Chapter 15: Eating Disorders, Body Image, and Body Positivity

INTRODUCTION

Traditional treatment paradigms and research regarding patients with disordered eating (a range of irregular eating behaviors that do not meet Diagnostic and Statistical Manual of Mental Disorders, 5^th edition [DSM-5] criteria for a specific eating disorder) and eating disorders (clinical presentations that meet DSM-5 clinical criteria for specific eating disorders) focus primarily on white, cisgender, and straight girls and women. Although knowledge about eating disorders among lesbian, gay, bisexual, and queer patients¹ cisgender straight men,^2,3 and Black, Indigenous, and People of Color^4,5 is increasing, information about eating disorders among transgender and gender diverse (TGD) patients remains scarce.

Published studies often combine gender minority and sexual minority groups in their samples. As a result, the sample of TGD patients included is frequently too small to produce statistically significant or generalizable information.^2,6,7 There is nevertheless a need to develop culturally responsive best practices on clinical care, given the number of TGD individuals with clinical and subclinical disordered eating.

In 2014, a large-scale study surveyed approximately 300,000 college students at risk for anorexia nervosa and bulimia nervosa,⁸ revealing that transgender students had a risk of developing these disorders that was four times greater than their cisgender peers. This study suggests that mental health professionals are likely to encounter TGD patients who experience concerns with disordered eating and eating disorders.

Another area of risk for TGD patients involves gender minority stress⁹ and the marginalizing nature of social environments for TGD people. Such discriminatory or marginalizing experiences have been linked to various mental health concerns, including depression,¹⁰ substance use disorders,¹¹ and posttraumatic stress disorder (PTSD). Depression and substance use disorders often co-occur with eating disorders. Some people with eating disorders may also exhibit symptoms of PTSD.¹²

This chapter examines the connections between gender identity, gender minority stress, body image—particularly the experience of a body that does not align with gender identity—and the development and treatment of eating disorders. The chapter reviews themes available from the current literature and includes clinical observations and case studies that highlight eating disorders among TGD patients.

BODY IMAGE

Body image concerns are key factors for TGD persons presenting for mental health treatment.¹³ Concerns range from body dissatisfaction—which can be considered a normative experience when the body and gender identity do not align—to body hatred, a more complex clinical presentation in which there is extreme body aversion. Body image is considered to be a primary but not the only factor leading to eating disorders in TGD communities.¹³

It is helpful to understand the concept of body image when considering the intersection of eating disorders and gender identity. Thomas Cash, an expert in the field of body image, defines it as “the multifaceted psychological experience of embodiment, especially but not exclusively related to one’s ...