What is Needed For Eating Disorder Prevention for Transgender and Gender Diverse Young Adults? Findings from Asynchronous Online Focus Groups

Abstract

Transgender and gender diverse (TGD) young adults face higher risk of eating disorder (ED) symptoms than cisgender peers. Evidence-based ED prevention programs exist but must be adapted to meet the needs of diverse TGD populations. We conducted eight asynchronous online focus groups in 2019 with 66 ethnically and gender diverse TGD young adults (18–30 years) living in the United States. Participants were recruited online; groups took place over four consecutive days. We conducted inductive thematic analysis of participant responses to three prompts about ED prevention needs and advice for program developers. Findings fell into three domains. In Domain 1: Developing Program Content, themes included (1.1) need to address multiple dimensions of gender; (1.2) intersectional representation matters; (1.3) limitations of eating disorders research; (1.4) being responsive to trauma. Domain 2: Program Delivery Considerations, included preferences for (2.1) group composition, (2.2) intervention modality, and (2.3) program leadership. Domain 3: Cultivating Affirming Spaces included themes addressing the need for programs to (3.1) create judgment-free environments and (3.2) center lived experience. TGD young adults in this study described a range of needs and recommendations for ED prevention content and delivery, with relevance to clinicians, program designers, and ED prevention advocates.

1. INTRODUCTION

In the United States (US), an estimated 5% of young adults ages 18–24 are transgender or nonbinary (A. Brown, 2022). There is growing evidence that transgender and gender diverse (TGD) young people face at least 2–5 times greater risk of disordered eating behaviors than their cisgender (i.e., non-TGD) peers (G. R. Brown & Jones, 2016; Diemer et al., 2015; Guss et al., 2017; Simone et al., 2022). For example, a survey among college students showed that eating disorder rates were significantly higher for TGD students (17.6%) than for cisgender women (1.8%) or men (0.2%) (Diemer et al., 2015). In another large sample of college students, over one in three TGD students screened positive for probable eating disorder, including 34% of transgender men, 37% of transgender women, and 39% of genderqueer students (Simone et al., 2022).

To address this disproportionate risk, primary prevention is needed. Evidence-based eating disorder prevention intervention programs exist but have historically been designed for and tested among cisgender girls and women (Becker & Stice, 2017; Breithaupt et al., 2016; Cook-Cottone et al., 2017; Stice & Presnell, 2007). Among these prevention programs is the Body Project, an internationally recognized cognitive-dissonance based eating disorder prevention program (Stice et al., 2012), which has been adapted to meet the needs of diverse populations, including sexual minority young adult men (T. A. Brown & Keel, 2015). More recently, Klimek et al. developed and implemented a prevention intervention program utilizing cognitive behavioral therapy to increase mindful acceptance and cognitive reappraisal for body image issues for sexual minority men living with HIV (Klimek et al., 2020). To date, these evidence-based interventions have not been adapted or tested for TGD young adults.

It is crucial to consider adapting existing evidence-based primary prevention programs, such as those noted above, given mounting evidence of both shared and unique ED risk factors experienced by TGD emerging adults. Like their cisgender peers, TGD young adults report ED risk factors such as body dissatisfaction, perfectionism, anxiety and low self-esteem (Ålgars et al., 2012; Jones et al., 2018; Romito et al., 2021). Some research has also shown that the tripartite influence model (Thompson et al., 1999) and related sociocultural models of body image and ED (Rodgers et al., 2015) can be as relevant for TGD youth and young adults (Brewster et al., 2019; Gordon et al., 2016; McGuire et al., 2016; Romito et al., 2021) as they are for the cisgender female populations for whom these models were developed (Thompson et al., 1999). That is, several studies have suggested that beauty, fashion, weight loss, and related industries exacerbate ED risk for TGD young people by promulgating gendered appearance ideals, such as masculinity and femininity ideals (Brewster et al., 2019; Gordon et al., 2016; McGuire et al., 2016; Muratore et al., 2022; Romito et al., 2021). At the same time, several forms of resilience in the face of such pressures have been documented, including seeking out community support in person and online, and creating individual and collective critical resistance via media literacy (Gordon et al., 2016; McGuire et al., 2016).

In addition to the risk factors shared by TGD and cisgender young adults, there is growing recognition of unique pathways to disordered eating behaviors and ED among TGD young adults (Gordon et al., 2016, 2021; Nagata et al., 2020). These pathways include needs related to gender dysphoria and gender affirming care, and exposure to social stressors such as anti-TGD stigma and discrimination (Gordon et al., 2021; Nagata et al., 2020). Much current research highlights the importance of improving access to gender affirming care and collaboration across medical teams in order to reduce body dissatisfaction and ultimately prevent disordered eating among TGD young people (Coelho et al., 2019; Goldhammer et al., 2019; Jones et al., 2018; Nowaskie et al., 2021; Testa et al., 2017). Indeed, in one study in a clinical setting, 63% of a transgender youth population endorsed engaging in intentional weight manipulation for gender affirming purposes (Avila et al., 2019). Some cross-sectional research has demonstrated that access to gender affirming medical interventions such as hormone therapy or surgeries is associated with decreased ED symptomatology (Nowaskie et al., 2021; Testa et al., 2017), although one longitudinal study of 91 TGD adolescents in a clinical setting did not find associations between initiation of gender affirming medications (hormone therapy or puberty blocking medications) and ED symptoms over a 12-month follow-up period (Pham et al., 2022).

