This is the second excerpt of a two-part interview. Be sure to read the first part here.
- Coming out to loved ones as a person with an eating disorder, as a gender-expansive or intersex person, and as a survivor of sexual assault are all moments that can cause intense emotions and an increased sense of vulnerability. For professionals treating clients who have done or continue to need to do all three in their lives, how can they create spaces that are welcoming, honoring of that bravery, and serve as a refuge to turn to when those moments occur?
Some providers want to be overly supportive in a way that overemphasizes someone’s identity and centers it when that’s not something that someone wants to talk about, or that they may not be seeking care around. This is likely well-intentioned but can be harmful and alienating. For professionals, it depends on which kind of professional. If it’s a therapist, that might be a conversation like, “I want to be an affirming space, but I am someone who doesn’t share that identity with you. Is there anything you need or want to discuss, given that?” Therapeutic spaces, peer-support spaces, trauma-specific spaces, whatever space someone is coming into where that is a conversation to be had, I think that can be really empowering. It also means creating space for the potential for error or harm. That immediately introduces a conversation of “How do you feel about that?” and “What can I do if I do cause that harm? How do you want to engage in that conversation? What do you feel comfortable telling me? What does repair look like to you?” That creates an introduction to those conversations, and providers and professionals can understand that there’s a wider frame behind them. Even if they are very aware about trans health, they might still have misconceptions or assumptions.
Providers work within a system that isn’t necessarily prepared to support individuals who have an eating disorder, are trans or intersex, or are survivors of sexual assault. Many places don’t have any understanding of that and are going to have assumptions around it, whether that be what an eating disorder looks like, how it represents itself, who experiences it, or in relationship to whom and how they believe sexual assault impacts.
Having resources available is very important. Providers need to be aware that the space they are in cannot solve everything because that’s unrealistic. It’s important to have different community resources to share, like sexual assault centers or eating disorder providers that are in the area and that they have been told are effective by others that have similar identities. It’s helpful when providers are giving space for those resources to be available and used alongside their care and services.
- Are there differences in how eating disorders manifest between transgender men and transgender women that eating disorder treatment facilities and rape crisis centers should know about?
I’ll give a simple answer to that: yes. The full answer to that is not one that I can give in short words. Everyone has a different experience in their relationship to their eating disorder. Transgender men are going to have different manifestations of eating disorders from one another. So will trans women. Sometimes there’s a lot of emphasis in terms of inclusion to try and categorize people as, “These people coming in with this identity are going to have this experience,” and “These people are going to have these experiences,” and it’s just not that simple. If someone’s identity is affecting their eating disorder and that’s something they want to engage with, it’s important to have more literacy around what transitioning means and how to ask questions and follow-ups in a relevant way.
There’s a mainstream (and also in the medical world) definition of what transitioning is, that “every trans person wants to be as close to the body of a cisgender person as possible,” which is completely untrue.
So, coming from a place of curiosity like, “How do you feel about your body? What care are you looking for around those feelings?” and having definitions of social transitioning, legal transitioning, and medical transitioning and the things within it so that there’s not this one-size fits all perception of transitioning that isn’t realistic. This is critical because a client might not want any of the things that the provider is assuming.
In terms of gender, I also think it is important to be aware of the ways in which gender norms and the perception of gender are going to affect somebody’s experience. Being someone who’s perceived as trans is going to be a thing that affects their experience. Being perceived as a trans woman and being perceived as a trans man is going to be a different experience. Being perceived as a man or woman is also going to affect that experience of an eating disorder and the experience of the body, just as race, disability, ethnicity, and trauma shape these experiences. It is important to be aware of and consider the pressures, expectations, and stereotypes around gender and what it means to be and “pass” as a man or a woman, and how these factors may result in different experiences of eating disorders and embodied experiences for trans men and trans women. At the same time, it is also important to understand and hold space for the fact that not every trans man or trans woman will be impacted by these forces in the same way.
- Similar to sexual assault, disordered eating is an issue that disproportionately impacts transgender people of color. Yet, they are similarly less likely to receive care for that issue. How would you like to see medical settings, eating disorder facilities, and rape crisis centers better serve transgender women of color struggling with eating disorders rooted in sexual trauma?
I am not a transgender woman of color, so I am not responding through lived experience. Many others are more equipped to provide this response and speak to how these intersectional identities affect access and effectiveness of care. This is also going to be very individual based on different transgender women of color who have an eating disorder and/or have an experience of sexual assault. There are a lot of factors within medical care that are going to be working against someone with that identity. Whether that be the cisnormative structure of care and the assumptions someone is going to have around trans people, the lack of cultural diversity in terms of foods that are offered in eating disorder care treatment centers and dietetics, the pervasive centering of whiteness in many conceptualizations of transgender experiences, literacy, and discussions, and countless other structural racist, cisnormative, and sexist issues. This can look like experiencing racism daily about food, access to food, and how other people are going to perceive and talk about food. There are many interconnected ways in which cultural expressions of eating are never integrated into care. One of my other jobs at Safely Connected has been working to raise awareness of that. We have been developing a training specifically around cultural expressions of eating because there’s such a diversity of food that needs to be integrated into a more diverse way in care and nutritional guidance and that is inclusive to people of different cultures who are coming into care, instead of this one-size-fits-all model of eating.
