Affirming Care for Every Body

A Guide to Eating Disorders in the 2SLGBTQ+ Community by Individuals with Lived Experience for Community Members and Carers


This project was funded by a Rainbow Grant from the Community One Foundation

  • About This Resource

    • What this resource means to us

      This resource speaks to our experiences as 2SLGBTQ+ individuals who have accessed support for eating disorders. While the dominant narrative of eating disorders only affecting white, middle-class,  heterosexual, cisgender, teenage girls is being challenged, this long-told story has informed our experiences of care. It informs how doctors understand eating disorders, who might be perceived to struggle, and who can access referrals for support and treatment. The dominant narrative informs how treatment is provided and to whom. It dictates who feels comfortable sharing their story and who is given a platform to tell it. It is present in the “recovery” images we see on social media and the “recovery” biographies we read. 


      The problem is not with the individuals who have told their stories of struggle and “recovery”. When you access eating disorder supports but none of the recovery stories speak to the experiences of 2SLGBTQ+ individuals, you wonder if you can recover from this thing you are not even sure you can have. When treatment has not been created with you in mind and you do not see 2SLGBTQ+ healthcare providers in eating disorder treatment, you are often left to educate and advocate for yourself. 


      Our intention is not to lay blame for the healthcare system we currently have. We are grateful for the many people who do their best in an underfunded system. We call for change. We want to emphasize it is not enough for existing eating disorder support to be more inclusive of 2SLGBTQ+ individuals. We need to question how it came to be the way it is and how we can do better. We need to ask ourselves who else is being left out of eating disorder narratives and, by extension, eating disorder supports. 


      Eating disorder support and treatment were informed by research and treatment models that are considered the gold standard of care. But when those studies do not include 2SLGBTQ+ individuals, or anyone outside of white heterosexual, cisgender youth, we are not offering gold standard programming for all. We are also not offering adequate education about eating disorders. 


      This resource will by no means discuss every experience, best practice, or gap in eating disorder care for 2SLGBTQ+ communities. We recognize that once we name something and identify common experiences, inevitably, people and experiences will be left out. Our most important message is that 2SLGBTQ+ individuals will have their own personal experiences which may or may not be similar to those of other 2SLGBTQ+ individuals. If you’re reading this in hopes of better supporting a loved one, client, or patient, the best piece of guidance we can offer is to be open to multiple possibilities of experience and believe the person who tells you they may be struggling, even if their experience doesn't align with your current knowledge and understanding of what an eating disorder is.

    • A note on language

      In recent years the word Queer has been reclaimed as an umbrella term to describe a large number of experiences and 2SLGBTQ+ identities. The term eating disorder is a very specific label for a cluster of mental health disorders. We would like to move away from this way of understanding eating disorders to a more Queer understanding. While an eating disorder diagnosis can help a person access formalized treatment and support, it is by no means the only way of approaching recovery. Eating disorder diagnostic criteria have been criticized for not taking into account differences in biology and for being developed with a focus on white, Western beliefs around body size. They have been critiqued for creating a system in which care is provided only after symptoms and behaviours severely affect one's life and goals, rather than earlier on when those symptoms might be less engrained. Psychiatry and the Diagnostic and Statistical Manual (DSM) have been used to invalidate 2SLGBTQ+ people’s various natural and valid experiences. We have faced violence, been ignored, discredited, and misunderstood; we have been told we are unnatural, and often over-pathologized. When you see the term eating disorder in this resource, know that we acknowledge that experiences with the medical system have ranged from helpful to violent. 

    • Bringing our "voices" to this resource

      This resource was created collaboratively with members of the 2SLGBTQ+ community with lived experience of eating disorders. However, we recognize that everyone is an expert of their own experience, which may not be reflected here. We cannot attempt to be representative of every 2SLGBTQ+ experience, only of ourselves sharing our journeys with you. 

    • Glossary

      "Language is dynamic, shifting and changing over time. These definitions are not meant to be understood as exhaustive, absolute, exact, or static. Think of these definitions as approximations that may be used differently by various people and communities. This is a starting place; there are many more terms in existence than we have space for. There are terms specific to diasporic cultures, and Indigenous communities within Canada as well as terms commonly used outside of Canada that we have not included here. It is important to respect how someone self-identifies and use the language they use to describe themselves." (via Public Health Agency of Canada)


      • 2SLGBTQ+: An evolving acronym for Two-Spirit, Lesbian, Gay, Bisexual, Trans, Queer and additional identities.
      • Androgynous: "Neither specifically feminine nor specifically masculine; or, a combination of the two." (via LGBTQ Youth Initiative)
      • Body neutrality is rooted in acknowledging what your body does, not how it looks. In contrast to body positivity, body neutrality recognizes that loving one's body may not be an attainable goal. Body neutrality promotes treating your body with care regardless of how you feel about it.  (via Leigh Weingus)
      • Cisgender: "Having a non-trans gender identity. You may also sometimes see “cissexual” or “cisgender”. Thus, non-trans men are “cis men” and non-trans women are “cis women”. It is preferable (and more accurate) to use “cis” than to use terms such as “bio”, “genetic” or “real”. It is also preferable to use “cis” rather than only using “woman” or “man” to describe non-trans persons. If cis is not used as a descriptor for non-trans persons, then such persons may be presumed to be the more “normal” or “valid” instantiation of that particular gender, thus contributing to cissexism." (via Rainbow Health Ontario)
      • Cisnormative: "Cisnormativity refers to the commonplace assumption that all people are cisgender and that everyone accepts this as “the norm”. The term cisnorma­tivity is used to describe systemic prejudice against trans [people]. This form of systemic prejudice may go unrecognized by the people or orga­nizations responsible." (via Rainbow Health Ontario)
      • Coming out: "To declare and affirm to oneself and possibly to others your identity as LGBTQ+. Coming out is often an ongoing process. Not everyone comes out or thinks it’s necessary to do so." (via LGBTQ Youth Initiative)
      • Fatphobia is an “irrational fear of, aversion to, or discrimination against obesity or people with obesity.” The roots of fatphobia can be traced back to racism and the hatred of Black bodies, spiraling into the multi layers of oppression that fat folks face today.  (via Gianluca Russo)
      • Gender dysphoria: "Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Only some gender nonconforming people experience gender dysphoria at some point in their lives." (via Rainbow Health Ontario)
      • Gender expression: "How a person publicly expresses or presents their gender. This can include behaviour and outward appearance such as dress, hair, make-up, body language and voice. A person's chosen name and pronoun are also common ways of expressing gender. Others perceive a person's gender through these attributes." (via Rainbow Health Ontario)
      • Gender identity: "A person's internal and individual experience of gender. It is a person's sense of being a woman, a man, both, neither, or anywhere along the gender spectrum. A person's gender identity may be the same as or different from their birth-assigned sex. A person's gender identity is fundamentally different from and not related to their sexual orientation." (via Rainbow Health Ontario)
      • Heteronormative: "Refers to the commonplace assumption that all people are heterosexual and that everyone accepts this as “the norm”. The term heteronormativity is used to describe prejudice against people that are not heterosexual, and is less overt or direct and more widespread or systemic in society, organizations, and institutions. This form of systemic prejudice may even be unintentional and unrecognized by the people or orga­nizations responsible." (via Rainbow Health Ontario)
      • Heterosexual: "Being sexually and romantically attracted to someone of a different sex." (via LGBTQ Youth Initiative)
      • Non-binary: "Umbrella term for anyone who does not identify with static, binary gender identities. Includes persons who may identify as having an intermediary gender (e.g. genderqueer), as being multiple genders (e.g. bigender, polygender, etc.), as having a shifting gender (gender fluid), or as not having a gender altogether (agender)." (via Rainbow Health Ontario)
      • Questioning: "A period where a person explores their own sexual and/or gender identity, reflecting on such things as upbringing, expectations from others, and inner landscape." (via Rainbow Health Ontario)
      • Sizeism refers to discrimination or prejudice directed against people because of their size and especially because of their weight. (via Merriam-Webster)
      • Transnormativity: The idea that there's a "correct" or "right" way to be trans, often perpetuated in community, healthcare, and legal settings. (via Austin H. Johnson)
      • Two-Spirit (2S): "A term used by Indigenous People to describe from a cultural perspective people who are gay, lesbian, bisexual, trans, or intersex. It is used to capture a concept that exists in many different Indigenous cultures and languages. For some, the term two-spirit describes a societal and spiritual role that certain people played within traditional societies; they were often mediators, keepers of certain ceremonies; they transcended accepted roles of men and women, and filled a role as an established middle gender." (via Rainbow Health Ontario; you can read more here)
      • White supremacy culture: "​White supremacy culture is the idea (ideology) that white people and the ideas, thoughts, beliefs, and actions of white people are superior to People of Color and their ideas, thoughts, beliefs, and actions." (via Tema Okun)
    • Resources

      Information about 2SLGBTQ+ people and eating disorders



      Information to help with healthcare experiences and for healthcare providers

      Self-care



      For parents and care partners



      For schools and youth

    • References

      American Academy of Pediatrics. (2018). Coming out: Information for parents of LGBT teens. Retrieved from https://www.healthychildren.org/English/ages-stages/teen/dating-sex/Pages/Four-Stages-of-Coming-Out.aspx.
       

