This resource speaks to our experiences as 2SLGBTQ+ individuals who have accessed ‘eating disorder’ support. While people have been moving away from the dominant narrative of ‘eating disorders’ only affecting white, middle-class, heterosexual, cisgender, teenage girls, this long-told story has informed our experiences of care. It informs how doctors understand ‘eating disorders’, who might be seen as struggling, 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 stories and who is given a platform to tell their story. 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”. The problem is that, when you do not see yourself in the stories, you do not exist. When you do not see aspects of your 2SLGBTQ+ identity in ‘eating disorder’ narratives, you wonder if you can even be experiencing an ‘eating disorder’. 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. With that said, we must 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 on ‘eating disorders’.
This resource will by no means discuss every experience, best-practice, or gap in ‘eating disorder’ care for 2SLGBTQ+ communities. Our experiences are not everyone’s and we do not represent every perspective. We recognize that once we name something and identify common experiences, inevitably, people and experiences will be left out. We are hoping to provide a bridge highlighting some of our experiences as 2SLGBTQ+ individuals with ‘eating disorders’. If we can only convey one message, it would be that 2SLGBTQ+ individuals will have their own personal experiences which may or may not be similar to those of other 2SLGBTQ+ individuals. The best piece of advice 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 ‘eating disorders’.
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. For this resource, we will use quotations around the term ‘eating disorder’ as a way of highlighting that not all individuals will want a diagnostic label (Grant, 2020). 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 in white, Western beliefs around body size. Particular bodies may not be eligible for ‘eating disorder’ support and treatment. It has also been critiqued for creating a system in which care is provided only after symptoms and behaviours might be severely affecting 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, and been ignored, discredited, misunderstood, told we are unnatural, and often over pathologized. We therefore use quotes around the term ‘eating disorder’ as a way of acknowledging that our experiences with the medical system have ranged from helpful to violent.
We do not use the word ‘stigma’. In recent years ‘stigma’ has been used to describe the negative consequences of struggling with one's mental health or having a mental health diagnosis. The idea of ‘stigma’ has broadened and is sometimes applied unilaterally to people of varying identities, which erases the difference between each person’s experience. Social science and psychological researchers have noted some differences in roughly how many 2SLGBTQ+ people experience ‘eating disorders’ and have put out some theories on why they may be at ‘higher risk’ than cisgender, heterosexual people. However, ‘eating disorders’ research almost always incorrectly frames the issue as an individual, biomedical problem, detached from the effects of living under capitalism and patriarchy. While we find any discrimination unacceptable, we believe that the word ‘stigma’ has become a polite replacement for what is occurring and as such we will use the word oppression or sanism. Sanism is the discrimination against anyone with or who is perceived to have “mental health stuff”.
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 ‘eating disorders’ affect people of all backgrounds. Despite this, treatment and support for ‘eating disorders’ tend to be rooted in a white, heteronormative and cisnormative view.
The DSM-5 defines an ‘eating disorder’ as “a persistent disturbance of eating or eating-related behaviour that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning” (APA, 2013, p. 329). ‘Pica’, ‘rumination disorder’, ‘avoidant/restrictive food intake disorder’, ‘anorexia nervosa’, ‘bulimia nervosa’, and ‘binge-eating disorder’, are all classified as ‘eating disorders’. ‘Other specified feeding and eating disorders’ is listed as a diagnosis which is applicable to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class (APA, 2013, p. 353, as cited in Grant, 2020)
While this definition reflects what the medical community currently classifies as an ‘eating disorder’, the experiences of individuals can present in a variety of ways. Anyone, regardless of age, gender, class, sexuality, race, or body size can experience an ‘eating disorder’. While many of these intersections have been acknowledged in ‘eating disorder’ literature over time, 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). For myself, someone who began my eating disorder journey in a larger body and continues to live as such, this connects with me as I remember looking back on my journey and having people commend me for my weight loss. They did not care how I got there or what I was struggling with. It was my body that was shrinking in size that was viewed with positivity, while 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 related to 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 has remained primarily static. 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 greater degree in certain people. 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 the Christian church 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.