Those things are all going to compound if someone is coming into care and only being offered Anglo-American or Mediterranean diets as the supposed standard of normative or “healthy” eating. Nutritionists and dietitians often have assumptions about what is “healthy” or not, without consideration of how the model of “healthy” food has been created or what’s healthiest for the individual coming to them. Many medical and professional systems try to fit someone into a very specific category, whether it’s for gendered roommate options in in-patient care, scales, or whatever else to “simplify” their identity and needs. You can’t force “fit” someone into a system that’s been made to oppress them. You have to question and challenge why the system was built this way and how it fails marginalized communities. There is so much context of the greater ways in which the system of healthcare is working against trans women and Black Indigenous People of Color and people in larger bodies and all the complexities within those identities all happening at once and how care will respond to them.
In terms of the question you initially asked, I think being more political in terms of medical care matters. This means being open to discussing the discriminatory practices and experiences of daily life or political events because when someone’s identity is inherently politicized and discriminated against, that’s not something that they can exclude from their care, access to care, and experiences.
Another factor might just be recognizing that many things might not have been created for people with those identities. The default of care might have been created for people who are white, cisgender, endosex, thin, and able-bodied. For those reasons, how those diagnoses might have been written, treatment has been drafted, and what that’s going to look like is, there’s going to be a lot of people that are going to be treated and viewed as non-compliant or wanting to avoid care. That’s not the reality of those experiences and those people. It’s more of, “This form of care has not been created to cater to people with those identities.”
- Could you speak to the importance of having spaces like the FEDUP Collective that are led by and made up of gender-expansive and intersex people to discuss and heal from the community-specific experiences with eating disorders, sexual trauma, and other related mental and physical health issues?
I want to acknowledge that there are ways in which the discriminatory processes of healthcare, perceptions of gender, eating disorders, and sexual trauma can still be replicated in community-led spaces. White supremacy and capitalism are still the fundamental structures of our society and put restrictions on groups to abide by. However, community spaces include a level of relatability and understanding that increases access, emotional work, and connection. Your community knows and sees the barriers you face every day, and you no longer have to explain who you are, what happened to you, or how you feel. You can access vital information about your health and find resources. Access to other people with your shared identity safely and with confidentiality increases trust because the people who run the space are aware of the different dangers you face, how you’re being targeted, and can be more proactive in protecting you because they know those dangers themselves.
Then there are also a lot of ways they’re run in which trans people and intersex people have had to make up their own ways of navigating the world. Finding their own answers because the medical system won’t, the legal system won’t, and many areas of the system won’t find them. There is a lot of information that people need to understand to live their lives, whether that be where to find gender-affirming care, how to change their name, how to get this part of their care covered as a trans person, or this issue that they’ve faced. There’s a lot of isolation in terms of experiencing all of this and not having any support from the systems that more often create that harm and exclusion, so having community-run spaces creates a resource hub for people within that community.
In the many ways in which insurance coverage, liability, and healthcare are going to create a million different scenarios for a trans and/or intersex person who is relying on it. Finding the tools to understand how to navigate it all can be very empowering. It addresses that sense of powerlessness and isolation that people will experience because there are solutions and people out there, and they don’t have to do it on their own. When you carry that isolation of being different from the systems that you are navigating, face all those microaggressions and macroaggressions within them, and share those experiences of other people who have also experienced it, it makes that path forward easier because they have someone who’s navigated this before and can give them guidance and advice.
So much about trauma and healing also centers around having control after it’s been lost. Coping is about finding control and agency through whatever means you have. Community spaces give agency, control, understanding, and solidarity in a way that no other space can. Being excluded from so many spaces based on gender, body, income, etc, makes healing and understanding sexual trauma and eating disorders incredibly difficult. Community-run transgender and intersex spaces don’t force people to justify who they are or explain their identity, their body, and their needs. They create spaces that consider those.
- There are serious deficits in research about eating disorders as they relate to the gender-expansive and intersex communities. For people who want to learn more, especially as this issue relates to sexual violence, which resources, documentaries, books, etc. would you recommend our readers check out?
