“there is a paywall to my happiness”: The influence of socioeconomic determinants on transgender and gender diverse young adults’ experiences with eating disorders

Abstract

Transgender and gender diverse (TGD) young adults experience elevated risk for eating disorders (ED), partially due to cissexist discrimination and victimization; less is understood about how socioeconomic determinants contribute to their ED risk. Qualitative data collected from 66 TGD young adults (18-30 years old; 29% self-identified as transgender women, 29% as transgender men, 39% as nonbinary people, and 3% as another gender identity (e.g., māhū)) in eight asynchronous online focus groups explored how socioeconomic determinants in conjunction with other dimensions of identity and lived experience shape disordered eating behavior (DEB) and ED risk. Participants described how economic barriers—including poverty and dependency on others (e.g., parents for health insurance)—and challenges produced by insurance and healthcare systems impeded healthcare access to the detriment of their overall mental health and risk for ED. In addition, participants shared different ways they leveraged financial resources to cope with stress, sometimes in ways that impelled disordered eating behaviors. Finally, participants described how poverty, socioeconomic advantage and disadvantage, and classism compound other systems of oppression (e.g., racism, ableism, weight bias) to adversely impact their general health and ED risk.

Transgender and gender diverse (TGD) populations report elevated rates of eating disorders (ED), with lifetime prevalence rates ranging from 2% to 18% (Coelho et al., 2019). TGD young adults have 2-4 times the odds of engaging in disordered eating behaviors (DEB) compared to their cisgender peers (Diemer et al., 2015). Cissexist discrimination and victimization based on gender identity and expression are key determinants of gender-based health inequities, including related to DEB and ED (Bauer & Scheim, 2019; Gordon et al., 2016; Testa et al., 2017). Less is understood about how socioeconomic determinants, such as income, education, employment, and place of residence (Galobardes et al., 2007) contribute to ED risk in TGD populations.

EDs affect individuals across all socioeconomic strata (Huryk et al., 2021), with recent research focusing on the impact of resource insecurity on ED risk (Becker et al., 2017; Fournier et al., 2009; Hazzard et al., 2022). In studies with community and college student samples, individuals experiencing food insecurity have been found to have elevated risk for bulimic-spectrum disorders (Becker et al., 2017; Hazzard et al., 2022). Adopting a life course perspective, socioeconomic determinants may uniquely shape the development, treatment, and recovery experiences of TGD young adults with ED. Quality medical insurance is often tied to type of employment, and experiences with cissexism and discrimination across education and work settings (Grant et al., 2011) may result in achievement and employment disparities that leave TGD populations with inadequate insurance coverage for ED. In addition, TGD young adults are more likely than their cisgender peers to report resource instability, such as food insecurity (Arikawa et al., 2021; Linsenmeyer et al., 2021), which can impact dietary behaviors and increase risk for engagement in DEB, including dietary restriction and binge eating (Becker et al., 2017; Hazzard et al., 2022).

Research on ED among TGD young adults has often focused on the protective effects of receiving gender affirmation to mitigate gender dysphoria (i.e., the sense of distress or dissatisfaction a person experiences because of a mismatch between their gender identity and their biological sex) (Riddle & Safer, 2022). Gender affirmation is a complex, life course process, encompassing social (e.g., acknowledgement of correct pronouns), psychological (e.g., experiencing gender euphoria), medical (e.g., gender affirming surgery), and legal (e.g., legal name change) domains (Scheim & Bauer, 2015). Not all TGD individuals experience gender dysphoria or experience gender dysphoria in the same way, nor do all TGD individuals seek every form of gender affirmation (Kearns et al., 2021; Nieder et al., 2020). Prior research has found that receiving gender affirmation is associated with increased body satisfaction, decreased gender dysphoria, and reductions in DEB and ED risk (Riddle & Safer, 2022; Testa et al., 2017). However, the pursuit of gender affirming interventions includes economic costs. Further, the geographic maldistribution of gender affirming providers may increase economic burden for TGD patients seeking healthcare (Downing et al., 2022; Gamarel et al., 2021). Affirming providers are concentrated in urban centers (Downing et al., 2022; Gamarel et al., 2021), and access to such providers is increasingly constrained within the current socio-political climate, in which some states and jurisdictions are restricting access to affirming health care to youth and adults (Ghorayshi, 2023; Redfield et al., 2023). TGD young adults may engage in DEB as a means of achieving gender affirmation or to cope with minority stress (Gordon et al., 2016). DEB are frequently associated with physical and mental health comorbidities (e.g., cardiometabolic health risks; depression; substance use) (Calzo et al., 2016; Micali et al., 2015). In addition, TGD youth have a higher risk of experiencing co-occurring health conditions relative to their cisgender peers (Newcomb et al., 2020), and may thus present for ED treatment with costlier healthcare needs.