      Arcelus, J., Mitchell, A., & Wales, J. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archive of General Psychiatry, 68(7), 724-731. DOI:10.1001/archgenpsychiatry.2011.74


      Bem, S. L. (1974). The measurement of psychological androgyny. Journal of consulting and clinical psychology42(2), 155.
       

      Chastain, R. (2020). We need to end fatphobia in eating disorder awareness and recovery. The Mighty. Retrieved from https://themighty.com/2020/02/fatphobia-eating-disorder-awareness-recovery/.


      Chen, I. C., Huang, H. J., Yang, S. F., Chen, C. C., Chou, Y. C., & Kuo, T. M. (2014). Prevalence and effectiveness of laxative use among elderly residents in a regional hospital affiliated nursing home in Hsinchu county. Nursing and Midwifery Studies3(1).
       

      Chrisler, J., & McHugh, M. (2017, August 3). Weapons of mass destruction - confronting sizeism [Symposium]. 125th Annual Convention of the American Psychological Association, Washington, DC, USA. 


      Donaldson, A. A., Hall, A., Neukirch, J., Kasper, V., Simones, S., Gagnon, S., Reich, S. & Forcier, M. (2018). Multidisciplinary care considerations for gender nonconforming adolescents with eating disorders: A case series. International Journal of Eating Disorders, 51, 475-479. https://dx.doi.org/10.1002/eat.22868


      Gordon, A. R., Austin, S. B., Krieger, N., Hughto, J. M. W., & Reisner, S. L. (2016). “I have to constantly prove to myself, to people, that I fit the bill”: Perspectives on weight and shape control behaviors among low-income, ethnically diverse young transgender women. Social Science & Medicine165, 141-149.
       

      Grant, Z. S. (2020) Beyond Binaries: what trans adults with ‘eating disorders’ want from healthcare professionals. [Masters thesis, Ryerson University]. Ryerson University Digital Repository https://digital.library.ryerson.ca/islandora/search/*%3A*?f[0]=mods_extension_degree_department_ms%3A%22Social%20Work%22


      Guerdjikova, A. I., O'Melia, A. M., Mori, N., McCoy, J., & McElroy, S. L. (2012). Binge eating disorder in elderly individuals. International Journal of Eating Disorders45(7), 905-908.


      Higa, D., Hoppe, M. J., Lindhorst, T., Mincer, S., Beadnell, B., Morrison, D. M., Wells, E. A., Todd, A., & Mountz, S. (2014). Negative and positive factors associated with the well-being of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth. Youth & Society, 46(5), 663-687.
       

      Kennedy, N., & Hellen, M. (2010). Transgender children: More than a theoretical challenge. Graduate Journal of Social Science7(2).


      Kennedy, N. (2013). Cultural cisgenderism: Consequences of the imperceptible. Psychology of Women's Section Review, 15(2). Accessed August 24, 2020. Retrieved from https://www.academia.edu/5112152/Cultural_Cisgenderism_Consequences_of_the_Imperceptible


      Kirsch, A. C., Shapiro, J. B., Conley, C. S., & Heinrichs, G. (2016). Explaining the pathway from familial and peer social support to disordered eating: Is body dissatisfaction the link for male and female adolescents?.Eating Behaviors22, 175-181.
       

      Lapid, M. I., Prom, M. C., Burton, M. C., McAlpine, D. E., Sutor, B., & Rummans, T. A. (2010). Eating disorders in the elderly. International Psychogeriatrics22(4), 523.


      Munto, L. (2017). Everyday indignities: Using the microaggression framework to understand weight stigma. Journal of Law, Medicine & Ethics, 45, 502-509. doi: 10.1177/1073110517750584.


      Okun, T. (2020) White supremacy culture. Retrieved from https://www.dismantlingracism.org/white-supremacy-culture.html


      Pinelli, A. (2019). Trans(cending) recovery: Discussions with trans and non-binary folks around recovery in the context of eating disorders (Thesis). McMaster University, Hamilton, ON.


      Roehrig, J., & McLean, C. P. (2010). A comparison of stigma toward eating disorders versus depression. International Journal of Eating Disorders, 43(7), 671-674.


      Shearer, A., Herres, J., Kodish, T., Squitieri, H., James, K., Russon, J., Atte, T., & Diamond, G.S. (2016). Differences in mental health symptoms across lesbian, gay, bisexual, and questioning youth in primary care settings. Journal of Adolescent Health, 38(43), 38-43.


      Smith, C.A. (2019). Intersectionality and sizeism: Implications for mental health practitioners. Women & Therapy, 42(1-2), 59-78. https://doi.org/10.1080/02703149.2018.1524076.
       

      Statistics Canada. (2018). Population Estimations July 1st, by age and sex. Ottawa, ON: Statistics Canada.


      Tompkins, M. A. (2014). Creating a Harm Reduction Plan. In Clinician's Guide to Severe Hoarding (pp. 233-276). Springer, New York, NY.
       

      Watson, H. J., O’Brien, A., & Sadeh-Sharvit, S. (2018). Children of parents with eating disorders. Current Psychiatry Reports20(11), 1-11.

  • The “Journey”

    • There is no single “2SLGBTQ+” experience of an eating disorder

      Within Canada, an estimated 1-2.7 million individuals meet the diagnostic criteria for an eating disorder (Statistics Canada, 2018; Arcelus, Mitchell, & Wales, 2011). Historically, it was believed that only young, white, cis-gendered females struggle with eating disorders. However, research has proven that anyone, regardless of age, body size, class, gender, race, and sexuality can experience an eating disorder. Despite this, treatment and support for eating disorders tend to be rooted in a white, heteronormative and cisnormative view, and size-based stereotypes continue to be widely endorsed. Folks living in larger bodies are discriminated against in many areas of life, including eating disorder treatment and support. Sizeism can be defined as, “oppression based on body size” (Smith, 2019, 61). Sizeism and fatphobia, the fear and dislike of fat people and the stigmatization of individuals with bigger bodies can be seen all around us, from the media to our medical care system. Dr. Deb Burgard, eating disorder specialist, has stated that “We prescribe to fat people the same things that we diagnose and treat in thin people” (Chastain, 2020). 



      As someone who began my eating disorder journey in a larger body and continues to live in one, this resonates as I look back on my journey and remember being commended for my weight loss. They did not care how I got there or what I was struggling with. My shrinking body was viewed with positivity, overshadowing the struggle that was growing every day. While this is only my account, research has shown that “doctors repeatedly advise weight loss for fat patients while recommending CAT scans, blood work or physical therapy for other, average weight patients” (Chrisler & McHugh, 2017). 

