Transgender Clients’ Experiences of Eating Disorder Treatment

Abstract

This study examined the treatment experiences of transgender individuals with eating disorders (EDs). Despite this population’s elevated risk for EDs, clinicians may be ill equipped to treat these clients. Eighty-four transgender individuals with EDs completed an online questionnaire about their experiences with ED treatment. Inductive thematic analysis produced three themes: role of the body in treatment, negative experiences with clinicians, and recommendations for treatment centers and providers. Participants reported deficits in clinicians’gender competence, resulting in beliefs that ED treatment was ineffective, sometimes harmful. Further attention to this population’s needs is crucial, as inadequate care is potentially life threatening.

A recent nationwide health survey of adolescents in the United States demonstrated significantly higher rates of eating disorders (EDs) and related behaviors in transgender-identified respondents than in cisgender respondents of any sexual orientation (Diemer, Grant, Munn-Chernoff, Patterson, & Duncan, 2015). EDs have the highest rates of related medical complications, hospitalizations, and mortality of all psychiatric disorders (Klump, Bulik, Kaye, Treasure, & Tyson, 2009). Effective treatment of EDs among transgender, gender nonbinary, and gender-diverse individuals (people who do not identify exclusively with their assigned sex at birth, hereafter referred to under the umbrella term transgender) is therefore critical. There have been several published case studies describing incidences of EDs among transgender clients (Hepp & Milos, 2002; Murray Boon, & Touyz, 2013; Surgenor & Fear, 1998; Winston, Acharya, Chaudhuri, & Fellowes, 2004), but only recently have there been case studies addressing the need for specialized approaches in the ED treatment of transgender individuals (Ålgars, Alanko, Santilla, & Sandnabba, 2012; Couturier, Pindiprolu, Findlay, & Johnson, 2015; Ewan, Middleman, & Feldmann, 2014). All three case studies suggest interaction between ED symptomology and gender identity such that the individuals described used ED symptomology to control their physical shape to be more in line with their gender identity (Ålgars et al., 2012; Couturier et al., 2015; Ewan et al., 2014). These reports have described individual cases, but research has not examined ED treatment experiences among transgender individuals on a larger scale to lend additional support for those findings.

Gender dysphoria may be a risk factor in the increased incidence of EDs among transgender individuals. Case studies like that conducted by Couturier et al. (2015) have suggested that transgender individuals may control their body shape with disordered eating, such as stunting breast growth by restricting caloric intake. Gender dysphoria is a feeling of mismatch between a person’s emotional and psychological sense of gender and their biological sex (American Psychiatric Association, 2013). As a result of gender dysphoria, shape and weight-based self-evaluation and body image have a particularly significant influence on the self-worth of individuals who identify as transgender (Grossman & D’Augelli, 2007). Additionally, body dissatisfaction in transgender individuals has been connected to disordered eating and attempted suicide (Muehlenkamp, Peat, Claes, & Smits, 2012). Individuals who identify as transgender (Clements-Nolle, Marx, & Katz, 2006; Grossman & D’Augelli, 2007; Institute of Medicine, 2011; Testa et al., 2012) and individuals with EDs (Guillame et al., 2011; Pisetsky, Thornton, Lichtenstein, Pedersen, & Bulik, 2013; Preti, Rocci, Sisti, Camboni, & Miotto, 2011) have elevated rates of self-harm and suicidality, so the combination of transgender identity and disordered eating should be of significant concern to the mental health community.

Research suggests that mental health professionals lack competence in treating clients who identify as transgender (Carroll, Gilroy, & Ryan, 2002; Shipherd, Green, & Abramovitz, 2010). In recognition of this problem, the American Counseling Association has endorsed and adopted “Competencies for Counseling with Transgender Clients,” specifically dedicated to competencies in counseling transgender clients (Association for Lesbian, Gay, Bisexual & Transgender Issues in Counseling [ALGBTIC] Transgender Committee, 2010). The guide complements the “Transgender Standards of Care” created by the World Professional Association of Transgender Health (Coleman et al., 2012). Despite the availability of these resources, the majority of clinical training programs include little, if any, information relevant to transgender populations (Benson, 2013; Carroll et al., 2002; Shipherd et al., 2010). As a result, therapists are often uneducated in gender-identity issues (Benson, 2013; Carroll et al., 2002; Shipherd et al., 2010). Transgender individuals who seek mental health services often face discrimination, stereotyping, insensitivity, and misunderstanding from therapists (Benson, 2013; Institute of Medicine, 2011).