It is critical to examine socioeconomic oppression (e.g., poverty, classism) with respect to how it intersects with cissexism and other forms of oppression faced by TGD young adults in shaping ED risk, given the historical impact of, for example, racism on economic inequality (Crenshaw, 2014). As such, this study is guided by intersectionality theory, which originated in the work of Black feminist scholars to explain the unique experiences of oppression faced by Black women in social, legal, economic, and political domains, and delineates how interlocking systems of power and oppression work together to advantage some groups at the expense of others (Collins, 2015; Crenshaw, 2014). In one prior qualitative study of young adult, low-income, ethnically diverse transgender women, participants described growing up in contexts that were often simultaneously heterosexist, cissexist, and weight-stigmatizing (Gordon et al., 2016). Additional research can unpack how socioeconomic determinants, uniquely and at the intersection with cissexism and other experiences of privilege and oppression, across social, legal, and health contexts contribute to eating disorder risk in TGD populations. We used qualitative methods to give voice to the myriad ways that socioeconomic determinants shape DEB and ED risk among TGD young adults.

Method

Participants and Procedure

From August to October 2019, TGD young adults were recruited for a mixed methods study to identify needs and opportunities for ED prevention. Thus, the current research was a secondary data analysis of the focus group data from the mixed methods study. Eligible participants were ages 18-30 years, lived in the United States (US), were conversant in English, who identified as transgender or nonbinary, and had access to a device with internet access. We recruited participants via: (1) social media posts by 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; (3) email outreach to LGBTQ community organizations; (4) chain-referral sampling; and (5) email to previous participants in the senior author’s TGD health research projects who requested contact about research opportunities.

We hosted asynchronous online focus groups on the platform Discourse.org, a subscription-service with a dynamic online message board, which allowed moderators to post prompts and participants to respond at their convenience. Participants were instructed to choose an anonymous username. The study coordinator posted two prompts per day (i.e., morning and evening) over the course of four consecutive days with manual post-approval enabled by administrators. Two trained moderators elicited dialogue and thick description (i.e., participant perspectives on the contexts and interpretations of their behaviors) by asking follow-up questions and inviting responses from other focus group participants on participant responses when appropriate. Eight focus groups were conducted with 5 to 11 participants per group, with participants grouped based on their preference (i.e., group with participants of their same gender identity, a group for people of color, a non-identity-specific group, or no preference). More information on the focus group approach used in this study has been shared in a prior publication (Gordon et al., 2021).

Participants received a $25 digital gift card for completing the pre-focus group survey (which gathered data on self-reported age, gender identity, race/ethnicity, highest level of education, and housing security status; instrument available upon request from the senior author) and an additional $25 digital gift card if they posted at least once per day on three out of the four days of the focus group. Study engagement was high, with 80% responding to at least six of the eight total prompts. Study procedures were approved by the Boston Children’s Hospital Institutional Review Board. The authors report there are no competing interests to declare.

Focus group guide.

A structured focus group guide was first developed by the core data collection team (A.R. Gordon and moderators) and then iteratively revised through consultation with FEDUP and a clinical psychologist with expertise in youth populations. Focus groups began with introductions and a social identity wheel exercise (adapted from University of Michigan, n.d.) in which participants self-described aspects of their own identities and lived experiences (e.g., sexual orientation identity, socioeconomic status), circled identities that affect how they feel about their appearance and/or bodies, and starred identities that affect how others perceive them. The remaining prompts centered on appearance ideals, the impact of social media and dating apps on appearance ideals, coping behaviors, sources of stress and support around gender identity, definitions of gender affirmation and how they relate to body satisfaction, experiences with gender affirmation, and recommendations for developing programs to support positive body image development and to prevent ED for TGD young people. As participants could raise topics related to socioeconomic status (SES) in response to any question, data generated from all domains in the focus group guide were analyzed.

