Out On The Couch
*Content warning: eating disorders, sexual assault, aggressive behaviors
The intersection of eating disorders with LGBTQIA+ youth is a challenging presentation to treat. A therapist’s chief concern is that eating disorders have a higher mortality rate than any other mental health disorder (Edakubo & Fushimi, 2020). Secondly, people in the LGBTQIA+ community have a high rate of dysphoria around body image, which can complicate symptoms of eating disorders and treatment. (Austin et. al., 2009).
Prevalence of Eating Disorders with LGBTQIA+ Youth
LGBTQIA+ youth are at a much higher rate of developing an eating disorder than the heterosexual population (Nagata Ganson & Austin, 2020). Combining the fact that 1 in 5 people with an eating disorder commit suicide (Edakubo & Fushimi, 2020) makes this one of the most important and critical populations to not only understand and treat but utilize effective interventions for. This article aims to demystify and develop understanding around this presentation through the use of two case examples.
Eating Disorders and Body Dysphoria
LGBTQIA+ youth who present with an eating disorder are at risk of experiencing an immense amount of body dysphoria (Calzo et al. , 2018; Watson et. al., 2016). This is critical to consider in treatment, because gender dysphoria goes beyond one’s body image caused by an eating disorder. Gender dysphoria is characterized by a core discomfort with one’s own self-image.
A 14-year-old transgender man who utilizes he/they pronouns was assigned to me as an in-home therapy case. This client had a significant history of sexual abuse by a heterosexual male. The need for a rape kit after his assault added another layer to his experience of gender dysphoria. In our work together, he displayed a common trauma response of utilizing aggressive verbal communication. No one diagnosed him with atypical bulimia before we started working together. I came to learn this started shortly after the sexual assault. The client had been hiding his binging and purging from others but disclosed it to me after rapport was built. He shared that he felt like the assault was his fault. He thought if he had been bigger and more masculine, he could have prevented it. As we continued to work together, he shared that he would binge in order to gain weight, then purge because he couldn’t handle the body dysmorphia.
In working therapeutically with this client, I found it helpful to utilize a Trauma-Focused Cognitive Behavioral Therapy approach to challenge self-blaming thoughts, maintain unconditional positive regard, and provide psychoeducation about distorted thinking. As a therapist, I sought to help the client understand the influences of systemic oppression and discrimination on his experience as a trans man, and utilized the Gestalt approach of calling attention to the client’s body language.
I validated the client’s discomfort about how they look while challenging the societal expectations of how bodies should look. I provided psychoeducation about cognitive distortions by utilizing the client’s own words and expressions as examples. For example, the client stated they wanted to pursue a law degree, then when they were dysregulated they would talk about how they have no goals. I would draw out the discrepancy by comparing this to how when they are regulated they want to be a lawyer, and highlight the skill of arguing to challenge that distorted thought of “I have no goals.”
Systemic Considerations of Eating Disorders with LGBTQIA+ Youth
When being systematically discriminated against, that person will likely have a hostility bias. By their therapist validating that it is normal for the client to have a hostility bias towards the world due to being discriminated against, the client experienced empowerment. Throughout therapy, I maintained a validating but challenging stance with the adolescent to externalize the eating disorder and the body dysmorphia. This was effective with this client, and has been shown to be an effective intervention in the literature as well. Himmelstein et al. (2019) found that dysmorphia as a presentation can be effectively treated with a narrative therapy approach (pg. 734).
My second case with this presentation was a 15-year-old transgender man who utilizes both he/him and they/them pronouns. This adolescent presented with a history of medical trauma from being in and out of hospitals for the first 10 years of his life. Because of this, the client had delays in their social development, spending most of their time in isolation in their room due to co-occurring social anxiety and atypical anorexia nervosa.
With this client, I utilized Emotion-Focused Therapy to help him understand and identify his emotions. Learning this skill was instrumental in developing the client’s self-confidence, which had been damaged by social anxiety. By empowering the client to handle his emotions, he grew his ability to challenge his avoidance and isolation behaviors. With the reduction of anxiety around social interactions, he also experienced a decrease in urges to restrict calories and purge after eating.
With both cases this client’s eating disorder is classified as atypical due to the presence of gender dysphoria. While the first client sought to gain weight to feel more masculine, the second aimed to stay skinny to prevent development of female indicators (breasts, wider hips etc.) The function of weight gain/loss was in a similar vein for each. It is vital to understand that there is a major interconnectedness between eating disorders and trans youth, even if it doesn’t rise to the level of a full eating disorder.
Conclusions on Eating Disorders with LGBTQIA+ Youth
Overall, the intersection between gender dysphoria and eating disorders can be a challenging case presentation. It is vital to highlight the client’s needs for validation, empowerment, and challenging of distorted thoughts as key interventions to create an environment of positive change. The “lifeguard approach” can be used to move a client’s deep-rooted dysphoria in a more positive direction. This means the therapist must wade into the water of the client’s dysphoria and help them back to shore by utilizing empowerment and challenging cognitive distortions. By taking this approach, therapists have a much higher likelihood of being able to create a trusting environment with their clients, and maintainable positive change.
Learn more from our CE courses
Austin, S. B., Ziyadeh, N. J., Corliss, H. L., Rosario, M., Wypij, D., Haines, J., Camargo, C. A., & Field, A. E. (2009). Sexual orientation disparities in purging and binge eating from early to late adolescence. Journal of Adolescent Health, 45(3), 238–245. https://doi.org/10.1016/j.jadohealth.2009.02.001
Calzo, J. P., Austin, S. B., & Micali, N. (2018). Sexual orientation disparities in eating disorder symptoms among adolescent boys and girls in the UK. European Child & Adolescent Psychiatry, 27(11), 1483–1490. https://doi.org/10.1007/s00787-018-1145-9
Himmelstein, M. S., Puhl, R. M., & Watson, R. J. (2019). Weight-based victimization, eating behaviors, and weight-related health in sexual and Gender Minority Adolescents. Appetite, 141, 104321. https://doi.org/10.1016/j.appet.2019.104321
Nagata, J. M., Ganson, K. T., & Austin, S. B. (2020). Emerging trends in eating disorders among sexual and gender minorities. Current Opinion in Psychiatry, 33(6), 562–567. https://doi.org/10.1097/yco.0000000000000645
Watson, R. J., Adjei, J., Saewyc, E., Homma, Y., & Goodenow, C. (2016). Trends and disparities in disordered eating among heterosexual and sexual minority adolescents. International Journal of Eating Disorders, 50(1), 22–31. https://doi.org/10.1002/eat.22576