With regard to exposure to social stressors, minority stress theory (Brooks, 1981; Hendricks & Testa, 2012; Meyer, 2003) articulates the way that exposure to a stigmatizing social environment (including stigmatizing laws and policies, healthcare, workplace, and school settings, and interpersonal interactions) can produce physiologic and behavioral stress responses putting TGD populations at increased risk of disordered eating behaviors (Gordon et al., 2021). Several studies have provided evidence for these hypothesized associations between exposure to anti-TGD stigma and discrimination and worsening gender dysphoria and/or internalized cissexism, both resulting in higher risk of ED (Muratore et al., 2022; Tabaac et al., 2018; Urban et al., 2022; Watson et al., 2016). Conversely, affirming or supportive social environments can function to prevent or buffer the effect of such minority stressors on stress and coping behaviors (Watson et al., 2016, 2019), but little research has examined these protective processes in relation to ED prevention specifically. In sum, the extant research suggests that while having access to gender affirming care is vital for the mental health and body satisfaction of TGD young adults who seek it, there are multiple, intersecting pathways that can increase risk of disordered eating and ED, including those related to sociocultural appearance pressures and exposure to stigmatizing social environments.

1.1. Present Study

To reduce health inequities and improve ED-related outcomes in underserved populations, there is a need for primary prevention programs that are responsive to the particular body image and ED-related needs of TGD young adults. Given the relative scarcity of community-based intervention research in this area, formative research is essential to learn from geographically, ethnically, and gender diverse TGD young adults’ lived experiences and to inform meaningful, culturally-responsive program development. To ensure inclusion of a wide range of voices and perspectives, the study used an innovative qualitative research method known as asynchronous online focus groups (Gordon et al., 2021). Using this innovative method, this study sought to address the research question: What are the ED prevention needs and preferred intervention strategies among TGD young adults in a US community sample?

2. METHODS

2.1. Participants

The present study analyzes data from the BRIGHT Project, an asynchronous online focus group study for TGD young adults, conducted August-October 2019 (Gordon et al., 2021). Participants were eligible to participate if they were 18–30 years old, lived in the US, were conversant in English, and identified as transgender, nonbinary, or another gender different than their sex assigned at birth. Participants also needed to have access to a device that could connect to the internet. We recruited 66 participants using a multi-pronged approach to create a purposive sample, including: (1) Social media (e.g., Instagram) posts from our community partner, Fighting Eating Disorders in Underrepresented Populations: A trans+ and intersex collective (FEDUP); (2) digital flyers posted to LGBTQ listservs and online forums (e.g., Reddit threads for transgender communities, regional Facebook Queer Exchange groups); (3) email outreach to community outreach contacts at LGBTQ community organizations; (4) chain-referral sampling (Biernacki & Waldorf, 1981); and (5) email outreach to previous participants in the PI’s transgender health research projects who requested to be contacted about future research opportunities. To ensure eligibility and data quality for this online study, all interested candidates completed a 5–10-minute telephone screening with a trained research assistant; following screening, study procedures were described, participant questions were addressed, and focus group scheduling preferences were discussed.

2.2. Procedure

Participants were assigned to one of eight asynchronous online focus groups. The asynchronous online focus group method was selected in order to increase accessibility to the study for those often underrepresented in TGD health research. More specifically, this method was selected in order to: (a) maximize geographic diversity (given that much prior research on TGD populations has focused on metropolitan areas); (b) allow for scheduling flexibility and convenience to enhance participation of socioeconomically, ethnically, and gender diverse young adults with complex school/work schedules, care-taking responsibilities, or multiple jobs; and (c) reach TGD young people who might not feel safe talking out loud about identities or sensitive topics, particularly given the pervasive stigmatization of TGD people.

The platform Discourse.org was used to host the asynchronous online focus groups. Discourse is a subscription-service that appears like a dynamic online message board, allowing moderators to post prompts and participants to respond at their convenience. Once a participant enrolled and completed the informed consent process (in REDCap, a secure online survey platform (Harris et al., 2009)), they were asked to complete a brief online survey with sociodemographic questions and provided instructions to register for the Discourse platform. The platform offered participants and moderators the choice of interacting with the platform in a web-based interface or by downloading a mobile app. Participants were also instructed to choose an anonymous username that consisted of a color, an animal, and the number of their screening ID (e.g., purple_elephant_05). These usernames ensured anonymity throughout the duration of the focus group.

The study coordinator posted two prompts per day over the course of four consecutive days: one in the morning and one in the afternoon (Eastern Time). Participants could respond to prompts at a time of their convenience. Each focus group was facilitated by two trained moderators who monitored the discussion in shifts from 8am-8pm Eastern Time. All posts were reviewed by moderators before being posted to the focus group to ensure safety and privacy protocols were being met. Moderators set a warm and engaged tone by responding to each participant’s post, asking follow-up questions when appropriate, and eliciting responses from other focus group participants by tagging their usernames in the response. Further details about the asynchronous online focus group procedures used in this study have been previously published (Gordon et al., 2021).

All participants who completed the pre-focus group survey received a $25 digital gift card for their participation, even if they did not end up posting on the focus group message board. Following procedures used in previous asynchronous online focus groups (Earnshaw et al., 2020), participants who posted at least once per day on three out of the four days of the focus group received an additional $25 digital gift card. Levels of participant engagement remained high throughout the study with 75% or more of the participants responding to every prompt and 80% responding to at least six of the eight prompts over the four days (Gordon et al., 2021). All study procedures were approved by the [Boston Children’s Hospital Institutional Review Board Utilization of the online focus group platform was approved by the Boston Children’s Hospital Clinical Research Informatics Team.