Just as some folks may identify with the 2SLGBTQ+ community, some may not identify concretely with any label at all. There is a multitude of sexual and gender identities in the world, 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. As discussed by Higa et al. (2014), during these times of uncertainty, systems surrounding an 2SLGBTQ+ individual may profoundly enhance or diminish the individual’s well-being. 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.
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.
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
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/.
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.
Author, A. (Year, Month Day(s) of conference). Title of conference session [Conference session]. Conference Name, City, Abbreviation of province, state, or territory (if applicable), Country. URL. https://www.apa.org/news/press/releases/2017/08/fat-shaming#:~:text=%E2%80%9CDisrespectful%20treatment%20and%20medical%20fat,College%2C%20said%20during%20a%20symposium.
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=mods_extension_degree_department_ms%3A%22Social%20Work%22
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.
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.
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 make their mark at any time during these years. We may only think of ‘eating disorders’ occurring in older youth and young adults, yet, they can and are diagnosed in children under the age of 12.
Body neutrality is the movement towards accepting one’s body by focusing less on one’s 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:
As children explore the world around them, and their identity, conversations around their gender may arise. Children can express gender creatively at any age or any point in their development, though they might not have the words to express themselves yet. Before the age of five, a child might not see gender as having permanence and may have a flexible mindset about it. Research shows us 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 how a fair number of children express their transness before leaving primary school (Kennedy, 2012). Some children may feel that there is something ‘wrong’ with them and may seek to place blame, externally and/or internally (Kennedy, 2012). Children should be reassured that there is nothing ‘wrong’ with them or the way they express themselves.
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 before you. As a caregiver, your experiences and approach with your child will be unique and geared to where they are in their journeys. It is vital to help your child understand the difference between gender identity and gender expression. Start by explaining to the 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; this could mean 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 the caregivers in their lives 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 that could happen among their peers. Connecting with other families who have gone through similar experiences can be a great resource 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. You can 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 through these conversations. Members of Indigenous communities may find support in two-spirit elders within their communities. Not all gender diverse children express discomfort with their gender. Don’t hesitate to ask your child questions. Listen to their perspective of their experiences surrounding gender without putting pressure on them to state their identity. You can also 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 this is an educator, coach, or mentor who can incorporate the things that make a child feel different or an outsider in their community is vital. On a personal note, I’d like to share my experiences on the role that educators play in creating safer spaces versus spaces that create a negative influence. A teacher’s ability to recognize the signs of disordered eating in the classroom would have made a difference in my own life. As a child with an ‘eating disorder’ and struggling with my identity, I often felt exhausted, fearful and isolated. I remember wishing the individuals who I saw as leaders in my life 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 or conversations and supporting students through calm and non-judgemental awareness could change a child’s outcome. Developing education upon how as an outside adult, one can be in a unique position to implement a support system can change in a child’s life.
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. Adversity has disruptive effects on overall brain development. It may lead to increased problems in school, behaviour, 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 is beginning to openly express their gender creatively and identify as part of the 2SLGBTQ+ community, they may experience homophobia or transphobia. This can increase their risk of developing eating or body weight or shape concerns in the future, and potentially being subjected to appearance-based discrimination (Gordon et al., 2016; Jones, 2015). Any discrimination a child faces in due to their identity is beyond positive stress; adults have a responsibility to support children to lower discrimination-related stress levels. Faced with threats and distractions surrounding their selfhood and identity, children cannot properly develop their ability for impulse control and focus. Adults can help 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.
Our experiences as children and teenagers go a long way in shaping our interactions with our selves, 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’s normal to struggle with making sense of the changes happening to our bodies and minds. For 2SLGBTQ+ youth, puberty can be an especially difficult time of their lives. For some teenagers, 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 a very difficult time in which they 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 themselves that they are not “normal” and there is something “wrong” with them or their bodies.
Other 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. In an example of extreme transmisogyny, TV and movies repeatedly 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, and that shapes their idea of what exactly non-binary looks like. Misconceptions 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.
Our 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 thin, 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 model thin-ideal femininity to help them “act”, “appear”, or “become” straight to fit in. 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 must be said that not every young person will experience these feelings or compulsions, but that these can be important aspects of a youth’s experience when dealing with an ‘eating disorder’. It should also be noted that there are typically fewer social repercussions for fat men than there are for fat women.
