminalization of everything I do. That might lead to gender policing of my clothing, body, actions, etc. That might lead to no options for me to sit on transit, in a classroom, on a plane. It might lead to having no or limited options for skin care, hair care, clothing brand sizes, etc.” For people experiencing multiple, intersectional forms of systemic oppression that impact the experience of living in their bodies, all of these different compiling external factors are going to affect the experience of their body and body image. When treatment only addresses this as an internal issue, something that is experienced due to personal beliefs and distorted thoughts, it cannot be effective. Not only will these experiences with providers and treatment be unrelatable, ineffective, and alienating, but this also leaves individuals unprepared for maintaining recovery in the outside world.
Systems of medical care and eating disorder treatment can be highly carceral and replicate many systems of oppression. These types of treatment are often based on rigid expectations of compliance and conformity to a one-size-fits-all treatment model, and punishment or removal from treatment can occur for individuals who are viewed as non-compliant or “too complex.” One negative outcome of this model of treatment is a lack of preparation for the non-linearity of eating disorder recovery and coping as soon as they exit those centers. The dismissive and invalidating responses to people who don’t fall into the “stereotype” identity of eating disorders will exacerbate that. Issues surrounding the misconceptions of “who” experiences eating disorders do not only impact the recognized causes of eating disorders. These misconceptions also impact how providers understand the experience of an eating disorder and the client’s relationship with food and bodies within the framework of societal, systemic, and social discrimination based on the client’s identity.
*** Someone who is endosex is a person who has innate physical sex characteristics like chromosomes, hormones, genitals, and other parts of the body that match what is expected for female or male bodies.
- Sexual trauma can manifest in a variety of ways. One common response is a sense of bodily shame, self-disgust, or even a desire to self-harm, and disordered eating is one of the means in which survivors may process those feelings. Simultaneously, transgender people who have experienced sexual assault may still be going to doctors for gender-affirming medical treatments. What sort of complications might there be for transgender survivors who need to constantly think about (and discuss with their doctor) their body’s need for gender-affirming care while also dealing with internalized body negativity from their sexual assault and associated eating disorder? What can medical settings do to affirm and balance those complicated emotions?
So, I’ll try to answer this on multiple levels. There’s a medical level in which diagnosis, treatment, and medical training function on the assumption that multiple diagnoses can easily be separated and identified in a straightforward way. There is little space for the nuance and complexities of the effect of co-occurring experiences, especially when it comes to pathologized identities within medicine. Healthcare as it currently functions does not recognize how it has excluded and experimented on different groups of people over time. Part of medical training should include and emphasize the history of medical apartheid, experimentation on Indigenous youth, past (and current) classifications of “transsexualism” (term used as a diagnosis in the ICD-10 classification) as mental illnesses, and non-consensual surgeries and interventions performed on intersex individuals. The gaps in care for marginalized communities are not due to the client’s identities but rather, how medicine was developed and is still put into practice. That already creates a conflict between healthcare providers who are faced with liability, contradicting training, limited research, and clients who are consistently dismissed, misdiagnosed, and facing barriers to accessing care. The complex effects of sexual trauma and eating disorders are only going to aggravate the existing barriers to gender-affirming care for transgender individuals, especially those with disabilities, who are Black, Indigenous, and people of color (BIPOC), and those living in higher weight bodies.
Providers should approach these intersections in a holistic way that does not forcibly silo different diagnoses or aspects of an individual’s experience, i.e., “This is the sexual trauma. This is the eating disorder. This is gender dysphoria.” These are not separate distinct things given the fact that they exist in one human being and body and may dynamically interact with each other over time and in treatment. Providers are expected to assign symptoms to a specific diagnosis and face restrictions to engaging with a client’s health differently. That can affect different medical approaches for providers who don’t have medical training to engage with sexual trauma, eating disorders, and even less in regards to transgender health.
There’s another scale of this with the integration of trans bodies into healthcare. The format of diagnosis and treatment for being “transgender” is a part of a system that consistently erases complex and diverse experiences of gender. Many aspects of medical care are very tied to a binary understanding of sex and gender, including assessment of health metrics, symptoms, and dosage of medication. It is also this binary system that trans people are often forced to navigate to access hormone prescriptions, gender-affirming care, and different forms of surgeries. Transgender folks have to “prove” their identity, dysphoria, and “need” within a system that consistently excludes them. It’s important to have background of how those diagnoses and processes have come to be, because now gender dysphoria is used as the modern substitute for what used to be categorized as “transsexualism” or “gender identity disorders” within the DSM-5 and ICD. Those specific diagnosis criteria went from pathologizing trans people entirely to substituting the same diagnosis to “gender dysphoria”. This is still following that same format of, “being trans is a disorder, and here is the treatment for it; we’re just going to frame it differently” rather than having a fuller understanding of trans identities and how those medical providers can engage with transgender health differently. Community members often have to go through 2-3 doctors to get “prescribed” a surgery, with some of these providers having limited understanding or knowledge of trans identities or how to engage with this process, resulting in frequent experiences of healthcare discrimination for transgender individuals. This isn’t a criticism of gender-affirming care, it saves lives, but transgender and gender diverse people have to fight for it on every level, given the many systemic problems with how this care must be accessed.