2.3. Focus Group Guide

The initial structured focus group guide was developed by the core study team (PI and moderators), based on a review of the scientific literature on key ED risk and protective factors for TGD YA and evidence-based ED prevention programs. The guide was developed to balance the goal of eliciting rich responses with the goal of minimizing participant burden. Based on best practices for asynchronous online focus groups (Reisner et al., 2017), it was determined that participants would be asked 2–4 questions within each prompt (morning and evening). The initial guide was then iteratively revised through consultation with FEDUP. Once all team members reached consensus on the guide it was reviewed by a clinical psychologist with expertise in adolescent/young adult populations to address and plan for any safety considerations. To address the current research question, one set of prompts (three questions posted at the same time) elicited participants’ thoughts related to programs supporting positive body image and eating disorders prevention (see Table 1).

Table 1.

Focus Group Guide: Prompts analyzed for present study

Focus Group Day 4 – AM Post
Prompt 4.1	What would you say you need in terms of positive body image development? In terms of having a space to talk about eating concerns?
Prompt 4.2	What advice would you give to people planning to develop a program to support positive body image development and prevent eating disorders for trans and nonbinary young people? What would have been helpful to you when you were younger? What would be helpful to you now?
Prompt 4.3	Please tell us about a space where you feel especially supported, safe, and/or satisfied with yourself - what is that space, what does it look like, who is there, etc.?

2.4. Analysis

The present analysis was guided by a template analysis approach (Crabtree & Miller, 1992), which combines a deductive approach grounded in the extant literature with the flexibility to include emergent (inductive) codes as needed. The principal investigator developed the initial codebook in conjunction with the two-person coding team, based on the research question and scientific literature. The coding team independently applied the initial codebook to three transcripts and then adjusted the codebook as needed until the team mutually agreed on codes and code definitions that reflected the data and met the study aims. The coding team independently coded each transcript. Each narrative response from each participant could have multiple codes applied, when appropriate. Discrepancies in coding were discussed and resolved through regular meetings of the coding team. Any outstanding questions or disagreements were resolved through discussion with the principal investigator. Coded excerpts were organized using multiple rounds of spreadsheets (similar to the approach described by Watkins (2017)) in order to establish connections between codes and iteratively build themes. All illustrative quotes below are contextualized with participants’ gender identity, race/ethnicity, and sexual orientation identity, as self-reported on the online demographic survey; these characteristics are shared here as indicators of selected intersectional social identities and positions that may be relevant to ED prevention in this sample. All quotes are verbatim except in a few cases where edits were necessary for clarity; in these cases edited text is indicated with bracketing.

Rigor and trustworthiness.

Our approach to rigorous template analysis is based in an epistemology that has been called contextual constructionism (Madill et al., 2000). This approach posits that knowledge is provisional and situation-dependent and that all accounts (including those of both participants and researchers) are shaped by subjectivity. This means that having alternative perspectives on the same phenomenon is not inherently invalidating; thus we do not calculate inter-rater reliability. Instead, the goal of analytic strategies such as multi-coder coding (i.e., “researcher triangulation”) is “completeness not convergence” (Madill et al., 2000, p. 10). Using this approach, we have multiple coders with different positionalities iteratively review and code the data; areas of discrepancy are discussed in routine meetings until the team reaches agreement about the interpretation of a given narrative and the shared definitions of the codes in the template. Other strategies we implemented to enhance rigor included keeping an audit trail (of the multiple rounds of spreadsheets and memos regarding coding decisions) and periodic memoing by team-members to promote reflexivity. In addition, to ensure our selection of prompts did not cause us to miss data directly responsive to the research question, we also had one coder review narratives not extracted for this analysis (i.e., responses to other prompts); no other relevant excerpts were identified.

Reflexivity statement.

The BRIGHT project was a collaboration between researchers at Boston Children’s Hospital/Harvard Medical School and San Diego State University and members of FEDUP. The authors of this paper hold diverse gender, sexual, and racial/ethnic identities, as well as diverse lived experiences related to body image and eating disorders and a range of backgrounds in research, advocacy, and activism. This array of identities and forms of expertise likely shaped the research process in ways that are both explicit (e.g., discussed in team meetings, articulated in reflexivity memos) and implicit (i.e., may not be visible to the research team).

3. RESULTS

A total of 66 TGD young adults participated in asynchronous focus groups. The sample was geographically and gender diverse: participants lived in 25 US states; 29% were transgender women; 29% were transgender men; 39% were nonbinary people (including those who identified as nonbinary, genderqueer, gender nonconforming gender fluid, and agender); and 3% endorsed another gender identity (demiboy, māhū). In terms of race/ethnicity, the sample was 56% White, 18% Multiracial, 12% Latina/o/x, 8% Asian or Asian American, 3% Black or African American, and 3% another racial/ethnic group. See Table 2 for detailed demographic characteristics.

Table 2.

BRIGHT Focus Group Participant Characteristics (N=66)