This study explored the ED-specific treatment experiences of transgender individuals diagnosed with EDs. Studies including transgender individuals usually place them in a catch-all lesbian, gay, bisexual, and transgender (LGBT) group (Benson, 2013; Institute of Medicine, 2011; Mustanski & Liu, 2013; Scourfield, Roen, & McDermott, 2008). There has been little research exclusively addressing the transgender community and their unique needs (Institute of Medicine, 2011), including needs relating to ED treatment. This study addresses these limitations of past work by focusing on transgender individuals. The study sought to explore the extent to which current ED treatment practices meet the needs of this group, as well as what improvements could be made. Despite the increased incidence of EDs in transgender individuals, ED clinicians and treatment centers may be ill-prepared to work with this population.

Method

Participants

The study sample consisted of 84 transgender and gender-diverse participants, of whom 7% identified as women, 36% as men, and 57% as nonbinary (not categorically either gender). Participants averaged 22 years of age, ranging from 18 to 33 years old (M = 22.3, SD = 3.91). The sample was 79.8% White, 3.6% Black, 3.6% Hispanic or Latino, 1.2% Asian, and 11.9% mixed ethnicities. Eighty-two percent of participants were living in the United States, 8% in Europe, and 7% in Canada. Data regarding EDs were self-reported and were not confirmed with medical records, in order to protect participants’ anonymity. Twenty-three percent of participants self-reported a clinical diagnosis of anorexia nervosa, 13% bulimia nervosa, 6% binge eating disorder, and 49% eating disorder not otherwise specified/other specified feeding and eating disorder. The remaining 8% of participants were self-diagnosed (no official ED diagnosis).

Procedure

Participants were recruited with the assistance of Trans Folx Fighting Eating Disorders (T-FFED; http://www.transfolxfightingeds.org), an ED support organization focused on the transgender and gender-diverse community. T-FFED promoted the study through postings on social media (Facebook, Twitter, and Tumblr) over the course of 2 weeks, and participants self-selected into the study. Participants gave consent electronically and confirmed they were at least 18 years of age before being directed to the online questionnaire. To preserve anonymity, participants were assigned random ID numbers and IP addresses were not collected. Participants were informed that the data they submitted were completely anonymous and could not be connected to them at any time, allowing them to feel comfortable responding to the survey in an honest way. The researchers also established trustworthiness by partnering with T-FFED, an organization that was already an established welcoming community for transgender individuals with a history of EDs. Participants were not given compensation. This study was approved by the Institutional Review Board at University of Saint Joseph.

Measures

Participants completed an online questionnaire addressing their psychiatric history, ED and treatment history, and experiences as a transgender individual. The questionnaire was developed in concert with, and piloted by, members of T-FFED to ensure the items were culturally sensitive and clear in meaning. Closed-ended items queried demographic information, ED diagnosis and history, and levels of care at which participants had been treated for their ED. In open-ended items, participants were asked to identify barriers to seeking care, describe why they did or did not return to ED treatment after their first experience, evaluate clinician competency in working with gender identity, explain the extent to which ED treatment met their needs, and suggest ways quality and accessibility of care for transgender individuals with EDs could be improved. Please see the appendix for a list of questions that were asked of the participants.

Data analysis

Responses to open-ended items were analyzed using inductive thematic analysis, a procedure for exploratory research with qualitative data (Braun & Clarke, 2012). The first and second authors familiarized themselves with the data by independently reading and rereading all participant responses to questionnaire items. When rereading the data, each author took notes independently, producing preliminary codes. Both authors assessed all transcripts. After this, the authors compared notes, clarifying and revising codes, and then began coding the data. As coding progressed, coding notes were reviewed for overlapping and repetitive codes, which were collapsed into subthemes. Similar subthemes were clustered together to delineate major patterns in the data, creating overarching themes. Disagreements during the analysis process were discussed until agreements were reached. The authors achieved saturation of codes by the 11th participant. That is, no new codes were discovered after coding the first 11 participants’ responses. The remaining data were coded according to the codes previously identified. Finally, the third author independently reviewed the coding scheme and resulting data analyses to verify the credibility of results.

Results

Three major themes emerged from inductive thematic analysis: the role of the body in ED treatment (subthemes, n = 4), negative experiences with clinicians (subthemes, n = 4), and recommendations for treatment centers and providers (subthemes, n = 3).

