Providing Better Care for Transgender and Non-Binary Patients

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Carly Guss, MD, MPH and Allegra Gordon, ScD, MPH

In our work as a public health researcher (Allegra) and clinician (Carly), we have been excited to see growing interest in improving care for transgender and non-binary patients within the eating disorders field. Below we offer some lessons we have learned and suggestions for steps eating disorders professionals can take to begin to provide better care for transgender and non-binary patients and clients.

This matters because transgender individuals have a disproportionate burden of eating disorders compared to cisgender peers. Moreover, non-binary populations (that is, people who identify with genders other than girl/woman/female or boy/man/male) have not been included in most research on eating disorders. What we do know is that care that is not gender affirming can be harmful. In a 2015 survey of 27,000 transgender adults in the United States, one in three who saw a health care provider in the past year reported a negative health care experience including being refused treatment, verbally harassed, or physically or sexually assaulted. This highlights why gender affirming care is necessary to reduce stigma-driven health inequities.

So, if you are provider thinking about how to make your practice more gender affirming, what can you do?

The Basics

A caveat: These suggestions may not apply in all treatment settings but are a good place to start. Also, keep in mind that language is constantly evolving and different people may use different terms to describe themselves and their experiences. This is why, in addition to the ideas in the list below, we encourage you to connect with local organizations, advocates and communities.

• Pronouns: Ask them, use them. Here’s one starting point if you are new to thinking about pronouns.

• Take an audit of how welcoming your clinic or practice is from when your clients/patients schedule an appointment, to walking into your office or clinic, to the clinical encounter:

o What’s on the walls? Do you have images or materials that represent diverse genders, racial, ethnic, and cultural backgrounds, and family compositions?

o Do you have any symbols showing you are a welcoming provider? This may include rainbow stickers or other materials that have a rainbow and/or trans pride flag.

o What are your intake forms like? Do they have options other than only male or female? Do you ask for assigned sex as well as gender identity? The Fenway Institute’s LGBT Health Education Center has a wealth of terrific resources including this guide on asking questions about gender identity and sexual orientation.

o If you have frontline staff (such as schedulers or administrative support): Are they trained in creating a welcoming environment by avoiding assumptions and using correct names and pronouns? Here’s another helpful Fenway Institute resource with best practices for frontline staff.

o Have you been able to make gender-inclusive bathrooms in your setting? If not, this is the time to do so! If you already have single stall, add “All Gender” signs to make it clear.

• Mistakes happen (even experienced providers make them). The important thing is to apologize, continue care, and afterwards review from a systems standpoint what could be done better next time.

Guidance for Eating Disorder Treatment Providers

Unfortunately, the evidence base for making specific suggestions in this area is still lacking. One study highlighted several concerns for transgender and non-binary individuals who have received eating disorders treatment (Duffy et al, 2016*). For example, the study found that 40% of respondents did not disclose their gender identity during treatment due to fears of stigma, past negative experiences, or trouble finding treatment facilities.

This study also had several recommendations, including:

• Don’t make assumptions about gender identity or the client’s gender journey
• Eating disorder centers should facilitate access to care for the transgender community
• Clinicians should pursue continuing education related to gender diversity

Another way to advocate for transgender and non-binary patients is to speak up when you see non-affirming practices, such as providers not using a patient’s correct pronouns or treatment centers that celebrate the return of menses, which may be invalidating to transgender individuals who find menstruation dysphoric.

The final, and perhaps most important, point is that providers of all gender identities must listen to the voices of transgender and non-binary individuals with eating disorders. More and more community members are creating spaces to share their experiences and lead the way towards better care for transgender and other marginalized populations. One example is the the organization Fighting Eating Disorders in Underrepresented Populations (FEDUP). Eating disorder specialists should be accepting of feedback and suggestions from the community. A recent article by Jamie Bushell in The Huffington Post sheds light on the ways in which eating disorder providers and treatment centers are failing LGBTQ communities and offers important insight into what can be done better. It may take time to find the best path forward through some of the challenges discussed in this article, particularly given the need for more research—but that doesn’t mean that you need to wait to take action!

Take Home Messages

There is a huge need for research in this area in order to develop an evidence base for gender affirming eating disorder treatment. However, making small changes in your practice setting can make a large difference. It is also crucial to continue to seek ways in which to educate yourself and stay up to date on matters related to gender.

We can all do our part to support transgender and non-binary people with the work that we do—and to take every opportunity that comes along to speak up for the civil and human rights of trans people everywhere. Visit the National Center for Transgender Equality for ideas about actions to take right now.

*Duffy, Mary E., Kristin E. Henkel, and Valerie A. Earnshaw. “Transgender Clients’ Experiences of Eating Disorder Treatment.” Journal of LGBT Issues in Counseling 10, no. 3 (2016): 136–149.

Carly Guss, MD, MPH is an instructor in pediatrics at Boston Children’s Hospital and Harvard Medical School. She is an adolescent medicine physician who works clinically with transgender teens and young adults as well as individuals with eating disorders. Research interests include transgender and gender nonconforming adolescents’ experiences in primary care as well as the relationship of gender identity and body image. She is a member of the Sexual Orientation, Gender Identity and Expression Working Group  at Harvard T.H. Chan School of Public Health.

Allegra Gordon, ScD, MPH is a social epidemiologist and instructor at Boston Children’s Hospital and Harvard Medical School. Her research addresses the mental and physical health impacts of discrimination and gender norms, with a particular focus on body image and eating disorders in LGBTQ youth and young adults. She is a member of the Harvard Strategic Training Initiative for the Prevention of Eating Disorders and the Sexual Orientation, Gender Identity and Expression Working Group at Harvard T.H. Chan School of Public Health.