Why Eating Disorders Disproportionately Affect LGBTQIA2S+ Communities
Eating disorders are often inaccurately associated with white, skinny, cisgender, heterosexual middle class women. As a queer, nonbinary Korean therapist who has personal and professional experience with eating disorders (EDs), I want to offer a framework that challenges traditional, medical approaches to EDs, and considers the significant impact of the systems we live under. Considering the violent transphobic, homophobic, fatphobic, misogynist, and ableist conditions we continue to live in, EDs are often a strategy to survive and establish a sense of control.
Two ways eating disorders work
From a cognitive behavioral lens, eating disorders are typically driven by one of two things (or sometimes both).
The first is an over-evaluation of shape, weight, and control. When we have a tendency toward perfectionism, low self-esteem, and relational difficulties, controlling food and our bodies becomes a way to manage what feels unmanageable.
The second is affect dysregulation, often accompanied by difficulty labeling, trusting, or tolerating emotions. When the world feels overwhelming and navigating it feels dangerous, eating and/or controlling our food intake and bodies can become a strategy to manage emotional pain.
For many people, disordered eating is often a form of self-preservation and survival.
Why LGBTQIA2S+ people are disproportionately affected
Research has consistently shown that LGBTQIA2S+ individuals are more likely to experience eating disorders and to experience them more severely compared to heterosexual and cisgender people. (Trevor Project, 2022; Mensinger et al., 2020.)
This isn't because of anything inherent to queer communities. If EDs often emerge as a strategy to manage emotional dysregulation, then we have to reckon with what queer people have to deal with on the daily: discrimination, social stigma, internalized shame, fear of rejection, bullying, houselessness, and trauma. Facing ongoing, systemic, and cumulative marginalization, LGBTQIA2S+ folks will require additional strategies to manage the emotional overwhelm and to establish a sense of control over our lives.
There are also barriers to getting help. Many provider in the ED field have little to no knowledge about EDs in LGBTQIA2S+ communities. And the cultural narrative that still frames eating disorders as a white, thin, cis, straight girl problem further adds to the marginalization that queer communities face.
The particular weight carried by trans and nonbinary people
Even within LGBTQIA2S+ communities, transgender boys/men and nonbinary AFAB youth carry a disproportionate burden. (Trevor Project, 2022.) Trans and nonbinary people already face the highest rates of discrimination, violence, houselessness, and unemployment within the queer community. EDs can become a way to manage the emotional overwhelm that comes that reality.
Trans and nonbinary communities must also contend with both body dysmorphia (fixation on perceived defects or flaws in appearance) and body dysphoria (distress caused by a mismatch between a gender identity and physical characteristics). For many trans boys/men and nonbinary AFAB folks, weight gain means having more accentuated physical features associated with femininity. As a result, EDs are often a way to work towards what society may consider a more masculine body. EDs can be a protective strategy to feel safer in a violently transphobic world, as well as to feel a stronger sense of autonomy and control rather than feeling helpless to an oppressive society.
What actually helps: a harm reduction approach
More providers need to be specifically trained to support LGBTQIA2S+ people with disordered eating. Otherwise, queer and trans communities will continue to face massive barriers in getting help.
One framework I connect with deeply is harm reduction. Harm reduction comes out of a history of sex workers, drug users, trans activists, people with chronic illness and disabilities, and BIPOC communities building systems of change and support outside of mainstream institutions that only perpetuate violence and harm.
Rather than applying a binary, one-size-fits-all model of "recovery," harm reduction meets people where they are. It focuses on reducing health risks, honoring the person's immediate goals, and making small, achievable change, and above all, honoring personal autonomy.
Unlike a pathology or medical approach, harm reduction considers the whole context. Managing EDs cannot only be reduced to an individual endeavor. It requires building connection with others, building alternative systems of care, and changing the conditions we live within.
Under a harm reduction framework, Dialectical Behavioral Therapy can be an incredibly effective resource in supporting LGBTQ people with developing alternative emotional regulation strategies. When we feels dysregulated or emotionally overwhelmed, we can expand our tools to get through the moment by building our ability to identify and understand our emotions, mindfully riding the wave of our emotions and impulses, practicing radical acceptance and using self soothing strategies like TIPP.
Internal Family Systems is also an effective approach that can help individuals explore their "parts" and the underlying emotions and traumas that drive disordered eating. For example, you may have a manager part that monitors your diet to establish a sense of control and order in your life, and to manage feelings of dysphoria. A firefighter part, however, may respond to stressful times by bingeing to neutralize the emotional overwhelm. The manager part may then reassert control by purging or restricting. IFS can help you get to know your parts, understand their roles in protecting you, acknowledging the ways they may unintentionally harm you, and find additional ways to get your needs met.
Eating disorders in queer and trans communities are not a personal failing or an illness to be cured in isolation. They are a response to living in a a world that continues to tell queer and trans people that their bodies, their desires, and their very existence are problems to be managed. Real change requires more than treatment protocols. It requires more providers willing to do the political and personal work of understanding the conditions that affect the people we work with. We need to continue to invest in systems of care built by and for QTI communities, and make an ongoing commitment to dismantling the oppressive systems we live within.
References
Trevor Project. (2022). 2022 National Survey on LGBTQ Youth Mental Health.
Mensinger, J. L., et al. (2020). Mechanisms underlying eating disorder psychopathology in sexual and gender minority individuals. Eating Behaviors.