Theme #1: Role of the body in eating disorder treatment

This theme represented participant responses regarding the relationship between EDs and gender identity and the implications of this relationship for appropriate ED treatment methods. Some participants explained their relationship with their physical body as the underlying cause of their ED (subtheme #1), for example, using starvation to eliminate curves, body fat, or menstruation. About 32% of participants responded in ways that aligned with this subtheme. One participant said:

I had no visible breast tissue at all, and was thus able to have a more “androgynous” body without needing to come out to myself or transition. I have also known trans women who intentionally over-ate because it made them curvier.

Another participant reported that “Body fat and fat distribution have a lot to do with gender dysphoria, and sometimes trans people with eating disorders have them because they’re trying to manipulate their bodies without the use of hormones.” This subtheme echoes what previous case studies have reported—that individuals may use ED symptomology to bring their physical appearance more in line with their gender identity (e.g., Couturier et al., 2015)

Others felt their ED was unrelated to their physical body (subtheme #2), explaining, for example, that they did not wish to physically transition (and so were not using disordered eating as a means of doing so). About 56% of participants felt that their ED was unrelated to their physical body. Referring to a therapist, one participant said that “I felt like he was thrusting this idea of a feminine concern with weight onto me. I do not feel feminine/female, nor was my eating disorder centered around weight or body image.” Additionally, factors such as abuse and trauma were noted by some participants as non-body-related causal contributors to their ED. One participant reported that, “My eating disorder manifested long before I had a solid concept of what my gender was or meant to me. It is related to anxiety and abuse rather than being linked to my physical appearance.”

Regardless of the particular intricacies connecting gender identity to ED, 15% of participants expressed that the issue of body image is more complex for transgender clients than for the cisgender ED population, which their therapists did not understand (subtheme #3). The body discomfort of transgender individuals cannot be overcome through a “positive body image” approach, the approach that is typically used in ED treatment. Explaining why such an approach might be inappropriate, one participant said that, “A trans person may be trying to control unwanted aspects of their body structure with their eating disorder; trying to assure them these aspects are ‘okay’ or ‘normal’ is NOT the right answer and only aggravates dysphoria.” Participants found such approaches to not only be ineffective, but also highly invalidating and dismissive of their experiences. One participant even expressed worry about encountering this approach, “I am worried that the issues around my trans-specific body discomfort will be ignored or downplayed in favor of the traditional ‘learn to love your body’ approach to treatment.” Participants explained that, for them, body image disturbance is more than a cognitive distortion and suggested that clinicians discuss and support clients’ goals relative to physical transition, rather than solely relying on traditional ED treatment strategies.

Two respondents who felt they had made significant progress in moving beyond their ED emphasized the importance of transition in the ED recovery process (subtheme #4). One participant stated that, “My eating disorder would never, ever have eased up as it did if I hadn’t been able to transition and thus have the experience of liking and identifying with my body in that way first.” In addition, the goal of transition was a motivator and facilitator for recovery. For example, one participant noted that, “I was too unhealthy to keep on going the way I was, and it made me realize that if I ever wanted to start HRT [hormone replacement therapy], I had to be healthier than I was being.” Even though only two participants explicitly addressed the relationship between transition and ED recovery, the number of participants who used disordered eating to control their body shape to fit their gender identity (see subtheme 1) indicates that this should be an important consideration for treatment.

Based on participant responses, clinicians should be aware that for some transgender individuals, their ED symptomology may be related to an effort to control their body shape as it relates to their gender identity. However, this was not true for all participants, and some expressed so explicitly. Clinical approaches should be tailored to individual clients, in part based on the role their gender identity does (or does not) play in their disordered eating.

Theme #2: Negative experiences with clinicians

The second theme addressed in more detail the problems participants had in interacting with ED treatment professionals. Participants experienced varying degrees of dismissal, mistreatment, and incompetence from clinicians. In some cases, participant anticipation of mistreatment was a barrier to effective care.

Many participants (40%) hid their gender identity and did not disclose while in ED treatment (subtheme #1). For example, one participant said, “I did not discuss my issues around gender identity when I was in the treatment program, and I was treated as though I were a male patient.” Participants who made the decision not to disclose their gender identity attributed their choice to fears of stigma and discrimination, specific past negative experiences with providers, or simple logistics (e.g., treatment center accepts only women). For example, one participant reported negative past experiences: “I have stopped telling therapists, doctors, and groups that I don’t identify as a woman. It makes them uncomfortable and alienates me. Lying is easier.”