Analysis

We calculated descriptive statistics on pre-focus group survey demographic data to describe the focus group sample. Focus group responses were analyzed using the rapid and rigorous qualitative data analysis (RADaR) technique (Watkins, 2017), with 4 iterative rounds of data reduction to yield the presented themes. First, drawing from prior research on SES and health (Glymour et al., 2014), we extracted all excerpts related to SES, including references to housing status, education, insurance, income, class, employment, buying/consumption and purchasing, food insecurity, financial strain, access to healthy foods, economic tradeoff, perceived status (relative deprivation, social comparison), and debt (n= 236 excerpts). In subsequent rounds, we removed excerpts that had low or no relevance to our primary research question (e.g., no clear direct or indirect connection to body image or disordered eating; no clear content focused on SES upon secondary review) (Watkins, 2017) (n= 109 excerpts retained). Second, we used open coding and memos followed by the development of a codebook (Saldana, 2015; Watkins, 2017). We then tested the codebook on a subset of four transcripts using consensus-building to reconcile discrepancies until agreement on the coding application was achieved (Saldana, 2015; Watkins, 2017). We systematically coded all focus groups with a minimum of two coders and reconciled discrepancies through discussion (Saldana, 2015). Finally, we sorted data by code, then examined the frequency of code co-occurrences to understand linkages between codes and excerpts. Themes were developed using multiple strategies including identifying repetition and deviant cases, constant comparisons of text, and close reading of metaphors and analogies for meaning-making (Saldana, 2015).

Results

Focus Group Sample

The 66 young adult (18-30-year-old) study participants lived in 25 states across the US (see Gordon et al., 2021 for mapped distribution). Approximately 29% identified as transgender women, 29% as transgender men, 39% as nonbinary people (e.g., nonbinary, gender nonconforming, gender fluid, genderqueer, agender), and 3% endorsed another gender identity (e.g., māhū). 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. Regarding markers of socioeconomic position, 38% reported having at least a college degree, 49.3% reported having attended some college, but not graduated, and 12.7% reported not graduating high school. In addition, 12.7% of participants reported experiencing unstable housing in the past six months.

Key Themes and Synthesis

The analysis identified interrelated processes by which socioeconomic determinants shape ED risk among TGD young adults (Table 1). When providing illustrative quotations for each theme, identity markers (age, race/ethnicity, socioeconomic position, gender identity) are provided to identify participants as described verbatim in participants’ social identity wheels.

Table 1.