      2SLGBTQ+ individuals face unique experiences and stressors that result in a higher probability of developing an eating disorder. While public awareness about 2SLGBTQ+ identities has increased over the past decade, support within the eating disorder community is still lacking. Previous research has viewed the 2SLGBTQ+ community as a single entity, creating a common “2SLGBTQ+ experience”. In developing treatment and support options from this research, the experiences and perceptions of many voices are lost. While there may be a shared understanding between community members, identities, experiences, and individuals are unique. It is important to recognize that there are just as many “2SLGBTQ+ experiences” as there are 2SLGBTQ+ people. Every voice and experience is equally important and valid. Further, while some folks may choose to identify with this community, others may not. Some people are open and vocal about their identities or experiences and others are not. It’s important to remember that being “out and proud” is a privilege in a world that tolerates sexual and gender differences to a varying degrees in certain people and in certain places. White queer and trans people benefit greatly from white supremacy culture (Okun, 2020), which means that not only do they typically have greater access to resources including physical and mental health care, the nature of the discrimination aimed at them in or outside health care settings is markedly different than that aimed at a person who is Black, Indigenous, and/or a person of colour. This is possible because of the ways mass media, the education system, Western science, and some religious institutions frame Black and Indigenous lives as being “less than” to maintain white supremacy (Okun, 2020).


      Finally, we should be aware that in societies that value patriarchy, the experiences of those who identify and/or are read as being feminine will vary drastically from those who identify and/or are read as masculine, and this means that throughout their lives, trans women and femmes are not afforded their rights to safety, respect, and self-development. Consequently, they face significant challenges in maintaining positive mental health and social connection, as well as in securing adequate housing and food. 

    • Questioning

      While some folks may identify with the 2SLGBTQ+ community, some may not identify concretely with any label at all. A multitude of sexual and gender identities exist, some of which have been given a title or label, and some that are still to be explored. There are many different paths that individuals can take on their life journey, and the process of exploring these paths and identities is commonly referred to as  “questioning.” Research has shown that individuals who identify as questioning, or within a questioning stage, are at a higher risk of developing mental health concerns (Shearer et al., 2016). This is because many individuals define this as a vulnerable stage within their journey. During these times of uncertainty, the systems and supports surrounding a person may profoundly enhance or diminish their well-being (Higa et al., 2014). While some individuals may see questioning as an exploration, to others it is an identity. Therefore, it is important to note that supports need to respect the individual and where they identify within their journey.

    • Coming out

      In addition to questioning, coming out is an experience some 2SLGBTQ+ individuals may choose to engage with. Coming out can be seen as “a lifelong journey of understanding, acknowledging and sharing one's gender identity and/or sexual orientation with others” (American Academy of Pediatrics, 2018). For some, coming out might be a quick process, for others, it may be longer and some may choose not to include it in their story at all. Coming out is a personal decision that takes many forms. There is no one way to come out, and no matter how, or if, someone decides to, their experience is valid and should be respected. Questioning, coming out, and any part of someone’s journey can be momentary or lifelong. There are no time limits, no age restrictions, and no guidebook on how the process will look. 

    • Trying to support a friend who is questioning

      • Labels can be scary. Instead of labeling their identity for them, let them be the one to use a term when they’re ready.
      • Try not to ask yes-or-no binary questions. Instead, if they’re comfortable talking to you, try to get them to open up a bit. Ask questions like “What have you been thinking lately?” and “How have these thoughts or feelings affected you?” Sometimes, just having a space where one can express their thoughts and feelings out loud can help us clarify ours.
      • Every path is different. Yes, there are similarities between all human beings and it’s natural to want to relate to your friend. Normalizing feelings that you share can be helpful. They likely grew up with different parents and were exposed to different aspects of life than you. Being accepting and open-minded, and not trying to push them in a certain direction can give them permission to explore on their own terms.
  • Early Conversations about Gender, Sexuality, and the Body

    • Introduction

      The early years can be challenging to navigate, as children experience many changes ranging from rapid growth and development to periods of transition. Eating disorders and disordered eating can occur at any time during these years. Some think of eating disorders as occurring in older youth and young adults, but they can be and are diagnosed in children under the age of 12. 

    • Body neutrality

      Body neutrality is the movement towards accepting one's body by focusing less on your appearance. Feeling neutral about your body allows you to stop placing descriptions, whether positive or negative, on how you look. It is knowing that your weight and appearance do not define your worth; instead, it allows you to focus on what your body does versus how others perceive it. 


      Talking to a child about body neutrality:

      • Talk to your child about their strengths. It could be the kindness they exhibit by sharing their toys with their sibling, or their hard work as they learn to read or count. Focusing on a child’s strengths outside of their physical appearance encourages them to develop new ways of defining their identity.
      • Comments on your child’s body will come up from time to time, especially as they play, learn new gross motor skills (which involve the arms, legs and torso) or fine motor skills (which involve hand-eye coordination, hands, and fingers), and practice athletics. You can make these comments positive for the child by emphasizing the function and, in turn, helping the child develop gratitude. For example, “Your legs are strong; they allow you to run when you play tag.” Focusing on the functional aspects feeds the child’s ability to practice gratitude over negative self-image thoughts they may have when their form is consistently criticized.
      • Lead by example – avoid discussing bodies in negative or positive terms with children. Instead, talk about the qualities you admire in others, for instance, someone might be generous, compassionate, curious, or open-minded. Considering your own feelings about your body can be important.
      • If possible, carve out time to enjoy a variety of movement activities with your child. Instead of discussing exercise as a means of changing appearance or “burning off” food, help them explore different activities to see what they enjoy. Encourage fun in physical activity.
      • When possible, emphasize that diversity in body shape and size is natural. You could use examples from nature, like how there are many types of dogs or plants that look different, and how people do, too.
    • Gender expression and freedom

      As children explore their identity and the world around them, conversations around their gender may arise. Children can express gender creatively at any age or any point in their development, even if they might not yet have the words for it. Before the age of five, a child might not see gender as having permanence and may have a flexible mindset about it. Research indicates that children begin to develop a more precise concept of gender between the ages of three to five years until they start to see gender as a “stable trait” in later years (Bem, 1974). 


      Children are motivated to fit in with their peers. As body image concerns arise, so do worries about gender. From ages three to five, a child is motivated to fit in with those expressing the same gender identity and appearance; you may see a child this age engaging with gender stereotypes. Between ages seven and ten, children may become relaxed about gendered behaviours and appearances. In one study, the average age at which a person realized their gender was different from what they had been told was eight years, showing that a fair number of children express their transness before leaving primary school (Kennedy & Hellen, 2010). Some children may feel that there is something ‘wrong’ with them and may seek to place blame, externally and/or internally (Kennedy & Hellen, 2010). Children should be reassured that there is nothing ‘wrong’ with them or the way they express themselves. 


      In my journey and coming into my non-binary selfhood, my body was separate from my authentic being during my childhood. Seeing my body as a threat to my identity through its divergence from how society perceived a five-year-old ‘girl’ should look, act, and behave increased the body dissatisfaction I felt by the time I began kindergarten. I was told by both adults and peers that I couldn’t do the things I liked or wanted to pursue because of my sex. At this age, I had linked sex and body together, which led me to rationalize that my body was the ‘thing’ that stopped me from having fun and making friends. As a child, I wanted to see a role model that was like me, someone who was non-conforming to all the aspects society has us believe is apart of the “feminine” identity. In my early childhood, I thought being born in this body meant I was confined to the boundaries of not being seen or heard and that my authentic self was ‘bad’ or ‘needed to be fixed.’ Growing up, I focused on ‘fixing’ my appearance from my hair to my clothes, to my body, which led to the onset of disordered eating symptoms by age seven. My outlook would have been greatly changed if given the freedom to be and thrive in my identity.