The remaining 60% of participants disclosed their gender identity while in treatment. For some, about 10%, their disclosure was ignored (subtheme #2). One participant reported that, “Every primary care provider that I have interacted with simply sidesteps or ignores my articulation of a trans identity. It’s as if the gesture never happened.” Another said that, “Since coming out, my identity has been erased in treatment because clinicians and therapists aren’t comfortable with a transgender individual who does not identify as male or female.” When transgender individuals have their identity ignored by health care professionals, it impedes their treatment and may discourage them from disclosing their gender identity going forward.

About 11% of others who disclosed were faced with clinicians who disregarded their self-identification (subtheme #3). Some participants cited provider behaviors such as using inappropriate pronouns (e.g., referring to a transgender man as “she”). For example, one participant said that:

I have been regularly misgendered over the course of my treatment. It’s kind of par for the course by now, but it’s still really upsetting. Even my therapist doesn’t really understand how to use my pronouns, and has referred to me as “girl” and “daughter,” despite the fact I’ve come out to her.

Other participants suggested that their health care professionals wrongly assumed that all transgender individuals wish to pursue surgical transition:

My therapist asked me questions about my body, such as if I’d taken hormones or had ”the surgery” yet. She twice asked me if I was “really a boy or a girl,” despite my birth name and sex being on my records.

Like ignoring a client’s gender identity, misgendering clients also harms the therapeutic relationship and impedes successful treatment.

These subthemes are reflected in, but also expanded upon, by subtheme #4: lack of specialized training. About 19% of participants found it extremely difficult, if not impossible, to locate clinicians they felt were capable of working with gender-identity and EDs. One participant reported facing multiple issues and difficulty finding a clinician who could help with all three:

It’s difficult in general for me to find therapy and help that understands me being trans, being a rape survivor, and having an eating disorder. I tend to find any help I seek for one, or any combination of those, fails in at least one of those areas.

Participants described those skilled in ED treatment as generally uninformed about gender issues, leading to many of the negative experiences noted above. For example, one participant noted that, “My therapist is excellent in her work, but it seems she does not understand non-binary genders.” Some participants specifically selected therapists who specialized in gender, though these clinicians’ potential lack of specialized ED training could prevent them from providing effective ED treatment. Overall, this theme indicated that participants perceived a lack of gender awareness and competence among their ED treatment providers.

Taken together, this theme suggests that clinicians should take care not to make assumptions about gender identity in their clients and seek to understand how each client identifies and would like to be treated. In addition, clinicians who specialize in treating EDs may consider seeking additional training in counseling transgender individuals, whereas clinicians who specialize in gender may seek additional training in identifying and treating EDs.

Theme #3: Recommendations for treatment centers and providers

The final theme culled from the data provided examples of concrete goals and action steps recommended by participants that treatment centers and providers can take to increase their competence in working with transgender individuals with EDs. First, participants indicated their wish for providers to ask questions (subtheme #1) rather than make assumptions about clients’ identities, beliefs, and behaviors. About 25% of participants responded in ways that fit this subtheme. Participants advised that practitioners remain open to, and accept, clients’ self-definition and self-concept. One participant suggested that:

There needs to be better understanding that people develop disorders for different reasons. Many of my doctors told me I was trying to cover for my eating disorder by claiming that I was transgender, which couldn’t have been farther from the truth. I have an eating disorder in addition to being a trans person, they are not necessarily related, though there are parts of them that interact.

Of particular importance is respecting clients’ preferred pronouns, as articulated by one participant, “Always ask for pronouns. Use the name they ask you to use—I can’t stress this enough.” Participants generally suggested that clinicians meet clients where they are, rather than where the clinician assumes or would like the client to be.

Participants also suggested treatment programs facilitate access to care for the transgender community (subtheme #2). About 8% of participants said many transgender individuals struggling with EDs do not believe there is appropriate treatment available and will not reach out for fear of receiving incompetent care. Others have been barred from treatment centers with noninclusive policies or expressed that it is stressful to try to identify an appropriate treatment center. For example, one participant noted that:

It would be reassuring to see programs which include some sort of reference to their inclusivity of transgender/gender-diverse people. It is nerve-wracking to look for treatment options and wonder whether a program which works with women means that it works with all women, or only with cis women.

Participants suggested treatment centers wishing to serve this population make their intentions clear by, for example, advertising in LGBT spaces and creating policies outlining their services and guidelines regarding non-cisgender clients. One participant suggested that clinicians and treatment centers, “Reach out to LGBT centers, work with them. Consider helping them establish eating-disorder support groups and/or eating-disorder 1-on-1 counseling. Give presentations within other groups, to make known your services.” Creating inclusive policies, expressing them clearly, and working with existing LGBT resources are all strategies that may benefit transgender individuals who also need treatment for EDs.