Themes, theme definitions, and examples

Themes	Definition	Example Quotation
1. Economic Barriers to Healthcare Access
1a. Poverty and dependency limit access to health care, which contributes to psychological distress and may exacerbate body dissatisfaction and disordered eating behaviors	Participants described frank financial barriers to accessing care. Although some were able to overcome such barriers through their status as a dependent, the burden of poverty caused substantial psychological distress, and contributed negatively to body image and disordered eating.	“My general anxiety/social anxiety/depression cause a lot of body dysmorphia/dysphoria because I feel like I cannot trust my perceptions of myself and what I look like, leading to eating disorders. My socioeconomic status keeps me from affording clothing/medication and acts as a distraction from my ability to contemplate my gender, causing me to feel more confused about who I am. My body size/shape is the biggest factor that influences how I feel about my appearance and body. I have a curvy body and loose skin because of rapid and large changes in my weight. This affects which clothes I can fit into and feel good in. This often keeps me from wearing “masculine” clothing and, instead, relying on dresses and skirts to “flatter” my body type.” (25-year-old, “White & Mexican, working class, nonbinary, GNC, Big Question mark?” participant)
1b. Navigating health insurance is a barrier to ED treatment, medical gender affirmation, and other medical needs, potentially leading to increased psychological distress and disordered eating	Participants described the direct (e.g., financial) and indirect costs (e.g., time lost, stress) of navigating health insurance to access eating disorder care, medical gender affirmation, and other medical needs.	“Stress? HEALTHCARE. Has to be number one, constant stress in my life. navigating insurance and healthcare while trans has been a nightmare for me.” (“early 20s, nonbinary”)
1c. Policy environment shapes access to care	Variation in the geopolitical environment around insurance coverage for gender affirming healthcare further exacerbates health the health experiences of TGD young adults.	“Only about a year or so into transition, I learned I was going to have to move to a new location and new job where the provided insurance had a blanket exclusion on all gender affirming healthcare. This would mean no coverage of HRT, bottom surgery, top surgery, etc…” (29-year-old, “White, privileged upper middle class, transgender woman”)
2. Financial Spending and Coping
2a. “Retail therapy”	Participants described spending with the intention to alleviate stress or improve mood.	“Another activity that I do is go browsing and shopping for mens apparel. When I am looking around at clothes, it’s easy to shut everything out and focus on something that I see positively, which is having fun creating a wardrobe that fits who I am for once. Even if I don’t find anything that fits me right, I enjoy the search.” (23-year-old, “Latinx, middle class, trans male”)
2b. Cost-free methods of coping	Participants describe low- or cost-free methods of coping with stress or improving mood.	“I’ve been writing. I was surfing a bit, but that’s been a bit harder since transitioning. Hoping to get back into it soon. I take walks. I spend time with my wife and dog. We go camping and hiking.” (30-year-old, “Italian/Swedish/American, middle class, woman”)
3. Socioeconomic Position and Opportunity Structures for Health
3a. Obtaining higher education and being in higher education settings are protective factors and settings for mental health	Postsecondary education provided them with access to affirming spaces, often inclusive of multiple forms of diversity (e.g., race, ethnicity, sexual orientation, gender, ability). In addition, college and university settings provide access to vital healthcare (e.g., mental health providers, gender affirming care), often at a substantially reduced cost	“My university allows me to use my chosen name on my ID, nametags, etc., so I’ve been lucky enough to not have to experience much deadnaming.” (19-year-old, “Polish/Italian, lower middle class, transgender male”)
3b. Work as an inconsistent safety net	Work is a critical source of income and method of obtaining health insurance, but due to experiencing varying degrees of support or oppression in workplace settings, participants described work as an inconsistent safety net.	“When I came out as trans all of these behaviors amplified. I’d frequently walk into rooms where I’d find them talking about me, and the aggressive coworker’s behavior got so bad that I started carrying mace with me at work. Before I left, I repeatedly tried to talk to the owners and management about them. It was always thrown back in my face that it was my fault for making them uncomfortable, and that I shouldn’t have come out if I didn’t want them to treat me like this.” (28-year-old, “White, very lower middle class, female”)
3c. Intersecting social positions, including race, ethnicity, weight, and ability were related to SES and disordered eating behaviors	Participants described how low socioeconomic status may be a mechanism through which intersecting axes of privilege and oppression create disparities, as access to social determinants of health (e.g., housing, healthcare access) are less available to those with multiple marginalized identities.	“I learned that fatness is undesirable and intentional, that my body shape is “feminine”, that disabled bodies are worthless, and disabled people who “don’t look sick” are lazy liars. This is how others perceive me, it affects everything from income to housing to healthcare. (23-year-old, “White, middle class parents/personally poor, agender/non-binary” participant)

1. Economic Barriers to Healthcare Access

1a. Poverty and dependency limit access to health care, which contributes to psychological distress and may exacerbate body dissatisfaction and disordered eating behaviors.

Many participants described the high individual and collective costs of transition-related needs. As described by a 26-year-old, “Black/African-American, middle class, nonbinary” participant,

Transitioning is 100% an accessibility issue… being trans or nonbinary does not inherently mean that you will go through a medical or appearance transition, but if that is desired, then it requires the finances and insurance coverage to do so. Transitioning may include legal barriers to change your name or gender marker, financial barriers to finance a new wardrobe and haircut, and medical barriers accessing affirming support and healthcare. Transitioning is not cheap and many people cannot do it for financial and safety reasons…

Even with insurance coverage, the costs of medical gender affirmation may still preclude access. For some participants, being a young adult dependent on their parents’ insurance provided access to healthcare, but also exposed them to cissexism: “My dependence on my parents is a tricky and slippery slope of understanding the privilege of their support while not feeling as though they respect me as a person or my gender identity” (21-year-old, “White, dependent student, transmale”).