    • Talking to a child about gender identity

      As a child begins to understand words like ‘girl’ and ‘boy,’ they are ready to start having conversations around gender. Some children may already have questions for you. As a caregiver, your experiences and approach with your child will be unique and geared to where they are in their journey.
      ​​​​​​​

      • It is vital to help your child understand the difference between gender identity and gender expression. Start by explaining to your child that everyone may not identify the same, and gender is a spectrum. Let them know that people use words to describe their identity, such as woman, man, boy, girl, non-binary, etc.
      • Explain that everyone has different ways of expressing their gender, including how they behave, the way they dress, their hair, their name and whether they describe themselves as masculine, feminine or androgynous. Let them know they can’t presume gender identity based on gender expression.
      • Children succeed when their caregivers love and support them unconditionally. Allowing your child to fully express their gender creatively if they so choose leads to better outcomes. If your child is expressing their gender beyond the bounds of society's standards and expectations, remind them that you love and support them as they find their place in this world. This could mean consistently using the preferred name and pronouns of your child, or searching out and sharing resources with them on managing or mitigating bullying they might experience. Connecting with other families can be a great way to learn about similar experiences and navigate support for yourself.
      • If your child expresses discomfort, distress, or gender dysphoria, know that support is available from primary health care providers and mental health professionals. Seek providers who specialize in the care of gender-creative and transgender children who can help support both you and the child in your care. Members of Indigenous communities may find support in Two-Spirit elders within their communities.
      • Not all gender-diverse children express discomfort with their gender. Ask your child questions. Listen to their perspective on their experiences surrounding gender without putting pressure on them to state their identity. You can choose books to read and share with your child that show different ways of presenting gender and introduce your child to communities where gender-diverse individuals are loved and celebrated.
      • A child’s environment shapes their capabilities and can contribute to some risk factors for eating disorders. Having adults outside of the family, whether an educator, coach, or mentor, who can positively incorporate the things that make a child feel different or an outsider is vital.

      In my experience, educators can play a role in creating safer spaces: a teacher’s ability to recognize signs of disordered eating would have made a difference for me. As a child with an eating disorder and struggling with my identity, I often felt exhausted, fearful and isolated. I remember wishing the individuals I saw as leaders would step in and take action. Although this was not the case for me, adults who support children can make significant changes. Sharing gender-diverse stories in the classroom, having these conversations, and supporting students through calm and no-judgemental awareness could change a child’s outcome.

    • Toxic Stress

      When change occurs, whether it is within the home or a regional, national, or global crisis, children are most affected. Due to their physical and cognitive immaturity, they depend on adults to support them in regulating their stress response. Adversityhas disruptive effects on overall brain development, potentially leading to increased problems in school, behaviour concerns, later economic productivity, and lifelong physical and mental health problems inclusive of eating disorders. As a caregiver, you may feel obliged to protect children from all stress; positive stress, however, promotes behaviour that motivates preparation and perseverance. Children who learn early coping skills in response to positive stress (for example, having to share their toys for the first time or attending their first day of school), are more likely to become adept at managing stress and anxiety without the use of disordered eating. 


      If your child openly expresses their gender creatively and identifies as part of the 2SLGBTQ+ community, they may experience homophobia or transphobia. This can increase their risk of developing eating, body weight, or shape concerns in the future, and potentially being subjected to appearance-based discrimination (Gordon et al., 2016). Any discrimination a child faces due to their identity is beyond positive stress; adults have a responsibility to help children lower discrimination-related stress levels. Faced with threats and distractions surrounding their selfhood and identity, children cannot properly develop impulse control and focus. Adults can buffer children from sources of toxic stress and help children dealing with elevated stress levels return to baseline by modelling healthy coping skills, and providing safety and security. 

  • Youth & Puberty

    • Growing into your own experience as a young person

      Our experiences as children and teenagers shape our interactions with ourselves, others, and the world around us. As people grow up, they may begin to spend less time around their parents or caregivers and turn to their friends or peers as examples. Dieting is becoming more common in youth, at increasingly higher intensities and starting at younger ages.


      Puberty is a difficult time for most people. It is normal to struggle with making sense of the changes happening to our bodies and minds. For 2SLGBTQ+ youth, puberty can be especially difficult. For some, particularly trans teenagers, the changes to their bodies are unwelcome and can bring on new challenges with their mood or behaviour (e.g., depression and social withdrawal). The development of secondary sex characteristics (e.g., facial hair, breasts) and changing interpersonal relationship dynamics can be hugely distressing if a youth feels their body is changing in a way they do not want or cannot control. Some may have known about their gender or sexual orientation for quite a while, but kept it hidden because they were afraid of what might happen. Puberty can also be challenging if youth realize who they are is not considered “normal” by society and some of the people around them. This can be frightening and disappointing at the same time, and many youth are left navigating their gender expression or sexual orientation on their own. What’s more, some youth will start to believe that they are not “normal” or that there is something “wrong” with them or their bodies. 


      Older youth may begin to recognize stereotypes of 2SLGBTQ+ people, particularly from popular media. These stereotypes can be extremely harmful, putting forth the idea that there is only one way to be, behave, and look for lesbian, gay, bi, trans, queer, and Two-Spirit people. 


      Here are some examples:

      • TV and movies portraying trans girls and women as “boys/men in dresses” sends the message that trans girls and women are either deviant or imaginary. Such negative stereotypes often go hand-in-hand with the idea that trans people are simply “born in the wrong body”. While some trans people certainly feel this way, and transitioning gender can be enormously helpful for trans people of any age, the underlying message – that someone’s gender is tied to the way they look – remains. This idea can be harmful to trans people who do not feel that their body is “wrong” and do not desire any type of medical transition.
      • People who identify as non-binary are commonly told they don’t “look” non-binary. This may be because most people still see gender as a binary, which shapes their idea of what non-binary looks like. Stereotypes of non-binary people as white and having been assigned female at birth effectively erase both non-binary people assigned male at birth and the long traditions of gender-nonconformity in many cultures and communities, globally and within Canada. In other words, the white-washing of trans and non-binary identities disregards the vibrance and acceptance of transness in Black, Indigenous, and other racialized communities and cultures worldwide.


      Gendered expectations for how people should look include expectations about body shape and size. In Western cultures, girls and women are expected to be thin and monitor their diets closely to ensure they remain so, while boys and men are expected to maintain a muscular physique. 2SLGBTQ+ youth may pick up on these standards of attractiveness, and might consciously or inadvertently apply these guidelines to themselves. For example, because our society also assumes that women will be heterosexual, lesbian youth who have internalized this idea might attempt to fit in by modelling thin-ideal femininity to help them “act”, “appear”, or “become” straight. Similarly, young trans girls may feel compelled to lose weight to “prove” their femininity, and transfeminine people are often held to much stricter standards of femininity than cisgender women. On the other hand, young gay men and trans boys can feel the strong urge to lose weight (e.g., from the hips/butt/waist) and gain muscle because of popular conceptions of masculinity as physically strong and muscular. It should also be noted that there are typically fewer social repercussions for fat men than there are for fat women. While not every young person will experience these feelings or compulsions, they can be important aspects of a youth’s experience when dealing with an eating disorder. 


      Youth should be assured that there are many ways to be Two-Spirit, lesbian, gay, bisexual, transgender, or queer. A person’s body is not determined by their sexual orientation or gender, and vice versa. There are as many possibilities for gendered embodiment as there are people, and not accepting body diversity ultimately hurts people of all genders by forcing upon us the idea of only two possibilities: a thin woman and a muscular man. 

    • Transition

      Not every trans person will want to transition medically, and accessing or abstaining from gender-affirming treatments doesn’t indicate the validity of a trans person’s identity or experience. However, being able to access gender-affirming treatments is hugely rewarding for trans people who do desire them. Trans people who want and can access hormone therapy and gender-affirming surgeries typically experience many positive outcomes – including improvements in mood, greater body satisfaction, and decreases in disordered eating behaviours. 


      In many cases, it is ideal for trans people to begin hormone therapy when experiencing early signs of puberty – around the age of 16 or 17. However, without integrated systems of trans health care and an adequately-resourced network of gender clinics, many families cannot find timely support for their trans children among the medical community. Waitlists to access care at gender clinics can be years long. It is a continued struggle for younger trans youth to access hormone blockers that prevent a great deal of distress by granting the youth time before deciding to either discontinue blockers or begin hormone therapy.


      It should be noted that transition is not a cure, because it will not affect any of the other factors influencing that an individual’s eating behaviours. For example, after accessing hormone therapy, some trans people begin to feel dissatisfied or uncomfortable with the way their body fat has redistributed. Disordered eating behaviours might occur or reoccur post-surgery, because of stress and/or exercise restrictions. Concerns about acne (a fairly common side effect of hormone therapy using testosterone) can influence some trans people to drastically alter their diet so as not to eat anything they believe will cause or worsen breakouts. While acne is a normal skin condition, and not associated with cleanliness, some experience elevated distress over their breakouts because people with blemishes are often treated as undesirable or “dirty”. Finally, trans people may experience increased stress after they start hormone therapy because of the changes in ways their body is read and treated by others; this is not to be confused with so-called “transition regret”. 