Lastly, about 17% of participants expressed the need for clinicians to seek education (subtheme #3) about the transgender population. One patient expressed exhaustion at the need to educate health care professionals:

In spite of my identification, “professionals” tend to fall back on essentialist notions: “you are a man.” I am simply not interested in educating professionals about my gender or identity; it’s the one space where I do not have the energy left to do so.

They suggested ongoing continuing education around cultural competency and specialized counseling skills and techniques. In addition to professional training, other recommendations included participating in events in the transgender community and reading first-person accounts of life as a transgender person. Such education would prepare clinicians to approach transgender clients with a basic knowledge base and could drastically affect client outcomes. For example, one participant said:

I can’t help but … wonder how my life might have been different … if anyone who saw me in the course of my treatment had been able to recognize my gender dysphoria and inform me that there were ways of addressing my extreme discomfort with my post-pubertal body other than starving myself.

Clinicians and counselors who are trained to recognize and manage EDs and issues of gender diversity can make a big difference to clients who are struggling with both.

Discussion

Emerging evidence demonstrates that transgender individuals experience EDs at rates significantly higher than cisgender individuals (Diemer et al., 2015), partly in response to gender dysphoria and body dissatisfaction (Couturier et al., 2015; Muehlenkamp et al., 2012). Case studies have begun to explore the experiences of ED treatment among individual transgender clients (Ålgars et al., 2012; Couturier et al., 2015; Ewan et al., 2014). This study builds on past research by exploring ED treatment experiences among a larger sample of transgender individuals. Similar to the reports of transgender individuals seeking broad mental health services (Benson, 2013; Institute of Medicine, 2011), participants in this study described the care they received in ED treatment as inadequate. They attributed this primarily to clinicians’ lack of knowledge with regards to gender identity. Transgender individuals are at high risk for developing potentially life-threatening EDs, and the fear of negative experiences in treatment is a significant barrier to care for them.

None of the 84 participants in this study reported having had a positive experience in treatment for their ED. Some even expressed wishing they had never gone to treatment at all, despite acknowledging that it was likely life saving. This predominance of negative responses is striking because questions inquired about ED treatment in general, not just negative aspects. Participants felt they received inadequate care, which served to drive many of them away from further attempts to engage with mental health services in the belief that clinicians untrained in gender issues would be unable to understand or help them. The lack of positive experiences may be due to the lack of clinical competency among clinicians as well as resistance to addressing EDs among patients. Yet this work suggests there is a need for ED clinicians and programs to pursue training with regards to the treatment of this specialized population.

Of particular concern is that so many (approximately 40%) participants went through treatment without ever disclosing their transgender status. Although this may have helped clients avoid negative gender-identity-related experiences, it could have impeded treatment efficacy. Concealment of important aspects of one’s identity may prevent the formation of trust, mutual respect, and establishment of a therapeutic alliance, all of which are necessary for the treatment of EDs (Williams & Haverkamp, 2010). This is especially the case when the identity is interwoven and entangled in the ED and, in many cases, contributing to it. Those who did disclose their gender identity in treatment reported facing dismissal, stereotypes, assumptions, and bewilderment from clinicians. They felt this impeded treatment from addressing the relationship between their gender identity and ED, and also invalidated their identity.

Recommendations for clinicians

Participants in this study identified a number of areas of possible deficits in ED treatment for transgender individuals. These findings illustrate the need for increased awareness among treatment providers and researchers of the needs of transgender individuals with EDs. Greater attention in treatment and research with this vulnerable and at-risk population would potentially lead to more informed treatment approaches, potentially increasing the likelihood of help seeking by transgender individuals in need of care and improving outcomes.

Of particular importance are the necessity of addressing the body’s role in ED treatment (i.e., acknowledging the complex nature of the body), culturally competent interaction with regards to validating and accommodating clients’ gender identities, and willingness to continually pursue specialized clinical training. These are consistent with the content of the guidelines for the appropriate, competent treatment of transgender individuals (ALGBTIC Transgender Committee, 2010; Coleman et al., 2012). These guidelines should be introduced during clinical training. It may also be important for clinicians who treat transgender clients to raise their level of competence in assessing, diagnosing, and providing treatment for EDs, as some participants reported purposefully selecting gender-specialized providers who were not necessarily equipped to manage EDs.