	n	%
Age group
18–21 years	21	31.8%
22–26 years	31	47.0%
27–30 years	14	21.2%
Gender identity
Agender	1	1.5%
Gender fluid	2	3.0%
Gender nonconforming or gender variant	3	4.5%
Genderqueer	3	4.5%
Man	1	1.5%
Non-binary	17	25.8%
Trans man	18	27.3%
Trans woman	17	25.8%
Woman	2	3.0%
Write in: Demiboy	1	1.5%
Write in: Māhū	1	1.5%
Race/ethnicity
Asian/Asian American	5	7.6%
Asian/Asian American and White	2	3.0%
Black/African American	2	3.0%
Black/African American and Latina/o/x	1	1.5%
Black/African American and Latina/o/x and Native American	1	1.5%
Black/African American and White	1	1.5%
Black/African American and White and Native American	1	1.5%
Latina/o/x and White	2	3.0%
Latina/o/x	8	12.1%
Latina/o/x and White and Native American	1	1.5%
Middle Eastern or North African	1	1.5%
Native Hawaiian or Pacific Islander	1	1.5%
Native American and White	2	3.0%
White	37	56.1%
Write in: Afro-Latinx	1	1.5%
Assigned sex at birth
Female	43	65.2%
Male	23	34.8%
Sexual orientation identity
Asexual	3	4.5%
Bisexual	17	25.8%
Gay	1	1.5%
Lesbian	8	12.1%
Pansexual	9	13.6%
‘Polysexual, demisexual, demiromantic’a	1	1.5%
Queer	24	36.4%
Questioning	2	3.0%
Straight/heterosexual	1	1.5%
Education level
Grades 9 through 11	1	1.5%
Grade 12 or GED	7	10.6%
Some college (1–3 years)	33	50.0%
College degree	20	30.3%
Graduate degree	5	7.6%
Geographic Region b
Midwest (East North Central)	8	12.1%
Midwest (West North Central)	3	4.5%
Northeast (Middle Atlantic)	8	12.1%
Northeast (New England)	13	19.7%
South (East South Central)	4	6.1%
South (South Atlantic)	5	7.6%
South (West South Central)	4	6.1%
West (Mountain)	1	1.5%
West (Pacific)	20	30.3%

^a.Verbatim write-in response by participant

^b.From US Census Bureau: 2010 Census Regions and Divisions of the United States (https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf; 10/8/21)

Findings from the thematic analysis fell into three primary domains: (1) content that should be incorporated into eating disorder prevention interventions for TGD populations, (2) considerations for delivery of eating disorder prevention interventions, and (3) the imperative to create affirming spaces for TGD populations to explore their body image concerns. See Table 3 for a summary of domains and themes and their frequency within participant narratives.

Table 3.

Summary of domains and themes related to development of eating disorder (ED) prevention programs for transgender and gender diverse young people (N=66)

No.	Name	N mentioning this theme	% mentioning this theme
1	Key Considerations for Developing Content for ED Prevention Programs
1.1	Addressing multiple dimensions of gender	13	20%
1.2	Representation	25	38%
1.3	Limitations	16	24%
1.4	Being responsive to trauma	3	5%
2	Key Considerations for Delivery of ED Prevention Programs
2.1	Group Composition	28	42%
2.2	Intervention Modality	16	24%
2.3	Group Leadership	14	21%
2.4	Barriers to Access	7	11%
3	The Imperative to Cultivate Affirming Spaces
3.1	Environment free from judgment	24	36%
3.2	Lived Experience	8	12%
3.3	Moderation	5	8%

3.1. Domain 1: Key Considerations in Developing Content for Eating Disorder Prevention Programs

Many participants provided insights into the specific content they would benefit from in eating disorder prevention programs. These fell into four themes: (1.1) addressing multiple dimensions of gender, (1.2) representation matters, (1.3) acknowledgement of limitations in eating disorders research, and (1.4) consideration of trauma and safety for TGD participants.

3.1.1. Theme 1.1: Addressing Multiple Dimensions of Gender

It was important to participants that the tone and content of prevention groups was supportive and validating, particularly with regard to the multi-faceted role of gender in relation to body image and wellbeing. Ideas related to gender-related support and validation were raised by 13 participants. Specifically, participants cited the importance of program content that would foster a feeling of being free to be themselves without fear of stigmatization or dismissal. In particular, participants noted the need for validation of gender exploration and of diverse gender expressions. As one participant noted, “I think encouraging people to feel safe about exploring gender is a must” (White, bisexual trans woman). Another explained, “The space would also need to accept and support body ideals that are outside of the mainstream “male” vs. “female” or feminine vs. masculine image” (Black, pansexual nonbinary person). Resonant with this idea of supporting a diverse range of gender expressions and body ideals, another participant explained the importance of having program content validate that individuals are likely to have different body image experiences and goals related to gender transition and gender affirmation: “The best advice would be to acknowledge that there is no one ideal body type for trans folks. We all potentially have different goals in our transitions, or different factors affecting our means to reach these body-image goals” (White, bisexual trans woman). Another participant addressed a similar point—that body image concerns must be considered in light of an individual’s own gender affirmation needs and goals—and was even more specific about their desire for content that addresses the complexity of navigating both gender dysphoria and sociocultural appearance ideals:

What would be very helpful in terms of positive body image development would be candid explorations of what is driven by dysphoria and what is driven by desires to be something of an ideal. I struggle to know where that line falls, and I know there are a lot who argue where the line falls isn’t relevant. But, it would be nice to have a non-judgmental space to process those things.

(White, questioning, trans woman)

Notably, this participant points out that not all TGD young people are in agreement about whether or not this is an important conversation to have – but for her it would be valuable to be able to discuss this complexity in a non-judgmental, supportive setting.

3.1.2. Theme 1.2: Representation Matters

Related to these gender-specific recommendations, many participants (n=25) highlighted the importance of program content representing diverse, intersectional experiences and positive portrayals of a variety of body types and gender identities. As one participant put it: “I need a space where I will not feel invisible as a POC and as a nonbinary person” (Black, pansexual nonbinary person). Similar to the prior theme, for some participants this was explicitly linked to feeling affirmed in one’s authentic gender expression: “Seeing every type of body type and that they are all vaild [valid]. Knowing that I didn’t have to hyper masculine myself to fit in and I could just be me” (White and Native American, pansexual trans man). Other participants described the importance of seeing a variety of body sizes and racial/ethnic identities represented: “It would have been amazing to actually see different bodies being celebrated when I was growing up. Posters or pictures up in a space that showed more than thin white people would have been just a start. Having conversations about eating disorders that weren’t just for the thin people” (White, asexual trans man). Notably, this participant emphasized the value of such representation at younger ages, suggesting a need for interventions at multiple developmental periods.