The high costs of healthcare can be distressing. As one 19-year-old, “White, lower middle-class, transwoman” shared, “it’s simple, there is a paywall to my happiness with all the surgery I will need to be gendered correctly, and I can’t afford it, let alone food, rent, education, and anything else someone needs. I feel trapped and hopeless.” Even with financial resources, some participants indicated that they could only afford some of these needs, which had direct consequences for their body image. For example, as shared by a self-described “late 20s, Mixed/White-washed, broke af, transwoman”,

I can’t be perceived as feminine by others if I can’t afford to look feminine. I don’t make a significant amount of money, and a large portion of it goes to bills. I’m lucky enough to be living at home so I can afford services like HRT [hormone replacement therapy] and Laser Hair Removal to help with expressing my identity, but I don’t have the money to – for example, refit my wardrobe easily or start saving up for potential surgeries in the future, all of which would assist in others perceiving me as I want to be perceived/as I perceive myself.

Economic precarity forces TGD young adults to make difficult decisions about whether to prioritize gender affirmation over other needs, including whether to eat. The same participant further shared,

Having to choose between food, comfort in my image (ie. Clothes, makeup), and medication/treatment is brutal… Constantly living on the edge of a knife makes it hard to maintain a healthy diet or eating patterns.

1b. Navigating health insurance is a barrier to ED treatment, medical gender affirmation, and other medical needs, potentially leading to increased psychological distress and disordered eating.

Beyond describing the financial burden associated with accessing different forms of healthcare, several participants described the direct (e.g., financial) and indirect costs (e.g., time lost, stress) of navigating health insurance to access ED care, medical gender affirmation, and other medical needs. One “early 20s, nonbinary” participant described how healthcare settings and insurance are not established in ways to support multiple, simultaneous healthcare needs:

…tgnc [transgender and gender nonconforming] people have to go to multiple different places for care to meet their needs… I have to literally see two different doctors, one to keep an eye on my ED and related bloodwork, and another who can use my correct pronouns, talk to me about sexual health…Getting insurance to understand that there is no one provider in their network who meets my needs has been a nightmare. And then, if like any other person, other health things come up, i have to choose over and over, do I want an OBGYN who understands what ED has done/is doing to my body or one who cannot misgender me every second while talking to my genitals…

Furthermore, participants noted that healthcare providers sometimes lacked sufficient knowledge around insurance coverage for ED or for gender affirming care. One 30-year-old, “White, middle class, woman” described paying out of pocket for services that could have been covered by insurance, therefore contributing to financial strain: “I know doctors usually think that’s not their job, but it would’ve been really nice to know that things like electrolysis can be covered by certain insurances or that the doctor could do referrals. I wasted a lot of money paying out of pocket for things covered.”

1c. Policy environment shapes access to care.

Participants also described how the inconsistent geopolitical environment around insurance coverage for gender affirming healthcare further exacerbated their health. As shared by a 29-year-old, “White, privileged upper middle class transgender” woman,

Only about a year or so into transition, I learned I was going to have to move to a new location and new job where the provided insurance had a blanket exclusion on all gender affirming healthcare. This would mean no coverage of HRT, bottom surgery, top surgery, etc…

Thus, where TGD individuals live determines their degree of healthcare access.

2. Financial Spending and Coping

Several participants described spending money as coping behavior to elevate mood. 2a “Retail therapy” described spending intended to alleviate stress or improve mood, which was often mentioned alongside other coping behaviors that may have implicit financial costs. As described by one 29-year-old, “White, middle class, male/nonbinary/agender” participant:

I try to shower/bathe, brush my teeth, do stretches/exercises, moisturize and take care of my skin every day. I feel like little things add up over time. […] I have also given myself permission to wear and buy more comfortable clothes. Even if other people don’t like it or I feel like I’m wasting money, it really does help me.

“Retail therapy” activities were not only used for appearance-focused activities. For example, several participants reported spending money on CBD or cannabis (e.g., edibles) to mitigate stress or elevate mood. Participants generally reported engaging in a range of coping behaviors that incur or imply a cost, but also reported 2b. cost-free methods of coping, such as journaling, having sex, and connecting with friends, which similarly enhanced their mood and helped them cope with general stress and encounters with cissexism. For example, as described by a 21-year-old, “Black, middle class, demi-girl”,

…here are some healthier ways I deal with things: Sleep, watch shows, listen to music, phone a friend, set goals, focus on accomplishments, exercise (rare), socialize, go shopping, go to an event, and have sex. Oh, I also sometimes take edibles.