Limitations and future directions

There are several limitations to the scope of this study and the generalizability of its findings. Participants were self-selected. As such, results may not be representative of the experiences of all transgender individuals treated for EDs. All findings were drawn from self-reported data to protect participants’ anonymity. Future work should include objective measures when possible, including of ED diagnoses. Responses may have been negatively biased if participants felt that it was most important to raise awareness of adverse treatment experiences. The researchers made an effort to avoid bias in the wording of questions, but participants may have perceived the study to be aimed at assessing deficits in ED treatment rather than surveying treatment experiences generally, including positive and negative aspects. The current work draws on a relatively small sample. Future research should aim to include larger, more diverse samples of transgender individuals to explore variations in ED treatment experiences by specific gender identities, including by comparing transgender men and women, and by individuals living in different sociocultural contexts.

Future research is needed to explore clinician preparation for, and practice in, treating transgender clients with EDs. Participants in this study overwhelmingly reported having had what they described as insufficient and inappropriate treatment. It is unclear whether this is due to a lack of gender identity-related clinical training, a lack of implementation of such training within treatment interactions, or another reason. Future research should examine ED practitioners’ perspectives on working with transgender clients as well as the nature and depth of their training in transgender cultural competency to further understand and, ultimately, address these potential limitations to client care.

Conclusion

Research into concurrent treatment of EDs in the context of transgender identity is only just beginning (Ålgars et al., 2012; Couturier et al., 2015; Ewan et al., 2014). There are established guidelines for the physical and psychological treatment of transgender individuals generally (ALGBTIC Transgender Committee, 2010; Coleman et al., 2012), but not specifically in relation to ED treatment. Results of this study highlight potential inadequacies in current ED treatment of transgender individuals, suggesting a need for the development of specific evidence-based guidelines for clinical practice with transgender clients in treatment for EDs. Such guidelines, paired with specialized clinical training, could help to promote more effective ED treatment for transgender individuals.

Appendix: Questionnaire

Please answer each item below to the best of your ability. Your answers may be as short/long and give as much/little detail as you desire. The more information you give, the more helpful it is for the purposes of the study, but the most important thing is keeping you safe. You may skip any question(s) you do not wish to answer.

Age (years)

Race/Ethnicity

Gender Identity

Please indicate female-to-male or male-to-female if appropriate

Home State (Country if outside United States)

Eating Disorder Diagnosis (anorexia, bulimia, binge eating disorder, EDNOS/OSFED)

Eating disorder treated at the following levels of care (select all that apply: inpatient, residential, partial hospitalization, intensive outpatient, outpatient)

Other Psychiatric Diagnoses

Many people describe their eating disorder as having a function (i.e., coping with stress, exerting control, or numbing emotional pain). Briefly, how would you describe the function of your eating disorder?

Have you ever hidden your gender identity in eating disorder treatment (e.g. passing, stealth)? Please comment.

To what extent did you find the following areas of eating disorder treatment to be competent in meeting your needs as a transgender/gender diverse person: Intake/admissions department, clinicians, psychiatrist, nursing staff, support staff (MHAs, RPAs, CAs, etc.), other patients/clients, insurance companies. Please comment

During your eating disorder treatment, to what extent were your needs as a transgender/gender diverse person met in the following areas: using preferred pronouns, bathroom guidelines, general respect, housing arrangements/availability. Please comment

To what extent was your primary/individual therapist (in treatment) able to meet your needs as a transgender/gender-diverse person? Please comment

To what extent was the treatment program as a whole able to meet your needs as a transgender/gender-diverse person? Please comment

In eating disorder treatment, to what extent did you experience the following because of your gender identity: Prejudice (negative attitudes towards gender diversity), Discriminatory behavior, Inappropriate personal questions, Verbal harassment, Physical harassment. Please comment

What suggestions do you have for eating disorder treatment professionals and facilities when treating those who identify as transgender or gender diverse?

What (if any) barriers or exclusions have influenced your desire to seek treatment for your eating disorder? Include societal power imbalances (e.g. racism, classism, cis/heteronormativity) as appropriate, and please briefly explain your answer.

What (if any) barriers or exclusions have influenced your ability to seek treatment for your eating disorder? Include societal power imbalances (e.g. racism, classism, cis/heteronormativity) as appropriate, and please briefly explain your answer.

What can be done to increase help-seeking by transgender and gender diverse individuals with eating disorders?

How can eating disorder treatment be made more accessible to the transgender and gender diverse community?