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.
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. That said, 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.
It’s common for trans people to begin hormone therapy around 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 for a person is not a cure, because it will not affect any of the other factors influencing that their eating behaviours. This can be seen when, after accessing hormone therapy, some trans people begin to feel dissatisfied or uncomfortable with the way their body fat has redistributed. There are also cases where 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 it does not indicate anything about one’s cleanliness, some experience elevated distress over their breakouts because people with blemishes are often treated as undesirable or ‘dirty’. Finally, it should be noted that sometimes trans people experience increased stress after they start hormone therapy because of the changes in ways their body is read and treated by others and that this is not to be confused with so-called “transition regret”.
A parent or caregiver’s support can make a world of difference for a young person going through challenges, including challenges 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. It can also be difficult to for a youth 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. In this case, the youth may not be very likely to approach to their parent/caregiver to talk, especially if that person still controls what food they have access to at home and school. If you are the parent/caregiver of a youth that you think may be dealing with an ‘eating disorder’ or other body-based concerns, the Internet can be a good place to learn more about these types of challenges and how best to approach them with the youth (with appropriate caution, more on this later in the Navigating Online Spaces section).
Research suggests that family support can be highly influential in preventing disordered eating behaviours in youth through late adolescence (Kirsch et al., 2016). For example, one study has shown that trans youth who experience high levels of discrimination and high levels of support are drastically less likely to report certain disordered eating behaviours, compared to trans youth experiencing high levels of discrimination and low levels of support (Watson et al., 2017). Additionally, the absence of a coordinated care system for trans youth and/or ‘eating disorder’ treatment services, for a youth with an ‘eating disorder; family-based treatment that involves supportive parents/caregivers can help integrate clinical care with care at home. Youth are typically dependent on parents/caregivers to help them acquire gender-affirming medical treatment. In other words, parents/caregivers are likely to hold the key to restricting or allowing for the youth’s self-determination. Further, research with trans youth and their parents/caregivers indicates that supporting a youth’s access to the gender-affirming medical treatment can enhance parental/caregiver involvement in ‘eating disorder’ management and recovery (Donaldson et al., 2018). Logically, this research also showed that parents/caregivers 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).
It’s easy to be affected by the way our friends think and act. If they are concerned with their weight, appearance or think certain body types are just “better” or “healthier” than others, it can make a real impression on how a person thinks about themselves. If friends begin to diet or change how they eat because of the way they look, it can give the impression that dieting is the way to go if we’re unhappy with our bodies or the way we’re 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 be enormously helpful in breaking down expectations for how we should look and feel about our bodies.
Your school may have a Gay-Straight Alliance (GSA) in place to act as a “safe space” where all 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 a GSA or creating one in your school can be a starting point to 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 any 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 and we will talk more about online connections in the Navigating Online Spaces section within this chapter. In my own experience, 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. As a group, 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 that allowed us to connect. Making these connections and building your support system, no matter how small or large, made the world of difference in my life at the time.
It’s 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 wellbeing, 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 initially may be an uncomfortable experience, especially if it is the first time you are meeting them. You may have only seen them so far in the hallway or around the school in different capacities. 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 school social worker services and external community resources.
You may be wondering 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):
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 are feeling 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.
It can be very challenging to be a young person in high school, let alone one who has trying to navigate their gender identity or sexual orientation while experiencing an ‘eating disorder’. Here are some factors to keep in mind:
Be gentle with yourself: you may have bad days in recovery and it is an ongoing practice. Keep in mind 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 and take a break from school – your mental health and wellbeing comes first.
On a personal note, 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 in recovery or acknowledge my ‘eating disorder’ until my twenties, I hope as you read this resource you begin to see there’s hope and support available to you as a teen.
There are many benefits to being online, like being able to see and talk with other 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. .
For myself, I grew up in a small community where 2SLGBTQ+ was not an acronym I had ever heard, let alone the term non-binary. Being a queer non-binary person, I felt so 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 see that there is a community out there and that I belonged. This support helped me through so many difficult transitions through my youth where I needed the understanding of someone who was going through a similar situation. Even when I eventually moved from my small, rural town, it was these online connections that I carried with me to remind me that even if things were not the best in my current situation, there were always people out there who could understand me and what I was going through. This meant the world of change for my journey in both my queer identity and my ‘eating disorder’ recovery.