    • Family support

      A parent or caregiver’s support can make a world of difference for a young person going through challenges, including around body image, eating, grief, and inclusion. It can be difficult for a youth to predict how their parent or caregiver might react to new information about them – whether it is about their sexuality and/or gender or their eating habits. Youth might also be disinclined to talk to an adult about their difficulties if they expect that the adult will want them to immediately change. They may find that the adult struggles to understand the immense social pressure that they are feeling to “fit in” within a hetero- and cis-normative society. If this is the case, the youth may not be likely to approach their parent/caregiver, especially if that person controls what food they have access to at home and school. 

      Supporting a youth with an eating disorder often involves family-based treatment, recognizing that parents and carers have a crucial role in feeding and caring for their child (Kirsch et al., 2016; Watson, O’Brien, & Sadeh-Sharvit, 2018). Youth are also typically dependent on their carers to help them acquire gender-affirming medical treatment. Research with trans youth and their carers indicates that supporting a youth’s access to gender-affirming medical treatment can enhance a carer’s involvement in eating disorder recovery; on the flipside, carers who barred their child from accessing gender-affirming treatment also inadvertently prevented their involvement in the child’s care and recovery journey (Donaldson et al., 2018).

    • Navigating school

      Many of us are affected by the way our friends think and act. If they are concerned with their weight or appearance and/or think certain body types are just “better” or “healthier” than others, it can make a real impression on how we think about ourselves. If friends begin to diet or change how they eat in order to influence the way they look, it can seem like dieting is the solution if we are unhappy with our bodies or the way we are treated in our bodies. Of course, this works the other way too! Talking about things like body image, self-love, and the unrealistic body standards seen in movies and magazines can help break down expectations for how we should look and feel about our bodies. 
      ​​​​​​​

      Finding Peer-Based Community Support

      Your school may have a Gay-Straight Alliance (GSA) where students who identify as members of the 2SLGBTQ+ community and allies can work together to create an environment that is meant to be free from discrimination. Attending or starting a GSA can help you create space to express your identity and find others who may be able to relate. If you are living in a larger city or town, you may find support in 2SLGBTQ+ youth groups led by a trained facilitator or by peers, queer-based arts and culture initiatives, and opportunities to get involved with Pride festivities. If you are concerned about an individual in your life finding out about your attendance in these spaces, rest assured that many double as a coffee shop or community centre to support your safety.


      Finding community doesn’t always have to mean showing up in a physical space – see Navigating Online Spaces. I found that creating a small group of supportive friends who shared the plight in the face of discrimination and trauma was one of the key things that kept me feeling safe and connected. We found a safe space at school that was typically quiet and let each other know when we needed to chat using an indistinguishable code word. Making these connections and building a support system, no matter how small or large, made the world of difference in my life.

      Finding Safe Adults at School - Starting the Conversation

      It is natural to want someone in your life to understand what is happening for you, especially if there is a conflict or an unsupportive home environment. Adult staff at your school can help you learn positive coping skills and support you in reducing stress in the classroom. Guidance counsellors, for example, exist to promote and support students’ development and well-being, and have training in helping young people manage personal life stressors. Going to a teacher or guidance counsellor to speak about your mental health and/or gender/sexuality concerns may initially be an uncomfortable experience, especially if it is the first time you meet them. If the fear is overwhelming, prioritize talking to someone that you trust and believe will affirm and validate your lived experience. They can connect you with your guidance counsellor and other sources of support, such as other school mental health services and external community resources. 


      You wonder how you can tell if someone is affirming and supportive of the 2SLGBTQ+ community. Although there are no set guidelines, here are some actions adults in a school environment may take (Western Governors University):

      1. They have a safe space sign, safe zone sign or rainbow flag in their classroom or office (check the doors)
      2. They support or lead a GSA, equality group, or coalition that helps counter discrimination
      3. They stand up to homophobia and transphobia in the classroom and enforce zero-tolerance policies
      4. They use 2SLGBTQ+ topics within their curriculum


      If your educators don’t do these things, remember they may be oppressed by the overarching system or uncertain as to how to incorporate their values in their professional life. If you feel nervous heading into a conversation, you may find it helpful to think about: your intentions for starting a conversation, what you hope to get out of it, and what you plan to say. Trust your instincts if you feel unsure. 


      Managing Recovery in High School

      It can be challenging to be a young person in high school, let alone one who is trying to navigate their gender identity or sexual orientation while experiencing an eating disorder. 


      Here are some factors to keep in mind: 

      • You may need to work with school staff, your care team, and your family to ensure that you have support at school and that your recovery remains a priority.
      • Consider different plans for different aspects of your school life, such as academics, extracurriculars, peer pressure, navigating recess and lunch periods, and transportation to and from school.
      • For example, if your lunch period conflicts with other aspects of your eating disorder support, speak to your guidance department beforehand about scheduling a lunch period that meets your needs.
      • If exercise is detrimental to your recovery, talk to your primary care provider about an exemption letter from any mandatory physical education programs.


      Be gentle with yourself: you may have bad days in recovery, and it is an ongoing practice. Remember that you are doing the best you can with the information you have learnt over time. Learn to recognize when you need immediate support. If you are feeling anxious, depressed, overwhelmed and struggling with disordered behaviours emerging, know that you can seek support.

      I didn’t believe I could recover, get support, or speak about the some of the symptoms I was experiencing through my teenage years in high school, and did not actively receive support or acknowledge my eating disorder until my twenties. I hope you can see that there’s hope and support available to you as a teen.  

    • Navigating online spaces

      There are many benefits to being online, like being able to connect with people you can relate to. The Internet is an amazing place for gathering information, resource-sharing, and peer support. It can be positive for mental health when it is used to engage with online self-management tools and peer support communities. 

      I grew up in a small community where 2SLGBTQ+ was not an acronym I ever heard, let alone the term non-binary. Being a queer non-binary person, I felt alone for so long, thinking that I was the only one struggling with my gender, my sexuality, and its impacts on my body. It wasn’t until I was able to reach out online that I could find community and belonging. This support helped me through difficult transitions in my youth where I needed the understanding of someone who could relate. Even when I eventually moved, these online connections reminded me that even if my current situation was not the best, someone out there understood me and what I was going through. This created possibility for my journey in both my queer identity and my eating disorder recovery.

      Finding connection with other 2SLGBTQ+ individuals can be difficult, especially during our teenage years. Through online support, we can find others around the that globe can relate, and find comfort in that support. For trans youth, this can be particularly impactful, because language about transness is often kept from trans and gender-creative children until, as teenagers, they can identify this language for themselves (Kennedy, 2013). When trans and gender-creative kids learn words to describe themselves more accurately, it allows them to know themselves and to know there are others like them. 



      Exercising Caution 

      The Internet and social media can be amazing resources but it is important to be critical of what we see online. While many people uplift body diversity, some will insist there are ways to look and behave that are naturally “better” than others. This is, of course, untrue, but it is easy to get caught up in that messaging. 


      Here are some strategies to keep in mind while navigating the online world: 

      • Internet figures, such as social media influencers, can often push certain body types as being attainable for anyone. They may spend a great deal of money and time changing their bodies to look the way they do, or utilize face- or body-altering filters to change their appearance. Viewing these posts repeatedly can introduce or worsen body image concerns for anyone – it’s not just you. If you notice that you feel sad, bad, or more critical after being on social media, try changing the way you use it (e.g., follow/unfollow other accounts, set up a time limit for certain apps on your phone, etc.).
      • Some of these images or videos perpetuate stereotypes based on gender or race. For example, some popular filters add fuller lips to someone’s face, a feature that is often looked down upon when it appears on a Black person’s face. It is important to identify and refuse to adopt racist “trends” in our journeys for self-acceptance and care.
      • If it feels like you see unrealistic body ideals all the time, try to manipulate the social media algorithms in your favour. For the most part, we can choose who we follow or support. We can follow feeds that portray, celebrate, and uplift different bodies, genders, and sexualities. This allows us to tailor our experiences so that we see and encourage ourselves. Seeing someone like us, with similar experiences or struggles, can help remind us that we are not alone.
      • There is no correct way to recover from an eating disorder. Recovery can be difficult to talk about, and while you may not be ready to share your own story, many people have disclosed theirs. These stories remind us that anyone can be affected by the issues that affect us, and that even in the most difficult times, “recovery” is possible and support is available. While it is natural to compare your story to the ones you see, remember that we can both keep in mind our differences while feeling comforted by the sameness of human experience – we don’t have to choose one.