3.1.3. Theme 1.3: Addressing the Limitations of Eating Disorders Research/Knowledge

Almost one-fourth of participants (n=16) addressed limitations of the eating disorder field that could inhibit interventions’ efficacy for TGD populations. Some participants felt that the traditional focus on challenging the “thin ideal” did not effectively combat other sources of body dissatisfaction, like gender identity concerns or gender dysphoria. One respondent explained “Know that not every trans person may be able to accept the body that they have now, and make sure that you are comfortable discussing healthy ways of changing your body as well as self love and acceptance” (White, bisexual trans man). Further, some respondents felt that “body positivity,” or encouraging TGD individuals to love their bodies, may be non-affirming: “hearing that I should love my body can feel disrespectful of my experiences with dysphoria” (White, queer nonbinary person). Others were concerned that the eating disorder field was predominantly for White, cisgender women, a focus that failed to meet the needs of TGD individuals: “There’s this trend where thin, white, cis-women dominate the eating disorder field (from my experience, at least), and I find it maddeningly unhelpful when someone thin and ‘perfect’ (according to society) is telling me I need to gain weight, or that my body is good, when they don’t know what it’s like to live in a body that constantly brings on misgendering, etc.” (White, queer, nonbinary person). Together, these participants express the importance of dually encouraging positive body image development through discussion of diverse ideals while supporting individuals’ needs related to aligning their physical appearance with their gender identity, particularly in the context of exposure to misgendering and pervasive stigma and discrimination.

3.1.4. Theme 1.4: Being Responsive to Trauma

The final subtheme in this category was mentioned infrequently but is notable given the extant research demonstrating that TGD populations are disproportionately affected by violence victimization and other forms of trauma. A small number of participants (n = 3) emphasized the importance of making sure that program content is trauma-sensitive, noting that discussions surrounding the body have the potential to be triggering: “There is also a need to understand when and where to talk about dieting, fatphobic comments, bodyshaming etc. There needs to be warnings before these conversations occur in public, as it can be triggering” (Afro-Latinx, polysexual/demisexual/demiromantic nonbinary person). Other participants felt that conversations about the body had the potential to be affirming, even in the context of prior trauma:

Use inclusive language that respect our bodies. What would help me is if I see and hear that my body is my body. I am who I am regardless of what I have or don’t have between my legs. It would’ve helped to hear that my body is not an apology. Just because im trans, it doesn’t mean I get the short end of the stick. I’m deserving of love. I’m a sexual assault survivor, and I didn’t know that my body was valuable. I sometimes forget and try to remind myself.

(Asian, queer, trans man)

Examining this theme in concert with Theme 1.1 (regarding the inclusion of gender discussions in program content) points to an important dialectic. While participants drew attention to the value of creating a space for people to explore gendered appearance ideals and pressures, participants also underscored the necessity of attending to the possible effects of trauma in the lives of participants, including gender-based trauma and the potential for health programs to unintentionally re-traumatize. Indeed, programs will need to acknowledge that intersecting forms of structural discrimination (e.g., anti-transgender laws and policies, systemic racism via the legal system) and pervasive surveillance of TGD peoples’ bodies and lives represent significant barriers to feeling safe in or accepting of one’s body.

3.2. Domain 2: Key Considerations for Delivery of Eating Disorder Prevention Programs

Many participants detailed specific suggestions about the ways in which eating disorder prevention programs ought to operate. These included recommendations that aligned with four themes: (2.1) group composition, (2.2) intervention modality, (2.3) program leadership, and (2.4) addressing barriers to participating.

3.2.1. Theme 2.1: Group Composition

To be most effective for TGD communities, many participants (n = 28) felt that eating disorder prevention programs ought to be specifically for TGD people. For example, one participant shared “A forum or group with a wide variety of trans people with different experiences and identities can help. With that kind of environment, I think you get a better perspective of how there is no one way to be trans. There is no one trans body. And there is no one way to transition. There is a certain comfort in this variety. It’s like: we may not look the same, we may have different goals, but we are on the same journey of self realization” (White, pansexual trans woman). Others expanded that the group should be specific to their gender identity, for example: “I feel most comfortable online in ftm [“female-to-male”; i.e., trans men] only support groups. Because I can voice my concerns and get feedback from others that have already gone through it or are going through the same thing as me and learn from my questions” (White and Native American, pansexual trans man). Further, participants felt groups should consist of people of similar ages, with separate spaces for adolescents and young adults: “I think it’s important to have people of the same age together. As a struggling adult, I see space for conversation happening, but there is often a lot of youth involved, and most of the conversation is then centered on them, and it doesn’t give me much opportunity to voice my concerns” (White, queer trans man). Some participants offered examples of groups they had participated in, to serve as models for future eating disorder prevention programs. For example, “An ideal space where I feel supported and safe would definitely be kind of a version of [local group name], it’s this trans masc group that meets every other week and each week has a topic to discuss/educate but also there is just community building and getting to know each other and advice seeking and it all happens really organically” (White, queer nonbinary person). Overall, participants who spoke to this theme indicated that, for eating disorder prevention programs to be most effective, they ought to be composed of TGD individuals of similar ages who are able to express themselves authentically.