3. Socioeconomic Position and Opportunity Structures for Health

Beyond discussions of financial barriers to healthcare access and economic activities that have implications for ED risk, participants described lived experiences related to opportunity structures that affect material resources and health, including ED risk. These include the role of higher education and employment, as well as the intersection of these domains with other processes of power and oppression (e.g., racism, ableism, weight bias).

3a. Obtaining higher education and being in higher education settings are protective factors and settings for mental health.

Seeking higher education may be considered a process or driver of economic mobility. As young adults, many participants indicated that they were currently in college; others had completed their college degrees. However, rather than describing the potential economic advancement associated with being a college student or graduate, multiple participants described how postsecondary education provided them with access to affirming spaces, often inclusive of multiple forms of diversity (e.g., race, ethnicity, sexual orientation, gender, ability). For example, as shared by self-described 19-year-old, “Caucasian, lower middle class, transgender male”,

I attended my university’s rainbow reception (basically a mini pride) this year, and it was one of the most welcoming situations I’ve ever been in. I was able to meet and interact with both other LGBT people and with allies, as well as find resources for everything from LGBT groups to help with transitioning. As someone from a small town where I knew about 3 trans people from my county, it was overwhelming to see so many people who were in the same situation I was in. It was crowded and full of people, but they were all friendly and were ready to accept me for who I was, and as an autistic person who is often ostracized, that was very important to me.

Colleges and universities provided vital healthcare, often at a substantially reduced cost: “70 bucks a month on hormones and I only get any therapy because its free for uni students here” (22-year-old, “White, Proletariat, transwoman”). However, as shared by one participant, postsecondary education settings were temporary safe spaces: “I used to feel a ton of support when I was in college… I wish I still had a space like that” (27-year-old, “White, middle class, male”).

3b. Work as an inconsistent safety net.

As young adulthood is a period in which young people begin to enter the workforce in earnest, it was not surprising that participants also shared varying degrees of support or oppression in workplace settings. Given the financial and health implications of employment (e.g., health insurance coverage; financial resources to obtain healthcare; potential exposure to cissexism via customer or coworker interactions), participants described work as an inconsistent safety net with respect to health. For example, one participant reported experiencing a microaggression at work, even in the context of an event geared towards building inclusivity:

I’ve had a supervisor tell me that trans issues aren’t that bad for kids (at a youth work agency). It left me feeling completely unsafe in that organization. I then had to lead a workshop on gender pronouns. If I didn’t do it, no one would have. Maybe one or two people out of twenty tried to get my pronouns right after that meeting. (26-year-old, “White, working middle class, gender fluid” person)

Participants also reported enduring overt hostility from supervisors and co-workers. In such situations, some participants were not able to leave due to financial necessity. Changing jobs can be retraumatizing as it creates additional opportunities for experiencing cissexism and discrimination. As shared by one participant,

I’ve been misgendered, deadnamed, and discriminated against in hiring. My legal name is still my deadname after a year and a half on hormones, so it is difficult for those who know my legal name to reconcile that with my female identity and chosen name. This makes things like career fairs an enormous undertaking, since I have to come out over and over again to potential employers and am constantly worried who among them might be transphobic. (“early 20s, South Asian/White, upper middle class, Trans Female”)

Several participants offset experiences of cissexism in one workplace setting by simultaneously seeking experiences of validation and affirmation in another workplace setting. For example, a 19-year-old, “White, lower middle class, transwoman” shared how they were “not really” validated at their “normal job”, but they felt “comfortable” and “pretty validated when [they] do [their] escort work.” However, working multiple jobs may introduce additional stress and indirect economic costs (e.g., time management, transportation, criminalization of sex work, etc.).

3c. Intersecting social positions, including race, ethnicity, weight, and ability were related to SES and disordered eating behaviors.