      The 2SLGBTQ+ community is not a monolith – there are many people with many opinions, some based on internalizing some of the harmful messaging we have received about ourselves growing up. There are several prominent YouTubers, for example, who promote transnormativity– the idea that there is a way of being trans that is more “correct” or “natural”. According to them, to be properly trans is to identify as the “opposite gender”, to know about your transness from a very young age, and to transition medically to pass. The idea that one must transition “fully” to the “opposite gender” oppresses non-binary people and anyone who does not desire a medical transition by creating a binary of “real” trans people and “fakers”. Some trans and non-binary people might desire or require several types of gender-affirming treatment throughout their transition, while others may be satisfied and content with fewer procedures, and others still do not desire medical transition. There is no one right way to be trans. Every person in the world has a unique relationship to gender, and they have the right to determine the nature of that relationship. By tying the validity of a person’s gender to the way they look, transnormativity implies that if you want to be respected and safe as a trans person, you should be invisible as a trans person. Yet there is a huge range of natural body diversity for cis people, so why should trans people be any different? 

    • Trauma

      Traumacan live in the body for a long time. Many people who survive traumas like sexual abuse or assault experience difficulties with eating and their relationship with their bodies. While we may tend to think of trauma occurring after a single event, it can also occur because of ongoing discrimination and oppression. Since people of any age can be affected by trauma, people experiencing disordered eating and the people who care for them should look at past events, current triggers, and possibilities for healing.


      2SLGBTQ+ people might have experiences that convince them that the world is not safe. The possibility of encountering violence is high for 2SLGBTQ+ people, particularly as we see a rise in visibility for queer and trans communities but few improvements in health and life-enhancing support for them. There is also the psychological stress of expecting that you will face discrimination or violence. News and popular media often portray queer life as tragic, inevitably filled with self-doubt and fear. Combined with one’s real experiences, this dominant tragic narrative can create conflict and confusion centring around bodies, safety, and “passing”. 


      “Passing” has long histories in and outside the concept of gender and has to do with “blending in” to the mainstream. In Western culture, because the gender binary and gender roles are strictly upheld in health care, social services, and educational institutions, “passing” can be a way for 2SLGBTQ+ people to access necessary care and resources. “Passing” is sometimes misrepresented as being “necessary” for an 2SLGBTQ+ person to find acceptance. “Passing” can be rewarding for 2SLGBTQ+ people in that it gets them what they need, including safety from violence. However, there is often an unfortunate tradeoff where they are unable to express themselves authentically. 

    • What does body image mean to you?

      It is okay to not love the body that you are in and to voice your struggles with your body. Finding a community of supports (see Finding Support section) can help.


      When you find it hard to accept your body, consider:

      • Acknowledging all of the different parts of your body and what they do or do not do for you
      • Appreciating that your body has carried you all your life and does wonderful things that most of us fail to notice
      • Putting on some music and moving your body
      • Finding someone who inspires you to be yourself
      • Reflecting on those moments where you feel down – write it in a journal
      • Wearing something that makes you feel like yourself
      • Talking to your friends who may have similar body image issues
      • Moving away from labels like “pretty” or “ugly” and focusing on strengths that go beyond appearance
      • Remembering that health looks different for everybody, and that health is not a prerequisite for worth


      Talking with someone you trust about having a hard time in your body can help you process those difficult emotions. You do not need to navigate body image challenges alone! 

  • Adulthood

    • Becoming a parent: childbirth & fertility

      Becoming a parent is a unique decision and experience for everyone. 2SLGBTQ+ people have to decide not only whether or not we want to be parents but how we will become one. Do we adopt? Obtain sperm from a friend or purchase it from a sperm bank? Do we engage with fertility clinics? Find a surrogate? It can be an expensive and monumental undertaking that may take a toll on our mental and physical health, relationships, and bank accounts. What impact have our ‘eating disorders’ had on our fertility? How will our sexual and gender identity impact our journey through this highly medicalized system?



      These are important questions that each individual must find answers to.



      I was 32 and newly married when we decided we wanted to have a child. My wife was not particularly interested in carrying a baby so we decided to see if I could become pregnant. I had two decades of eating disorder history that I was concerned about. 


      While the hope is that a relationship with a fertility clinic is brief, it can be extensive. We wanted to have a medical team that we felt supported by, so we met with two fertility clinics. We lived in the suburbs and while one of the clinics was minutes from our home, we did not get the sense they had much experience with same-sex couples. So, we chose to work with a clinic further away in Toronto. 


      I became pregnant after treatment that spanned 10 months and ultimately succeeded with in vitro fertilization(IVF). Tests never indicated that my eating disorder caused any problems. I found the fertility clinic experience so dehumanizing and medicalized that I envied couples who could create a family with a romantic night at home. Instead, I got doctors who couldn’t remember my name, nurses who were agitated I didn’t know my weight (a recovery choice), and 7:00 a.m. penetration for regular internal ultrasounds. While I am among the ‘successful’ patients who had a successful and healthy pregnancy, I felt deeply disconnected from my body and struggled with triggers and mild eating disorder symptoms . 


      When my medical care was transferred to a doctor in my suburban town, I found that my new medical team had limited knowledge of IVF and sperm donors, and no idea how to speak to same-sex couples. Incorrect assumptions were constantly made and our choices were often labelled ‘interesting’ or ‘cute’. I was concerned assumptions were being made that could seriously impact myself or the unborn baby.


      I do not expect health care professionals to know everything, only to have an awareness of their limitations. As an example of a good experience, I had a consultation with a specialist at a Toronto hospital when the fertility clinic had a concern about my ultrasound. Because we had been referred from a fertility clinic, many of the intake questions were directly related to that experience, questions such as: How did you obtain the sperm? Please answer any questions about the donor to the best of your ability. Where did you obtain the egg? What is your relationship with each other? What is your relationship with the baby? They also took time to explain some of the terminologies they used to categorize our situation. 


      These questions, and the care this specialist showed in understanding my situation, built trust and an inclusive environment where our family was acknowledged and respected. This experience was the direct opposite of my first obstetrician appointment where the doctor became flustered when she realized she was not asking for the right person's medical history and did not have a chart set up to accommodate it. 


      I did not speak to my OB-GYN about my eating disorder history because I was not symptomatic during my pregnancy. In retrospect, the problem wasn’t that I chose not to speak about it, but rather that there was no discussion of my mental health. I enjoyed being pregnant but still felt the mental and emotional strain of my changing body. Weight gain is part of a healthy pregnancy but I didn’t enjoy reentering a relationship with a scale. I choose not to have one in my home but weigh-ins were a part of almost every check-up. Initially, I chose to do blind weigh-ins, but by the third trimester I was hooked on each week's number and how it had changed. 


      Outside of the medical office, my body was a point of interest and conversation like never before. The praise for how ‘great’ I looked, while well-intentioned, reminded me of the commentary I received when I had been very sick with my eating disorder. Additionally, family, colleagues and neighbours questioned how I had become pregnant and what our family would look like. What clinic did you use? How did you pick a donor? Can I see their picture? Your wife should get pregnant at the same time and then you can have two babies! What will the child call you? Won’t it be confusing to have two moms? Although I became good at deflecting them, these questions are inappropriate, dehumanizing, and an invasion of privacy. 


      My daughter was born after over 24 hours of labour; I was so exhausted I don’t remember much of that big moment. During my labour, the doctors and nurses were very attentive to my physical needs but emotional and mental health needs were of no interest, a pattern that would be repeated throughout my three-day recovery in the hospital and beyond. 