3.2.2. Theme 2.2: Intervention Modality

Nearly a quarter of participants (n = 16) provided suggestions for the intervention’s modality. Although data were collected before the proliferation of digital and tele-health approaches to mental health that accompanied the COVID-19 pandemic, many respondents felt that an anonymous, online platform would best meet their needs. Participants described feeling they could be their authentic selves online. For example, one participant shared “Having support groups online help me the most. I know that I am vaild [valid] for my authentic self” (White and Native American, pansexual trans man) while another explained “For me the internet was my saving grace. My safe space to be who i wanted to be free from anyone’s influence or expectations” (Latinx, pansexual trans woman). However, this same participant also shared concerns that online formats are unsafe in the face of transphobic content, and recommended anonymity: “I wish anonymity and/or a layer of protection weren’t so necessary, but in this day and age I don’t think we have much of a choice…one always has to be careful to protect themselves, maintain a certain arms length, or risk suffering emotional harm via the cruel attacks of the transphobic element.”

3.2.3. Theme 2.3: Program Leadership

Program leadership emerged as a concern for many participants (n = 15). While many eating disorder prevention programs are peer-led, participants reported they would prefer having a clinically-trained professional leader present: “I think it’s helpful to have therapist guided sessions rather than simply peer mediated sessions” (White, bisexual trans woman). It was recommended that therapists be trained in working with LGBTQ+ populations and have experience navigating body image concerns. There were a range of perspectives about whether a leader should have lived experience relevant to the group, and which dimensions of lived experience were most crucial to effectively lead. For example, several participants specifically felt that group leaders should identify as TGD. Participants expressed “i think if a program were to be developed for trans and nb people, it should be run by trans or nb people, perhaps those who have also struggled with their body image” (White and Native American, bisexual trans man) and “having other trans people (especially a trans therapist/dietician) would certainly help, but I can’t imagine that stuff existing in the level of care that’s recommended to me” (White, bisexual trans man). In contrast, one participant shared that a group of TGD young people would suffice, even if the therapist was not TGD: “group therapy made up of trans people seems to be the best thing ever even more so. That way the therapist doesn’t have to be trans and can just be a moderator” (White, bisexual agender person). Some participants also emphasized that the therapist ought to be a person of color (POC): “If a white person came in and told me how I should feel about my body and tried to offer support, I would probably struggle to take them seriously. I would also struggle not to see them through the lens of a white savior coming in to tell all the POC to feel better about their bodies when there are a lot of other things POC are worried about and when white people had full authority over black bodies (and in some cases still do with legislation, the school to prison pipeline, etc.) in the past. It would be more meaningful to hear a POC talk about body image because I’d be more likely to have similar lived experiences” (Black, pansexual nonbinary person).

3.2.4. Theme 2.4: Barriers to Access

It was important to participants (n = 7) that interventions directly address economic barriers to participation. Because eating disorder-related treatment is often expensive, respondents shared that it can be inaccessible: “You know what would’ve been helpful for me when I was younger? Affordable treatment. I couldn’t afford to go into a treatment facility” (Latinx, bisexual demiboy). Rather, participants felt eating disorder prevention programs should be free: “These programs… should also be free in consideration of the bias and discrimination that trans poc experience and how that can affect finances” (Latinx, pansexual nonbinary person). One participant discussed the difficulty of accessing care through their parents, preferring anonymity: “I would also suggest building a layer of anonymity into the system so that people are able to ask for resources without going through parents first” (Asian, lesbian trans woman). Another discussed unique challenges for trans men – highlighting the lack of discussion about men and eating disorders: “I’m finding more and more researching showing how susceptible trans men are to eating disorders, myself being one of them. i think there needs to be a private, almost discrete platform for youth to talk about these issues without exuberayting [sic] them” (White, queer trans man).

3.3. Domain 3: The Imperative to Cultivate Affirming Spaces

An underlying thread that ran through many participants’ narratives spoke to the need for any preventive intervention to create an environment where TGD young people can feel safe and affirmed. This underlying thread constituted a third domain, comprising three themes: (3.1) the need to feel free from judgment, (3.2) the need to include the perspectives of TGD individuals with lived experience of body dissatisfaction and/or disordered eating, and (3.3) the need for strict moderation policies to ensure participant safety.

3.3.1. Theme 3.1: Creating an environment free from judgment

Many participants (n = 24) underscored that for a space to feel safe and supportive it needed to foster a feeling that one could be one’s true self. For some that meant being seen as their correct affirmed gender: “in general, I feel most supported and welcomed when I’m with my friends, with whom I’m accepted and get to feel as though I’m any other girl” (White, questioning, trans woman). For others that meant not being held to rigid gender expectations. As one participant recounted: “Make sure that everyone is actually accepted. I’ve been turned away from so many groups for being “too binary” when I lived in [western US state], being “not binary enough” when I lived in [eastern US state]… There should be a space where everyone fits without having to fight for one or being turned away” (White, asexual trans man).

3.3.2. Theme 3.2: Include perspectives from TGD individuals with lived experience

The second strategy for cultivating affirming space came from participants (n = 8) who recommended including the perspectives of TGD individuals with lived experience navigating body image concerns and/or disordered eating. For example, one participant shared “I think I got all go [of] my positive body image from fellow trans people. So I think it would be nice to have different trans folks and say ‘you non binary kid, here are tons of ways to show your non binary’” (Latinx, pansexual trans man). Another emphasized the intersectional aspects of lived experience, as these intersections underscore critical differences in experiences of power and systemic inequality: “Listen to plus sized people who are people of color especially, weight affects us very differently than white plus sized people, we have less access to resources…Listen to people who’ve recovered from eating disorders” (Latinx, queer nonbinary person).