There is a lack of training in how to give and “prescribe” gender-affirming care. There’s a lack of training in how to engage with sexual trauma. There’s a lack of training on how to recognize and understand eating disorders. General healthcare appointments, completely unrelated to gender-affirming care, may still involve discussions around transgender health and around the body, but often not in positive ways. Providers who may have limited knowledge of how certain types of gender-affirming care impact overall health may assume that any health problem a transgender person has is related to their trans status or gender-affirming care and may also ask invasive questions not related to the reason for the medical visit.
Considerations around touch and consent are also not included in most practices. There’s a lack of humanity created for the client/patient coming into care and what the provider needs to do. There’s a lack of trauma-informed care that is implemented within the medical system that can engage with someone having a need for conversation, a boundary, drinking water, walking around afterward, or any kind of safety that they need when a provider is going to be engaging with their body in a very specific way that may be touching it in ways that may be activating. Clients are expected to “put aside” their trauma and experiences, treat them in mental health care, or hide them, because it’s not seen as relevant.
I think the path forward is complex, but the bare minimum would be having a more holistic model of care. Gender-affirming care can be a way to gain agency and control over their body or gain more bodily autonomy. That addresses different symptoms of sexual trauma because this is a way for someone to be empowered in that experience.
People are going to heal differently on an individual basis. It’s more about, “What is the training for how to engage in that conversation?” and not having this power imbalance where a provider can decide whether or not you have the right to have these surgeries or medications.
- For some intersex (people born with sex characteristics that do not align with binary understandings of male or female bodies) people, unwanted surgeries on their reproductive system experienced in infancy, childhood, and/or adolescence can register as a sexual trauma. When some members of this population deal with that trauma through disordered eating, what are some considerations and best practices both eating disorder treatment facilities and rape crisis centers should keep in mind when treating them?
I’ll frame my answer with the fact that I’m an endosex trans person, so whatever I say does not come from personal experience but rather from professional experience and education I’ve done myself. There are definitely other people who can give more qualified and detailed answers. What I will say from my work and research is that little to no medical environments, rape crisis centers, or eating disorder care institutions have intersex literacy. Most people don’t consider or know intersex identities and intersex variations. Many have assumptions around who intersex people are, what they look like, and what their needs are. That’s if they even have any understanding that intersex people exist. That’s just the baseline, having some understanding of intersex people and what endosex means.
We must include language that doesn’t assume that all bodies are endosex and allows intersex people to provide an accurate account of their bodies, life experiences, and care needs. That also helps us engage in those conversations and create more awareness around the fact that intersex people exist. Another layer of this is also not pathologizing intersex identities and bodies. Medical systems for the last 70 years have been coercing intersex people into an endonormative standard by performing nonconsensual surgeries and other interventions and treating their intersex variation as a medical condition to “fix.” All of this leads to dangerous health outcomes that clients did not consent to. Fitting into the binary is treated as a priority over the individual’s actual health and embodied experience.
In another layer, providers should be receiving training or doing research online and including that language into everyday practices, and addressing the ways endosex normative practices are implemented -- how we define sex, how we engage with sex, what someone looks like when they come in -- so that someone seeking services doesn’t already have to do that education to begin with. Also, community-specific care that is evidence-based and lived experience-based has been shown to be incredibly effective in terms of safety, access, accountability, and understanding. Having peers or staff that can create a safer space for whoever’s coming in so no one is put in a space where they’re going to be tokenized, misunderstood, and pathologized for whatever their experiences are.
It’s not only representation but it’s having that literacy in terms of the language and not just being like, “Here is what intersex people need. Here is what intersex people are going to experience.” That’s just not a realistic model. There’s so many intersex variations and experiences within the intersex community that are going to exist. Those conversations need to be at the core of whatever training there is. Research needs to be focused on what is medically necessary or not, what the health impacts are, and more, rather than how can a client’s body be coerced and molded into an endosex cisnormative model.
This blog was published in The Resource 2025 online magazine special issue Sexual Violence and Sexual Health Outside the Gender Binary.
About the Author:
Cody (he/him) is a trainer and staff member at the FEDUP Collective and Safely Connected, two organizations centered around healthcare access for marginalized communities, an advocate in the ED field since 2018. Fighting Eating Disorders in Underrepresented Populations (FEDUP): A Trans+ & Intersex Collective (FEDUP) is a collective of trans, gender-diverse, and intersex (TGDI) people who believe EDs in marginalized communities are social justice issues. FEDUP centers harm reduction, body neutrality, community care, and peer support. They organize and advocate for more accessible, affordable, trans and intersex- inclusive and affirming, and culturally competent ED treatment. FEDUP envisions representative research, media visibility, intersectionally-educated, gender-literate professionals, and viable treatment options that speak to diverse trans and intersex experiences.