For many of us, finding support from other 2SLGBTQ+ individuals can be difficult, especially during our teenage years. Through online support, we can find others around the globe who may be experiencing similar situations, 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). On the other hand, when trans and gender-creative kids can learn words to describe themselves more accurately, it allows them to know themselves and to know there are others like them.
The Internet and social media can be amazing resources but it is very important to be critical of what we see online. As often as there are people uplifting body diversity, there are those who will insist there are ways to look and behave that are naturally “better” than others. This, of course, is blatantly untrue, but it is surprisingly easy for anyone to be caught up in that kind of messaging. Internet figures, such as social media influencers, often push these body types as being attainable to anyone, although they may spend a great deal of money and time changing their bodies to look the way they do. Face-altering filters on social media sites enable users to capture “influencer” looks for themselves.Because the looks in question are often unattainable in real life (at least without a significant amount of plastic surgery), failed attempts to conform can introduce or worsen existing body-based concerns among youth. It should also be noted that many of these filtered features are distinctly racialized. For example, this can be seen with the popularity of full lips, 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.
Lastly, one should exercise caution and think critically when looking for more information about transness online. We are all exposed to the same harmful messaging as we grow, which means some trans people have adopted harmful ideas about gender and appearance which can often hurt others. 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 their videos, 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”. These same YouTubers have been known to single out and target trans and non-binary people who disagree with them, often labelling them as “fake” or “transtrenders”.
There is no one right way to be trans. Every person in the world has a unique relationship to gender, and each has the right to determine the nature of that relationship. Some trans and non-binary people might desire and 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 ever desire medical transition. 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 new binary of “real” trans people and “fakers”. By tying the validity of a person’s gender to the way they look, transnormative messages are saying that if you want to be respected and safe as a trans person, you should be invisible as a trans person. Yet as we see there is a huge range of natural body diversity for cis people, why should trans bodies be any different?
While unrealistic body ideals are unfortunately widely promoted via social media, there are also positives to these platforms. We can choose who we follow, and who we support. We can follow feeds that portray different bodies, genders, and sexualities being celebrated and lifted. This allows us to tailor our experiences so that we see and encourage ourselves.. Being able to see someone similar to us, with similar experiences struggles, can help remind us that we are not alone.
“Recovery” is difficult to talk about, and while you may not be ready to share your own story yet, there are so many people out there who have disclosed theirs. Through the online world, you can find blogs, social media influencers, and celebrities who have shared their stories of “recovery”. These stories remind us that anyone can be affected by the same issues that affect us, and that even in the most difficult times, “recovery” is possible and that there support is available.
Trauma can live in the body for a long time after a person has experienced a traumatizing event(s). Many people who survive traumas like sexual abuse or assault will experience difficulties with eating and their relationship with their bodies. It is important to know that while we may tend to think of trauma occurring after a single event, it can also occur because of regular discrimination and other microaggressions. Since people of any age can be affected by trauma, it’s important for people experiencing disordered eating and the people who care for them to look at past events, current triggers, and possibilities for healing.
For 2SLGBTQ+ people, there are several instances that might convince a person the world is not safe for them. First and foremost, the possibility of encountering violence is much more likely 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. Then there is the psychological stress that comes with expecting that you will face discrimination or violence. News and popular media alike often give the impression that a queer life is a tragic one, filled with self-doubt and fear, and this is just to be expected. This may be a side effect of increased visibility and discrimination together, and perhaps a cisgender fascination with showcasing specific trans stories. When it is mainly this tragic narrative that is shown to young 2SLGBTQ+ people, it’s unsurprising that when combined, real experiences and the mythic storytelling of reporters and movie-makers 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 the care and resources they need. “Passing” is sometimes misrepresented as something that is “necessary” for an 2SLGBTQ+ person to find acceptance. That is, queer and trans people normally face huge pressure to conform to what the cisgender and heterosexual majority consider normal or acceptable. “Passing” and “going stealth” can be rewarding for 2SLGBTQ+ people in that it gets them what they need, including the physical need for safety from transphobic violence. However, there is often an unfortunate tradeoff where they are unable to express themselves authentically.