3.3.3. Theme 3.3: Enforcing moderation policies to ensure safety

A third recommendation for cultivating affirming spaces included the enforcement of strict moderation policies (n = 5). Some participants observed that having a trans-specific space alone would not be enough to ensure safety. As this participant explained: “I would like for health providers/program staff to know that just simply establishing a “trans space” for trans/NB people is not enough to secure their comfort and safety” (Latinx, queer trans man). Some participants specifically highlighted safety concerns related to eating disorders and online environments, such as “I think, if this platform was to exist, it would need to be closely watched before it could get out of hand, much like those holes of tumblr where eating disorders are romanticized” (White, queer trans man). These participants’ comments emphasized the need for intervention developers to engage with community stakeholders in order to identify a full range of safety considerations and strategies to maximize participant safety.

4. DISCUSSION & IMPLICATIONS

This exploratory study of the perspectives of 66 TGD young adults across the US offers important insights into development or adaptation of eating disorder preventive interventions to ensure such interventions are relevant and effective for TGD young people. Given the disproportionate burden of eating disorders and disordered eating behaviors experienced by TGD adolescents and young adults (G. R. Brown & Jones, 2016; Diemer et al., 2015; Guss et al., 2017; Roberts et al., 2021; Simone et al., 2022), and given TGD young adults’ elevated exposure to discrimination and structural violence (James et al., 2016; Reisner et al., 2016), it is imperative that prevention programs effectively meet the needs of diverse TGD young people. This need is more urgent than ever in the context of mounting local-, state-, and federal- legislative efforts to roll-back the human rights of TGD youth (Barbee et al., 2022; Lepore et al., 2022), and the toll that such assaults can take on the mental health of TGD populations (Hughto et al., 2022; Reisner et al., 2015).

Participants’ narratives spoke to several ways that ED prevention programs should be developed or tailored to address the needs and experiences of TGD young people, including acknowledging the limits of existing ED research and ensuring that program content is responsive to trauma. Two of the most common themes related to the need for programs to (i) address the complex ways that gender and gender norms play out in young adults’ lives and (ii) to take an intersectional approach to positive representation of diverse bodies and diverse trans lives. Recommendations that content be tailored to acknowledge the important and diverse roles that gender can play in ED risk align with recent calls for including more critical gender analysis in public health programs (Calzo et al., 2018) and research (Restar et al., 2021). There was not simply one way that participants conceptualized gender in relation to ED prevention. For example, findings underscored the need for programs to be gender affirming—which aligns with prior research on gender affirmation as vital for TGD populations’ body image and overall health and wellbeing (Romito et al., 2021; Sevelius, 2013; White Hughto & Reisner, 2016). In addition to centering gender affirmation, other participants highlighted the need for spaces that encourage gender exploration specifically, and provided space for constructive critique of gendered body ideals. This gendered critique may be similar to that offered by cognitive dissonance-based interventions (e.g., T. A. Brown & Keel, 2015; Stice et al., 2012) but prior evidence-based interventions have largely been cisnormative (i.e., centering conversation on gendered appearance ideals as they impact cisgender people). Our findings indicate an interest in content that is tailored to constructive critique of gendered body ideals as they impact those of other gender identities. Further, this recommendation should be considered in light of some participants’ desires for spaces to discuss the unique features of body image for TGD populations, including the role that dysphoria may or may not play in body image and the message that there is “no one way to be trans.” This aligns with recent research in this same study sample (Hartman-Munick et al., 2021) and in others (Romito et al., 2021; Testa et al., 2017) that gender dysphoria may be important to ED prevention for some TGD youth but not for others.

Participants’ call for more positive representation of diverse trans bodies and lives aligns with intersectionality frameworks, developed by Black feminist scholars and activists (P. H. Collins & Bilge, 2016; Crenshaw, 1989). Intersectionality frameworks demand that research and public health programs make visible the ways that multiple dimensions of power and privilege, as they relate to individuals’ social identities and social locations, are fundamental drivers of health and wellbeing, including inequities in EDs (Burke et al., 2020). By extension, positive representation and a focus on gender euphoria (Beischel et al., 2022), as suggested by participants in this study, can offer a celebratory contrast to the harms imposed by intersecting vectors of social oppression in TGD young people’s lives. Future research on program development should examine the potential for positive representation to be a component of ED prevention for diverse TGD young people.

In the domain of delivery of ED preventive interventions, participants highlighted key considerations with regard to group composition, group leadership, intervention modality, and the need to address the multilevel barriers to participation. Many participants described a need for prevention programs to be specifically designed by and for TGD young people, and to have program moderators with lived experience and/or shared identities (e.g., being a trans community member, being a person of color, and/or having a history of recovery from an eating disorder). This aligns with research on the power of community-led initiatives (S. E. Collins et al., 2018) as well as peer-led and peer co-led ED preventive interventions (Breithaupt et al., 2016; T. A. Brown & Keel, 2015; Ciao et al., 2021; FEDUP Collective, 2023; Stice et al., 2020). However, this was not a unified perspective, as participants also voiced interest in group moderation or program leadership by professional clinicians with strong training in TGD health, regardless of shared identities or lived experience. There was also some interest expressed in more gender-specific spaces, such as a group specifically for trans men. This aligns with the longstanding use of gender-specific cognitive dissonance-based interventions (e.g., T. A. Brown & Keel, 2015; Stice et al., 2012). Research to date has tested these interventions in presumed cisgender populations and has not included tailoring for TGD young people. Promising new interventions focused on TGD populations may soon offer more specific evidence for the efficacy of interventions that are for TGD people of all genders (e.g., Equip Health, Inc., 2022). There remains a need for research examining the strengths and limitations of programs for TGD people of all genders compared to gender-specific programming.