I would say look out for FEDUP’s research. Many of our team members have published research in the past and continue publishing research on eating disorders. We have a variety of them posted on our website. I know that InterACT also has a variety of work that’s not directly related to eating disorders and sexual trauma but is focused on the intersex community. There are a lot of individuals online doing that work and building their businesses as well. Whether it be influencers or people on social media just sharing their experiences, valuing lived experience in that area is important because there are huge deficits in research and limited research that I can refer people to. While recognizing that one individual may have a fundamentally different experience or opinion than another, it is really helpful to learn from other people’s experiences. This recognizes the barriers to creating and finding research specific to an identity and finding research that acknowledges the existence of trans and, intersex people. The amount of research that’s going to be made based on “men experience this and women experience this,”...most of the time, we have no idea if trans or intersex people were included in that. If that question is never asked (including more inclusive options for sex and gender), no one would know. There’s been a lot of attempts to apply cisnormative and endosexnormative research and data to people that don’t fit within those identities. Sometimes it’s accurate, but a lot of times it’s a lot more helpful to (if there is no other research or other understanding out there) bring up the research and ask the person how that relates to their experience.
Those pieces are important, but this nuanced approach to research gives more agency to people. Someone can say, “Here’s the only resource I have. How do you think it will apply? Will this help? Do you want to use this or whatever else?” Then there’s a conversation that’s more engaging about the deficits within the system rather than pretending that that system is going to work for everyone and creating more isolation and misunderstanding. Our community knows we are excluded from research, but we must also develop our tools and literacy to use what’s out there. A supportive healthcare professional can help bring more context and explanation to what we find.
- Anything else you’d like to add?
More work needs to be done around this. More funding is needed around it. There needs to be more support for organizations like yours and ours that are pursuing this work. There are a lot of people who are willing to work on the intersections of sexual assault, eating disorders, and trans and intersex communities. Certainly FEDUP does, but often this work is underfunded, underrecognized, and inaccessible. I could say a lot more about the intersections of gender, sexual trauma, and eating disorders, not only from my own experiences but also from the work and the research that I’ve done within the community. Other people have experiences that are different than mine. There needs to be more focus beyond having one resource out there and seeing it as enough. This work needs to be centered in the core research, guidance, and services if we do not always want to treat trans people and intersex people as outliers. And in those resources, also being aware that white transgender and intersex people are given more access, recognition, and platforms. Diversity needs to be understood through all of our identities, not as a checkbox that doesn’t include how race, gender, disability, body size, etc, will also affect someone’s experience. The responses I’ve given are nowhere near enough and don’t begin to cover how these experiences show up in our community and how eating disorders affect sexual trauma. As many of your questions have pointed out, a lot of the mainstream resources for eating disorders and sexual trauma are catering to cisgender endosex women, and that furthers the lack of recognition and resources for all who are underrepresented.
Resources Recommended by our Contributor:
Resources/research pieces on eating disorders that our contributor recommends (that are not necessarily specific to trans, gender diverse and intersex folks):
- https://asdah.org/media/
- https://www.theprojectheal.org/research-studies
- https://www.safelyconnected.org/training
- Baker, J. H., Freestone, D., Cai, K., Silverstein, S., Urban, B., & Steinberg, D. (2024). Eating Disorder Clinical Presentation and Treatment Outcomes by Gender Identity Among Children, Adolescents, and Young Adults. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 75(2), 254–260. https://doi.org/10.1016/j.jadohealth.2023.11.015.
- Brownstone, L. M., DeRieux, J., Kelly, D. A., Sumlin, L. J., & Gaudiani, J. L. (2021). Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based. Transgender health, 6(3), 121–124. https://doi.org/10.1089/trgh.2020.0068
- Kamoun, C., & Dalke, K. B. (2024). Embracing Difference in Intersex Variations. Clinical pediatrics, 99228241299909. Advance online publication. https://doi.org/10.1177/00099228241299909.
- Sharpe, S. L., Adams, M., Smith, E. K., Urban, B., & Silverstein, S. (2023). Inaccessibility of care and inequitable conceptions of suffering: a collective response to the construction of “terminal” anorexia nervosa. Journal of Eating Disorders, 11(1). doi.org/10.1186/s40337-023-00791-2.
- Urban, B., Smith, E. K., Adams, M., Sharpe, S. L., & Silverstein, S. (2024). Guidelines for research with transgender, gender diverse, and intersex individuals with eating disorders: recommendations from trans and intersex researchers. Eating Disorders, 1–12. doi.org/10.1080/10640266.2024.2306436.
- Velimirović, M., Robison, M., Abber, S., Duffy, A., Rienecke, R. D., Manwaring, J., Blalock, D. V., Riddle, M., Mehler, P. S., & Joiner, T. E. (2024). Anxiety, Obsessive-Compulsive, and Depressive Symptom Presentation and Change Throughout Routine Eating Disorder Treatment. European eating disorders review: The Journal of the Eating Disorders Association, 10.1002/erv.3160. Advance online publication. https://doi.org/10.1002/erv.3160.
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.