It is okay to need a safe space to not love the body that you're in and voice your struggles with your body. Finding a community of body image supports can help you get through those times.
In times where you are finding it hard to accept your body, consider these:
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!
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
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
While research demonstrates that mid-life (which may be defined as the period between ages 45 and 54) onset of ‘eating disorders’ occurs, there is currently limited information available that focuses on this intersection. A variety of major changes may take place in this life stage, ranging from employment and living situations, to love, grief, and loss. These can change the face of recovery for someone in the throes of a mid-life ‘eating disorder’, whether this pertains to relapse or a 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). Many of us who are living with or who have lived through an ‘eating disorder’ during our middle-age years have experienced hopelessness in adult ‘eating disorder’ support environments, as there is a collective sense of loss for the years that have passed that were dominated by the illness. Challenging the stereotype that ‘eating disorders’ are a young person’s illness is an endless plight for those in mid-life or beyond who face discrimination and ageism from health professionals who are not looking for or considering ‘eating disorders’ as a firsthand issue in this demographic. Body changes that naturally occur with aging can bring about or intensify body dissatisfaction and/or anxiety, and can contribute to disordered eating.
The definition of an ‘elder’ is skewed for many members of our community, as the AIDS crisis in the 1980s claimed the lives of many 2SLGBTQ+ individuals, and, consequently, collectively we were seen to have shorter life expectancies. Despite the crisis taking place 40 years ago, the medical community has a significant way to go in supporting better health outcomes for 2SLGBTQ+ individuals overall and as they age. Beyond health care providers, our collective community and allies need to take significant strides to end the ageism that is rampant in the community which may be contributing to the “perfect storm” for ‘eating disorders’ in older community members. Elder community members are often left behind by younger community members as spaces grow less accessible and their voices are silenced by the media outlets. Creating environments where younger and older 2SLGBTQ+ individuals can come together and share their stories in the fight against oppression could be the future of collective ‘eating disorder’ recovery spaces.
Internalized ageism is relevant for members of our community as well. Within the gay community, there is a significant spike in internalized ageism leading to depressive symptoms including behaviours affecting body image and appearance (Wight, LeBlanc, Meyer& Harig, 2015). Research suggests that gay males may feel that they are old even when they are relatively young because youth and physical attractiveness are disproportionately valued in the gay male community (Grant, 2010). These day-to-day realities – isolation, invisibility, and devaluation – create an environment of stress that, for individuals who are already predisposed, may further contribute to ‘disordered eating’ behaviours.
Many elderly individuals require assistance with various aspects of eating or feeding due to age-related physiological or psychological reasons. Someone who has mobility problems or requires a modified-texture diet may struggle to take in adequate nutrition, potentially leading to ‘disordered’ patterns (Karges, 2016). When acute other issues that commonly need to be addressed in long-term care settings, such aspain management, are a competing priority, individuals end up not receiving the level of feeding assistance they need, further contributing to ‘disordered eating’ behaviours. It is important to regularly follow up with your loved one and their caregivers in a long-term care home to inquire about any significant changes in their eating or feeding patterns or weight.
There is a high prevalence of laxative abuse in long term care communities, despite evidence that this is not the best course of care in elderly populations (Chun Chen, Huang, Yang, Chi Chen, Chen Chou, Ming Kuo, 2014). Nurses and practitioners need to provide conservative intervention, such as dietary fibre, movement, and fluids to reduce the risk of fostering a dependency on laxatives and ‘disordered’ behaviour in this already vulnerable population.
Beyond the risk of ‘eating disorders’, discrimination continues to impose a threat for 2SLGBTQ+ seniors living in long-term care homes (O’Neill, 2020). There is a growing concern that 2SLGBTQ+ seniors face more isolation and loneliness due to threats of discrimination and oppression; in surveys of older 2SLGBTQ+ people, some respondents reported worries that being ‘out’ while living in a long---term care community would affect the quality of carethey receive (O’Neill, 2020). Service providers and seniors alike both share firsthand that their biggest fear is being “recloseted in residential care” (O’Neill, 2020). Many seniors are forced to relive the traumas associated with their coming out in long-term care environments, and receive treatment lacking respect and dignity. Ending discrimination and oppression in long-term care homes requires both education of the staff members and changing policy within the organizations as a whole so every 2SLGBTQ+ person can live with dignity and pride as they age.