In terms of intervention modality, digital modalities such as online topical groups surfaced as a preferred modality, and findings underscored the strengths of anonymous online spaces for enabling people to connect, share a more authentic self, and feel supported by like-minded peers. This aligns well with the recent growth of research and testing of digital interventions, including for ED prevention (Kass et al., 2017; Nemesure et al., 2023; Ong & Sündermann, 2022). At the same time, safety-related considerations in online spaces must be considered, underscoring the need for strong moderation and attention to creating protected spaces for exploration.

Findings regarding program delivery preferences also spoke to the need for program developers to address the entrenched and multi-level barriers that may make it hard for TGD young people to access any eating disorders prevention or treatment services. Discrimination in healthcare environments is well documented (James et al., 2016; Wall et al., 2023), including in eating disorders treatment settings (Duffy et al., 2016). Anticipation of such mistreatment in health-related settings could act as a barrier to participation in programs (Kcomt et al., 2020); this further underlines the need to work with community leaders in any given setting to identify such barriers and community experiences and build trust moving forward. Pervasive anti-transgender stigma and discrimination in home, school and employment opportunities leads to economic inequities, meaning any program with a cost will inherently exclude some participants who would benefit from services. Such economic inequities experienced by TGD populations are documented (James et al., 2016) but remain underexplored in terms of how economic constraints can exacerbate eating disorders risk while also impacting TGD young people’s access to eating disorders prevention and treatment services. For example, food insecurity is a documented predictor of disordered eating (Hazzard et al., 2020; Zickgraf et al., 2022) and may be an important domain to consider in the development of ED preventive interventions.

Finally, the third domain of our results underscored that it is critical for any preventive intervention to thoughtfully cultivate an affirming space for TGD young people to explore body image concerns and joys. Participants identified both general needs (e.g., being in a place where they can feel free from judgment) and very concrete strategies for building affirming spaces (e.g., including people with lived experience in the development process, having clear moderation and inclusivity policies). Informed by best practices in community-engaged program development (Highfield et al., 2015; Nápoles & Stewart, 2018; Rhodes et al., 2017) and equity-centered design (Intentional Futures, 2020), it will be crucial to make sure that the creation of such gender affirming spaces is an iterative process, and that there are mechanisms in place for evaluation and modification in response to shifting youth needs, changing language, and unpredictable external forces. For example, the rapidly changing policy landscape, particularly a surge in state-level anti-transgender policies, including policies banning access to vital gender-affirming healthcare and preventing equal access to school resources (Movement Advancement Project, 2022, 2023), might exacerbate disordered eating risk and other adverse mental health outcomes for TGD young people and change their specific programmatic needs. Programs will need to be responsive to those changing needs.

4.1. Limitations

Findings should be considered in the context of a few limitations. By design this study recruited an exclusively online sample, which means that the perspectives of those who experience barriers to high-speed internet access or are otherwise under-resourced may have been missed. This could have particular implications for our findings related to preferring online intervention modalities since participants who were able to access the online focus group platform by definition already had at least some access to digital platforms. That said, digital access is nearly ubiquitous among young adult populations (Perrin, 2021) and use of digital interventions has only increased since this study was conducted due to COVID-19 pandemic-related increased uptake of tele-mental health platforms and other digital health interventions (Gorrell et al., 2022; Montoya et al., 2022; Taylor et al., 2020). Second, the study included participants both with and without a history of ED or disordered eating behaviors and we were not able to analyze results for potential variation by lived experience of eating disorder diagnosis or treatment. Future research should explore differences in prevention program needs among TGD young adults with and without lived experience of disordered eating. Finally, asynchronous online focus group methods confer many strengths but also face limitations related to reduced within-group interaction (Gordon et al., 2021]; thus, different insights might have been shared in a traditional in-person focus group discussion. Further, focus group methods in general confer both benefits and drawbacks. A focus group approach was selected because the researchers sought to create a space for TGD young adults to both individually and collectively make meaning of the factors that should be considered for ED prevention programs, an aim that aligns well with scholarship on the use of focus groups to foster group processes that can “help people explore and clarify their views in ways that would be less easily accessible in a one on one interview” (Kitzinger, 1995, p. 299). However, it is possible that individual interviews would have yielded different findings, particularly if participants did not feel comfortable sharing responses they perceived to be less socially acceptable by members of the group. Nevertheless, key strengths of this method included that it enabled us to recruit a geographically, ethnically, and gender diverse sample of TGD young adults from across the US, and that, as reported elsewhere, engagement across the four-day focus group period was extremely high, with 80% of participants responding to at least 6 of the 8 focus group prompts (Gordon et al., 2021).

5. CONCLUSION

Given elevated risk of ED and disordered eating behaviors among TGD young people, it is imperative that TGD community members’ voices and expertise guide the development of preventive interventions. This novel qualitative study of 66 transgender and gender diverse young adults from across the US offers a collection of such expertise in the hopes of informing such program development. This study’s findings underscore growing calls in the ED field for the use of an intersectional lens to examine and address longstanding inequities in eating disorders risk as well as in access to prevention and treatment services (Burke et al., 2020). The findings have implications both for adaptation of existing evidence-based preventive interventions to better meet the needs of TGD participants in these programs, and for the development of de novo preventive interventions created in partnership with TGD communities. This study highlights the need for programs to address more than body satisfaction alone and to take a social ecological approach that will support young people as they navigate multiple intersecting forms of social oppression, including navigating the role of gender norms and structural violence towards TGD young people, particularly TGD young people of color, while also centering and celebrating the strengths and power of gender diversity and TGD communities.

Highlights.

• Evidence-based eating disorder (ED) prevention programs are not one-size-fits-all

• Transgender young adults described unique needs for ED prevention programs

• Eight asynchronous online focus groups identified unique needs

• Several strategies highlighted for ensuring programs cultivate affirming spaces