Participants also voiced their perspectives on how socioeconomic status may be a mechanism through which intersecting axes of privilege and oppression create disparities. For example, access to social determinants of health (e.g., access to healthcare) and financial resources are less available to those with marginalized identities, and cissexist appearance ideals are intertwined with other forms of oppression. As described by one participant:

Body ideals for trans men are whiteness, flat chests, muscle, strong jawline, facial hair, all things achievable only with privilege, whether it’s the privilege of having top surgery or even just getting on testosterone hormones. Trans men that are fat, non-white, not passing, are seen as less than. Ideals for trans women leave no space for mistakes. The goal in mtf and ftm communities is to pass and be unclockable. Trans women are not seen as real women unless their voice is high, jaw is soft, there are no signs of facial hair, bodies are curvy, sex reassignment surgery is done. (23-year-old, “White/Latinx/DR/Peru, lower class nonbinary” participant)

As elaborated by the participant, cissexist appearance ideals intersect with (at minimum) weight stigma, colorism, and racism. In addition, the process of medical gender affirmation (which for some TGD individuals is a means of achieving appearance ideals) requires access to healthcare in addition to financial resources. The participant implies that to embody a “trans body ideal” is to embody socioeconomic “privilege.”

Participants also described the need for programs to consider the other forms of stigma and trauma that they experience and not merely focus on addressing cissexism. As further elaborated by the same 23-year-old, “White/Latinx/DR/Peru, lower class, nonbinary” participant,

I think these [eating disorder] programs need to ensure, beyond representing non-binary and trans people in all of the shapes and colors and sizes that we come in, that we get help getting employed, getting on hormone replacement therapy if that something that is desired, that we have food and shelter, basic necessities.

To promote equity and inclusion, healthcare professionals and healthcare settings should also address the potential multiple forms of stigma, trauma, and needs TGD people endure.

Discussion

The findings extend prior work examining risk factors for disordered eating among TGD individuals experiencing economic precarity (Linsenmeyer et al., 2021), and suggest possible mechanisms for future investigation. Socioeconomic factors were described as interacting with cissexism, along with other intersectional axes of oppression, including racism, ableism, and weight bias, to further exacerbate ED risk. High healthcare costs, particularly when accessing vital services, such as gender affirming care and ED treatment, present unique challenges for TGD young adults, who are forced to balance basic needs (e.g., food), gender affirmation (e.g., buying clothes, make-up), and seeking health care. Indeed, research from the 2015 national US Transgender Survey found that among 25-34 year-old TGD participants, 42% reported past-year unmet healthcare needs due to costs (Kcomt et al., 2021). Although cost challenges were described by participants across all socioeconomic strata, the burden appeared particularly stark among participants who described themselves as being members of low-income socioeconomic strata, reported experiences of resource insecurity (e.g., housing, food), and for participants with multiple marginalized or minoritized identities and lived experiences. Our intersectional qualitative analysis identified that, at best, general healthcare and ED treatment settings may be gender affirming, which may address cissexism, but this is not enough to address the other forms of co-occurring oppression that TGD young adults face. Consistent with this finding, some participants recommended the need for gender affirming and ED interventions to also address stabilizing food, shelter, and other necessities. Healthcare affordability and evaluating and addressing basic needs are fundamental to expanding healthcare access for TGD young adults.

Complicated health insurance systems created barriers to improving participants’ general health and receiving support for ED. In the US approximately 1 in 6 transgender adults is uninsured or underinsured (Kcomt et al., 2021), but coverage has increased since the implementation of the Affordable Care Act, particularly among TGD people who are in relationships (Bolibol et al., 2023). However, even with insurance coverage, participants in the current study described direct (e.g., financial) and indirect costs (e.g., time lost, stress) associated with navigating health insurance. Beyond identifying and sustaining affirming healthcare providers for co-occurring healthcare needs (e.g., hormones and ED treatment), financial burdens (e.g., copays, procedures not covered) may persist, and limited support in how to navigate insurance can result in additional, unnecessary healthcare costs.

The inconsistent geopolitical environment around insurance coverage for gender affirming healthcare can further exacerbate health challenges, as described by participants who lost health care coverage due to changing jobs or with relocation. At the time of writing this manuscript, politically conservative legislators are engaged in an aggressive effort to restrict access to gender affirming care for youth and adults in the US (Ghorayshi, 2023; Movement Advancement Project, N.D.), with devastating effects on TGD youth’s current and future mental and physical health (Gamarel et al., 2021; Goldenberg et al., 2020), and increased socioeconomic costs with respect to additional travel, time, and out-of-pocket expenses to access vital care (Borah et al., 2023).