As the years go by, terminology tends to change within our society, particularly in regards to the 2SLGBTQ+ community. What was once acceptable is now considered to be 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 completed by Employment and Social Development Canada (2018) noted that the changing 2SLGBTQ+ terminology means “some seniors do not fall under these labels or feel recognized or supported by this community” (4). Despite what may be “politically correct” it is important to also take into account how individuals themselves wish to be identified. If someone identifies with a term or identity whose meaning has changed over time, it is important to acknowledge and identity on their terms, rather than having a new identity forced upon them. For example, while the term “transsexual” is largely considered outdated and offensive now, many older trans individuals continue to utilize this terminology. Regardless of how you identify, you are valid, and deserve respect.
Self-advocating means communicating what your needs are, what your goals are, and what safeguards you need to be put in place. Reflecting on your boundaries is important, and you can write out or plan these ahead of time so you feel prepared to go into an appointment or for your peace of mind.
It can be hard to advocate for yourself at times, which is why it's important to have supportive people in your corner. This may look different for everyone, and might include family support, a trusted friend, 2SLGBTQ+ communities and spaces, or a school mentor. Remember many people are struggling with similar experiences as you, and peer support resources are available in person as well as online.
‘Eating disorders’ are notoriously difficult to resolve. Sometimes health care professionals and loved ones might blame a person for their challenges throughout recovery. It is hardly unexpected that people might struggle within a world that upholds a narrow range of body types and appearances as ‘normal’. When recovery focuses on weight-related outcomes and normalizing eating habits, it pushes people to get back to ‘normal’ – ignoring 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 there are bodies that will still be subject to body-based harassment, discrimination, and shame 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’ behaviour seem like a rational part of ‘correcting’ a body.
When getting better means getting to ‘normal’, it makes sense that some people don’t get well. When getting better also stifles free and authentic self-expression, asking us to repress all the complicated and messy feelings we have around gender, bodies, and food, we need to revise the approach to 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.”
When we let go of ‘normal’, recovery can mean opening possibilities for living with and enjoying the brilliance of our bodies exactly as they are, welcoming complexity and transgression. A recovery that moves towards ordinary and familiar allows us to be creative in how we promote body love, acceptance, and satisfaction. Creativity in how we resolve the distress we feel around food and bodies.
There is also space for complicated feelings about bodies, pain, struggles, and shame. Anger can be wrapped up in getting better, and not getting better. 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. For some, that pressure means recovery is a life-long process. 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.
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 and support us and who validate us are so important in the journey to finding peace and self-love. There is a whole community on this road with you.
Fear of negative experiences occurring in treatment is a completely valid concern. If you feel you are engaging in ‘disordered eating’ behaviour but are not ready to be diagnosed by a medical professional,reach out to supports with whom you do feel comfortable.
A diagnosis of any kind is meant to set apart what’s abnormal from a defined ‘normal’. When it comes to eating, we all have different habits. Many people have difficulties with their body image, food, and eating, but will never receive a diagnosis. They may not tell anyone or seek help, or the people around them may miss the signs. Some do seek help from health care providers but are denied the care they ask for because they don’t meet clinical requirements for a diagnosis. This invalidates the challenges they face.
Treatments for ‘eating disorders’ can be inadequate for a lot of reasons. Here’s a short list:
Communicate what your needs are, what your goals are, 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.
It can be hard to advocate for yourself at times, which is why it's important to have supportive people in your corner. This may look different for everyone, whether it be family support, a trusted friend, 2SLGBTQ+ communities and spaces, or school mentors.
Trust yourself when it comes to your experience with healthcare providers – only you know if it feels like a good relationship. What might be a good experience for some might not be acceptable for others. Based on your situation, you may need to find alternative ways to support yourself….. Community, online healthcare, non-western, and complementary healthcare providers.