LGBTQIA+ Discrimination and Treatment Trauma in Eating Disorder Settings—And how to be a True Ally
Written by Allyson Inez Ford, MA, LPCC
A (sad) Note on Discrimination and Trauma in eating disorder Treatment
Harm often happens in eating disorder treatment settings (often unintentionally) but impactful nonetheless. If you carry a marginalized identity, the likelihood for harm increases. I have had many queer and trans clients express blatant discrimination in eating disorder higher levels of care, and in the mental health system more broadly. This is real, and we need to talk about it so we can shift as a field to be more affirming and inclusive.
Imagine seeking help only to be made to feel like your identity isn’t real or valid?! Our clients deserve better. Below are some examples of how this shows up, and then we will explore how to be a true ally.
Examples include:
Misgendering or deadnaming during intake: to a cishetero person who has never had to think about their pronouns being respected and honored, this might seem like a case of “but I am just not used to it”- however, this is your privilege showing. You haven’t needed to get used to it because your identity has always been respected. Imagine how exhausting it would be to have to explain, prove and defend your gender or sexuality constantly?
Providers pathologizing gender identity: the DSM (Diagnostic and Statistical Manual of Mental Disorders) has a dark history of pathologizing marginalized identities. It wasn’t long ago that being gay or lesbian was considered a mental disorders and folks were sent to conversion therapy (which is now banned- thank goodness). And “gender dysphoria” is STILL in the DSM-5TR as a mental health disorder. This is beyond frustrating and sets the stage for queer and trans clients to be seen as “ill” or “abnormal” simply for not being cisgender or heterosexual. The truth is queer and trans identities have existed since the beginning of time and are a natural part of human diversity.
Dismissing dysphoria as “body image issues”: treating dysphoria as typical body image distress is NOT what trans and non-binary clients need. This is completely missing the point. We shouldn’t be seeking to help clients accept a body that fundamentally does not feel like their own and triggers dysphoria- it’s not a choice to feel dysphoric and this could greatly increase the person’s distress. Instead we should be collaborating on ways to help the client cope with the dysphoria, explore options for gender congruence (this could be clothing, hairstyle, hormones, binders, etc) and helping them heal from a society that pathologies their very identity.
Unsafe group spaces with unchecked homophobia or transphobia: providers should be calling this out when it shows up and redirecting this type of behavior. Maybe someone else in a group has hateful beliefs towards queer and trans people and thinks it’s okay to spew this nonsense in group settings. It’s NOT okay and we need to intervene and keep the space as safe as possible. Just like you wouldn’t allow racist beliefs to be normalized, we have to do the same for all marginalized identities. If genuine mistakes are made (like using incorrect pronouns), we should promote self correcting and acknowledging the harm- then moving on.
Family involvement without assessing safety: I’ve heard many iterations of this one and it makes me so upset every time. Sadly, many higher levels of care mandate family sessions, but fail to assess or believe clients when they tell them this is unsafe. Many queer and trans clients are estranged from family due to not being accepted as they are. Forcing them to face family who may be homophobia or transphobia is re-traumatizing.
Medical gatekeeping around gender-affirming care: this can look like creating conditions for clients to access gender affirming care. In eating disorder settings, treatment teams have been known to say things like “you can start hormones when you reach ‘x’ weight or we will approve top surgery if you are ‘x’ weight. This treats gender affirming care as a reward, when it is a basic need. There should be no stipulations to access life saving health care. Also, someone accessing hormones to feel more affirmed in their body is likely to support their recovery, not hinder it.
Treatment trauma leads to early dropout, relapse, and distrust of clinicians. So, how much of the lack of queer/trans clients getting proper treatment for eating disorders is directly related to experiences of discrimination and lack of trust in the mental health system? Probably A LOT.
So, what do we do?
Repair is crucial:
If a client tells you something was harmful, believe them, unlearn your biases, and collaborate on repair. Take the time to actually do the work in your personal and professional life to be a true ally.
What It Means to Be a True Ally:
Being an ally to queer and trans people is an active practice that requires unlearning your own biases, sitting with discomfort and using your privilege to fight for the rights of LGBTQIA+ community. It is not just having a pride flag in your front yard or on your website because you want queer and trans people to shop at your business.
It includes:
Self-education rather than relying on LGBTQIA+ people to teach you (unless they want to without you expecting it)
Seeking out perspectives across race, ability, size, class, and gender expression- intersectionality matters greatly.
Believing rather than challenging someone’s identity.
Not asking queer or trans people to “prove” who they are.
Standing up to harm while avoiding “rescuer” dynamics that strip agency.
Decentering heteronormativity and the gender binary in your own life.
Using privilege to redistribute access and safety, but not to speak for others or center yourself.
Allyship is relational and ongoing. And it matters deeply in eating disorder recovery spaces, where sadly, treatment programs have fallen short in accommodating the needs of queer and trans clients. While there is absolutely progress, there is still a ways to go.
Final Thoughts:
If you are queer and/or trans: we want you to know that affirming spaces DO exist and even though its unfair, please do not give up trying to find a space that welcomes you, that you don’t have to “teach” or mask for. You are not too much, and you deserve safe spaces to explore your relationship to food and body. If you want help looking for an affirming treatment center (there are some good ones out there) or provider, feel free to ask us. Even if we can’t work with you (e.g. if you need a higher level of care, if you aren’t located in a state we are licensed in, etc), we will help you find somewhere/someone that can. The organization FedUp: Trans Folks Fighting Eating Disorders has a wonderful list of resources and affirming providers, so be sure to check them out too!