The findings revealed several opportunities for addressing shortfalls in healthcare access, but also revealed how cissexism within such contexts can further exacerbate health. Some participants obtained healthcare coverage through parents/guardians, emphasizing the positive impact of allowing young adults to remain on parent/guardian’s health insurance plans until they are age 26 (Centers for Medicare & Medicaid Services, N.D.). However, such coverage may expose TGD youth to cissexism from their parents/guardians, which can exacerbate their stress and mental health. Medical care interventions that increase family acceptance and delineate caregiver roles as TGD young adults learn to manage their own healthcare may help mitigate such conflicts (Gridley et al., 2016).

Employment settings can facilitate healthcare coverage, yet enduring cissexist abuse from supervisors, coworkers, and customers to maintain coverage and wages may increase minority stress. It is important for workplaces to enumerate safe space and antidiscrimination policies to protect TGD workers. Colleges and universities may provide free or low-cost social and mental health support services and medical services. Such settings also have the potential to serve as sites for the implementation of evidence-based prevention and treatment programs for ED (Grammer et al., 2020). However, postsecondary education spaces may not be accessible to all TGD young adults, and such spaces are only available to TGD college students for a limited time. TGD youth are more likely to experience bullying and victimization in primary and secondary school and to have higher rates of absenteeism than cisgender adolescents (Pampati et al., 2020), and such experiences are associated with lower overall academic achievement (e.g., lower grade point averages or likelihood of pursuing postsecondary education) (Kosciw et al., 2016).

TGD young adults utilized multiple behaviors to cope with stress, ranging from cost-free activities (e.g., sex, going for a walk, spending time with friends) to frank retail therapy. Although some behaviors incurred financial expenses, participants framed such activities as necessary self-care, and even means of experiencing gender euphoria and enhanced satisfaction with appearance. However, additional research should explore the context and effects of some the coping behaviors reported (e.g., cannabis use).

Limitations

Although the focus group guide included prompts about the connections between socioeconomic status and body image, there were no specific prompts concerning socioeconomic determinants and DEB. Nevertheless, it is a strength that discussions of socioeconomic determinants and disordered eating emerged organically in focus group discussions. The asynchronous online format may have limited within-group focus group interaction or facilitator probing. The focus group sample was large and diverse and included participants across socioeconomic strata, but the online recruitment method may have excluded young adults who are currently unhoused or who have limited technology access. However, internet access (via smartphone) is nearly ubiquitous among youth 18+ years and older, regardless of income level (Pew Research Center, 2021).

Implications and Future Directions

Participants clearly stated the need to address structural and systemic barriers to their healthcare access, such as state-level inconsistencies in health insurance policies, difficulties with healthcare administration and insurance, and expansion of healthcare access (e.g., gender affirming care, ED treatment, mental health). Broad efforts, such as Medicaid expansion, could increase health insurance coverage for individuals with low income, among who TGD and other marginalized and minoritized groups are overrepresented (Baker et al., 2016; Mallory & Tentindo, 2022). Furthermore, accessible clinical settings must also consider the potential resource needs of TGD patients. Clinical settings could implement case management to address issues of economic precarity, and patient navigation services to guide participants through any complications encountered with health insurance, including aftercare (Budde et al., 2021). Future research can explore how cost barriers, navigating insurance, economic opportunity structures, and spending-oriented coping behaviors function as mechanisms contributing to the development and maintenance of ED among TGD populations. Future studies may also examine how policy interventions that address systemic health coverage and resource gaps may mitigate gender disparities in ED.

Implications for the Field of LGBTQ+ Health and Body Image/Eating Disorders

Transgender and gender diverse (TGD) young adults have elevated risk for eating disorders compared to their cisgender peers. Discriminatory policies and victimization based on gender identity and expression are key determinants of gender-based health inequities, including related to eating disorders. Less is understood about how socioeconomic determinants contribute to eating disorder risk in TGD populations. This qualitative study identified myriad ways that socioeconomic determinants uniquely, and at the intersection with cissexism and other experiences of privilege and oppression, shape eating disorder risk among TGD young adults.