      Once we moved to the recovery side of the unit, the baby became the focus of care. My wellbeing was not much of a concern and the staff did not acknowledge my wife as a co-parent and partner. She was repeatedly praised for being such a supportive sister, despite my constant correction. 


      I had a very long physical and emotional recovery journey after this experience, resulting in an eating disorder relapse before my daughter’s first birthday. This relapse could have been prevented. Being pregnant and becoming a parent are huge changes, which seems obvious, but I had no real understanding of what it would mean for me. Although I saw my psychiatrist regularly, I had to talk about and advocate for my mental health with every health care professional. While I wish I had advocated more for myself, I am not solely responsible for the lack of care. My health care professionals never asked about my mental health, and were dismissive and shaming towards me when I spoke up. 


      During the hospital stay after my daughter was born, I had not slept in days and my anxiety became unmanageable. More than once, I requested an anti-anxiety medication that was safe for me to take while breastfeeding so that I could rest. The doctor would not prescribe any psychiatric medication as it would enter the breast milk and harm the baby, even though breastmilk vs. formula is not life or death for a baby. However, health care professionals push breastfeeding and do not speak to mothers about alternatives. I was told that my plummeting mood was normal for new moms and to just ride it out. 


      After this conversation, I requested a discharge from the hospital so I could consult with my psychiatrist and family physician. Although I was advocating for myself, I recognized that no one was listening. My psychiatrist prescribed anti-anxiety medication that were safe while breast-feeding. I met with my family doctor, who asked that I return weekly for monitoring. Had this level of knowledge and medical care been in place during my hospital stay my distress would not have escalated so much. 


      I have a lengthy psychiatric history and am experienced at dealing with health care professionals, but this experience stunned me. I had never had such a dismissive, judgemental and careless experience with so many doctors and nurses. Had it not been for my established outpatient team, I am not sure what would have happened. 


      Socially, I had become quite isolated during pregnancy. There were no 2SLGBTQ+ resources in my community. I attended many mommy groups, but was always the only 2SLGBTQ+ individual. This left me feeling alone with my ‘unique circumstances’ (being a pregnant lesbian) and reluctant to reach out to others who might ask inappropriate and prying questions. I wish I had been able to find a community to relate to and be supported by. It would have decreased my isolation and increased my overall well being to connect to other people going through a similar experience. 

    • Developing an eating disorder later in life

      While research demonstrates that eating disorders can onset in mid-life (often defined as the period between ages 45 and 54), there is limited information available on this intersection. Media depictions of eating disorders rarely include older individuals, instead glorifying youth and physical attractiveness. Major transitions later in life, such as changes to employment or living situations, worsening physical health, supporting an older parent, divorce, a child’s departure, and natural biological changes in metabolism and body shape and weight can contribute to poor mental health, and to engagement in harmful eating and movement practices. Older adults may be more vulnerable to the medical complications of eating disorders, such as bone loss or organ dysfunction. These can change the face of recovery for someone in the throes of a mid-life eating disorder, a relapse or new onset. Among individuals receiving inpatient treatment, those at mid-life have been observed to display greater illness severity than their younger counterparts (Anderson, Murray, & Kaye, 2017). 

    • Ageism

      Ageism is a less-discussed aspect of the 2SLGBTQ+ experience, and refers to stereotypes, prejudice, and discrimination towards others or oneself based on age, and can be seen in our institutions, policies, and interpersonal interactions (WHO). 


      Many of us who have experienced an eating disorder during our middle-age years have experienced ageism and hopelessness in adult eating disorder support environments. It is normal to feel out of place or ignored in a setting where your health concerns might not be taken seriously by professionals focused on younger people’s needs and perspectives. You may feel a sense of loss for the years that were dominated by the illness, which younger peers might not understand. Feeling isolated, invisible, and devalued even within the 2SLGBTQ+ community can create stress that may contribute to disordered eating. For example, research indicates that many gay men feel old even when relatively young because youth and physical attractiveness are disproportionately valued within the community.


      Changing terminology can also be an issue, as terms that were once acceptable become thought of as discriminatory. While these changes are meant to create inclusivity and acceptance amongst the community, some individuals may not find a connection to the changing terms. Research by Employment and Social Development Canada noted that changing 2SLGBTQ+ terminology means “some seniors do not fall under these labels or feel recognized or supported by this community”. If someone identifies with a term or identity whose meaning has changed over time, it is important to acknowledge their identity on their terms, rather than forcing a new identity upon them. For example, while the term “transsexual” is now considered outdated and offensive, many older trans individuals continue to utilize this terminology. Regardless of how you identify, you are valid, and deserve respect. 


      The HIV/AIDS crisis in the 1980s and 90s decimated an entire generation of 2SLGBTQ+ people and increased stigma among healthcare providers and the general public, which continues to have an impact on perceptions of our community and the health and mental health care we receive. Additionally, our community was robbed of older adults, who might have been able to offer guidance, support, or even an example of how to live with an eating disorder. 

    • How can you help address ageism? 

      • Create educational activities that build empathy. Seek out and share stories of older people experiencing eating disorders when hosting educational events and present counter-stereotypical examples of who eating disorders affect. 
      • Counter misconceptions about eating disorders in different age groups. Speak up when someone says “oh, that’s just a young person’s issue” or comments on another person’s age. 
      • Create environments for younger and older 2SLGBTQ+ people to come together and share their stories. Building community and solidarity about shared issues can be the future of collective eating disorder recovery spaces. 
    • Older adults

      Eating disorders are dangerous in older adults; as we age, our bodies can become less resilient, and nutritional restriction can increase the risk of various complications, including osteoporosis and low bone density from sarcopenia, which includes the loss of muscle tissue. Although sarcopenia is a natural part of the ageing process, major nutritional deficiencies can cause muscle tissue loss surrounding the heart, leading to complications such as heart failure. 


      Family care partners may not recognize the signs and symptoms of an eating disorder, and may assume that the symptoms exhibited by the individual they provide care for are an expected part of the aging process. If you suspect that someone you provide care for is experiencing an eating disorder, plan how you will approach them and know that they might respond with anger or defensiveness. Do not trivialize the situation. Keep the lines of communication open, and let them know you are available to discuss next steps and help finding treatment when they are ready. Offering your unconditional support is often the way we can do the most good.

    • Long-term care homes

      Many older adults require support at meal times due to age-related physiological or psychological reasons. A person with limited mobility or who requires a modified-texture diet may struggle to take in adequate nutrition, potentially leading to disordered eating patterns (Guerdjikova et al., 2012; Lapid et al., 2010). Mental health issues around eating may not always be noticeable, and sometimes, other aspects of health such as pain management can take priority or are easier to identify. As long-term care homes are often understaffed and need to support a large number of residents, it may be harder for them to notice these changes in eating patterns. This may result in individuals not receiving the level of support they need at mealtime, contributing to disordered eating behaviours. It is important to regularly follow up with someone living in a long-term care home to inquire about any significant changes in their eating patterns and/or weight. 


      Laxative use, often a warning sign for eating disorders, might be more normal amongst older adults where it can be used to manage digestive issues resulting in constipation. If disordered eating behaviours are in a person's history, communicating that to team members at a long-term care home could reduce the risk of fostering a dependency on laxatives, instead focusing on dietary fibre, movement, and regular fluids (Chen, Huang, Yang, Chen, Chou, Kuo, 2014).


      Beyond the risk of eating disorders, discrimination is a threat for 2SLGBTQ+ older adults living in long-term care homes. In their National LGBTQI2S Action Plan, Egale notes that 2SLGBTQ+ older adults face more isolation and loneliness than those who are cisgender and heterosexual due to threats of discrimination and oppression. Some older 2SLGBTQ+ people worry that being ‘out’ while living in a long-term care community would affect the quality of care they receive. Service providers and older adults alike share that their biggest fear is being “recloseted in residential care” (Egale, 2020). Many older adults in long-term care environments are forced to relive traumas associated with their coming out, and may receive treatment lacking respect and dignity. Ending discrimination and oppression in long-term care requires both education of the team members and changing policy within the organization so that every 2SLGBTQ+ person can live with dignity and pride as they age. 

  • Self-Advocacy: Taking Action to Meet Your Needs

    • Introduction

      Every person who struggles with an eating disorder deserves compassionate, non-judgmental, affirming care from the support options they choose to access. Some, however, might not have this experience. As there is plenty of work to be done to better educate and train care providers to be eating disorder-sensitive so they avoid causing harm, 2SLGBTQ+ communities in particular often have to self-advocate. 



      This process often includes: 

      • An understanding that every person is deserving of support
      • Reflecting on what their goals and boundaries are
      • Communicating these goals and boundaries to the people who are caring for them
    • Thinking about recovery

      “Don’t mistake me: I don’t mean we need to find normal and make it our own. Normal – that center against which every one of us is judged and compared: in truth I want us to smash it to smithereens. And in its place, celebrate our irrevocable different bodies, our queerness, our crip lives, telling stories and creating for ourselves an abiding sense of the ordinary and the familiar.”                             

       Eli Clare


      Eating disorders are notoriously difficult to resolve. Sometimes healthcare professionals and loved ones blame a person for their challenges throughout recovery. It should be expected that people might struggle within a world that upholds a narrow range of body types, gender presentations, and appearances as ‘normal’. When recovery is defined by weight-related outcomes and normalization of eating habits, people are pushed to get back to ‘normal’. This definition ignores that their distress around bodies and food may have originated from rigid expectations of what it means to have a ‘normal’ gendered body. It ignores the fact that some people will still be subject to body-based harassment, discrimination, and shaming even after they have ‘recovered’. It ignores narratives that can make recovery difficult, like ‘born-in-the-wrong-body’ stories that can make disordered eating seem like a rational behaviour to ‘correct’ a body. 


      There is space for all the complicated and messy feelings we have around gender, bodies, and food. Recovery doesn’t mean that you will never feel pressure to control your diet, weight, or shape ever again, especially because so much of that pressure comes from outside. Recovery can look like loving your body, appreciating everything it can do, and still wishing it were different. For trans people, recovery can look like getting the transition you want, even though some parts of transitioning may not be exactly what you expected or desired. It is okay if you’re not ready to take another step forward and to ask people to meet you where you are instead.


      When we let go of ‘normal’, recovery can mean living with and enjoying the brilliance of our bodies exactly as they are. A recovery that moves towards ordinary and familiar allows us to be creative in how we promote body love, acceptance, and satisfaction. It allows for creativity in how we resolve the distress we feel around food and bodies. Recovery is about much more than just an absence of disordered eating. It’s about a reconnection with the self and with others. Perhaps the most important thing about recovery is that it very rarely happens alone. We heal best when we feel safe, connected, understood, and valued. Family, friends, and partners who love, support, and validate us are so important in the journey to finding peace and self-love. There is a whole community on this road with you.

    • Taking a harm reduction approach to goal-setting

      Harm reduction is an approach focused on reducing the harmful effects of some behaviours,  recognizing that abstaining from or eliminating those behaviours entirely might not be a realistic or desirable goal, especially in the short-term. It accepts that the behaviours, for better or worse, are a part of the person’s experience and often occur for complex reasons that are not easy to fix. Harm reduction acknowledges that there are often safer ways a person can engage in a certain behaviour, and involves non-judgmental planning around the behaviours to limit the danger to a person’s health and improve their quality of life. Harm reduction approaches have been successfully used to optimize the safety of people with HIV/AIDS, and people who engage in drug use and sex work, in both community and professional settings. (adapted from the National Harm Reduction Coalition)



      Some behaviours associated with disordered eating to which you might want to apply a harm reduction approach include the restriction of calories or certain types of foods (e.g., dieting, non-religious/spiritual fasting), over-exercising despite pain, and the misuse of substances like laxatives, diet pills, or performance- or muscle-enhancing supplements.



      The exact way that harm reduction can be applied to your life is personal; you have the power to choose how you will practice. 



      Here are some proactive steps that might be helpful to think about:

      • Know when to get help: What are the warning signs when you are beginning to struggle? Think about specific thoughts, feelings, or behaviours that come up.
      • Coping skills: What can you do, by yourself, to manage the concern? What obstacles might show up when you try to use these skills?
      • Social support: If you’re finding it difficult to deal with your distress alone, who is in your web of support? If you have trouble putting one together, you can always contact the NEDIC helpline to get some ideas! Think about aligning appropriate supports with your level of distress (e.g., calling a crisis line when you’re at an 8/10; calling a friend when you’re at a 3/10). You know yourself best.



      Here’s an example of how to set some goals around reducing the harm of over-exercising behaviours that one might experience when they’re struggling with disordered eating. These plans are best created with a support team (loved ones, peer support, professional support, etc.) to help you catch factors that you might miss.



      Realistic Harm Reduction Targets 
      Concrete and specific – “Change running habits from daily to four times a week”  
      Doable – “Only run after eating a meal”  
      Quickly and easily monitored – “After my run, I’ll ask myself: do I feel pain that’s higher than 5/10? Do I feel dizzy or faint? If yes, I know I need to adjust more.” 
      Prioritized – Immediate targets focus on minimizing risk from behaviour (e.g. running without corresponding energy intake); long-term targets focus on increasing comfort for the person (a different relationship with movement and eating) 
      Done with support or a plan – “I’ll talk about how I’m feeling in my support group next week”; “I know there’s a part of me that would’ve wanted to exercise more so I’ll plan to soothe those emotions by journalling when I get home.”  


      Unrealistic Harm Reduction Targets 
      Vague – “Change running habits”  
      Too big or difficult – “Stop running every day” 
      Ambiguous or lacking guidelines – “Decide if this plan is working based on how I feel” 
      Everything or nothing is urgent – “I have a big list of things to do next time I plan on running and I’ll try them all”  
      Done in isolation or without a plan for caring for yourself after engaging in the behaviour  - “When I get home, I’ll move onto my next task”  


    • Finding support

      It can be hard to advocate for yourself at times and communicating your needs does not always mean that they will be respected. This is one of the reasons why it's important to have supportive people in your corner. This will look different for everyone, and might include family support, a trusted friend, 2SLGBTQ+ communities and spaces, or a mentor. Remember many people are struggling with similar experiences as you, and there are resources that might be able to help online, or in some cases, in your local community. 

    • What makes it hard for people to receive inclusive medical care and treatment?

      Treatments for eating disorders can be inadequate for a lot of reasons. 


      Here’s a short list:

      • People whose bodies and eating habits don’t match up to specific criteria can face access barriers. Fat people often aren’t able to access treatment because their eating disorder isn’t seen as a risk, and their disordered behaviours may even be framed as beneficial if it means they are losing weight.
      • Fatphobia, transphobia, homophobia, racism, and other problematic attitudes exist throughout the healthcare system, which can cause marginalized patients to experience harm when they access medically based treatments.
      • Some professionals misunderstand the nature of our feelings towards our bodies. They may know little about eating disorders, and even less about 2SLGBTQ+ identities.
      • A diagnosis of any kind is meant to set apart what’s abnormal from a defined ‘normal’. Many people have difficulties with their body image, food, and eating, but aren’t diagnosed.
      • Finally, eating disorders can be treated as an individual, biological problem, when in reality they have as much to do with a person’s social environment as they do with their body.
    • What can you do if you don’t feel supported?

      • Communicate what your needs are, what your goals are, and what safeguards you need to be put in place. You can write and plan these ahead of time so you feel prepared to go into an appointment with a primary care provider, psychologist, therapist, or dietitian.
      • Determine if your care provider is 2SLGBTQ+ friendly. Ask (if you feel it is safe to do) whether they have experience working with 2SLGBTQ+ folks. You deserve gender- and identity-affirming care.
      • When possible, it can be helpful to talk to your closest or most supportive people first, and work with them to develop a plan for conversations youanticipate being more difficult (i.e., with parents or health care providers).
      • Trust yourself when it comes to your experience with healthcare providers – only you know if it feels like a good relationship, and what might be a good experience for some might not be acceptable for others.
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