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Non-binary Microaggressions in Psychotherapy

Posted: 9-24-21 | Nicholas Moran

The number 9 is set behind the word microaggressions to the right of a dart board bulls eye in yellow, white, and purple; the nonbinary colors. The darts represent the non-binary microaggressions people regularly experience in therapy. .

COVID-19 & (Re)claiming Gender

As a non-binary, genderqueer, and trans femme therapist myself, I have encountered my own fair share of microaggressions related to gender identity. During the pandemic, I have witnessed many people for the first time in their lives take a break from performing gender in a way society deems acceptable. As a result, many folx are exploring their gender identity and expression more than ever before. Many clients have questions and self-doubt about who they are with respect to their gender identity and/or gender expression. However, this is an aspect of mental health that is under-researched and is often overlooked in the graduate training of therapists, both masters and doctoral.

Because many clinicians lack in-depth training with regards to working with gender expansive people, many clients encounter harm in session. For example, being misgendered is just one of many microaggressions that occur in therapy sessions with gender expansive clients. For the purposes of this article, I will be focusing primarily on nine common microaggressions experienced by non-binary people in the therapy setting. 

Defining terminology

Before we delve into this important topic, let’s take a moment to define some key terms.  Cisgender is in reference to a person who’s sex assigned at birth matches their gender. Endosex refers to people whose sex characteristics meet medical and social norms for typically ‘male’ or ‘female’ bodies, which is the antonym to intersex. Heterosexuality refers to sexual and/or romantic attraction to or between people of the opposite sexes assigned at birth. 

Transgender is an an umbrella term covering a range of identities that transgress socially defined gender norms. Additionally, transgender can refer to a person who lives as a member of a gender other than the one expected based on their biological sex assigned at birth. Non-binary is also an umbrella term covering any and all gender identities that do not fall exclusively in man/male or woman/female categories. And, non-binary refers to a person whose gender identity and or expression exists between or outside the rigid gender binary system. 

But first… Microaggressions – What’s that?

The term microaggression was originally coined by Dr. Chester Middlebrook Pierce, who was an African American psychiatrist and Harvard University professor who died in September of 2016 (Sue & Spanierman, 2020). Early research focused on racial microaggressions, but has since been expanded to create a series of classification for most existing systems of oppression. Microaggressions are brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults toward people with marginalized identities (Sue & Spanierman, 2020;  Sue et al., 2007).

Nadal (2013) wrote the book That’s So Gay! Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community. This book is one of the first of its kind to make academic literature both accessible to a wide audience. Also, Nadal (2013) offered strategies to make the world a better place for queer and gender expansive people. Furthermore, Nadal (2013) provided distinctions between microaggressions based on sexual orientation as compared to gender identity. 

Of the microaggressions highlighted for transgender and gender non-conforming (TGNC) people, the book identified ten distinct classifications (Nadal, 2013).

  1. Nadal’s (2013) classifications included:  Using Transphobic Terminology Endorsing Gender Normative Culture and Behavior Assumption of Universal Transgender Experience Exoticization Discomfort with or Dissapproval of Transgender Experience Assumption of Sexaul Pathology, Deviance, or Abnormality Denial of the Reality of Transphobia Physical Threats or Harassment Denial of Bodily Privacy Systemic Microaggressions

Why should I care about this topic?

Non-binary folx continue to encounter harm and rejection both for cisgender and transgender communities. TGNC folx experience higher rates of gender-based victimization than cis- individuals, and the highest rates of suicidality of any group (Testa et al., 2015). Additionally, TGNC folx report significantly more negative clinical encounters in therapy (Levitt & Ippolitto, 2014). Lastly, gender identity microaggressions have been associated with therapeutic dissatisfaction, reduced ability to establish a therapeutic alliance, and early dropout from therapy (Spatrisano, 2019). 

So what gender based microaggressions are happening to non-binary folx in therapy?

I came to learn through my own consultations with prospective therapy clients that I wasn’t alone in my experiences of encountering gender based microaggressions. Although I don’t believe that all of the following microaggressions were intentionally meant to harm non-binary clients, it’s important to center the impact of our questions and statements as clinicians. The following common microaggressions occur to non-binary folx in therapeutic encounters:

Misgendering If you’re not a man, woman, or trans, then what are you? That (insert gender identity or neo-pronouns) sounds made up. Did you have the surgery? How are you non-binary if you aren’t androgynous? It sounds like your (insert gender identity) is a product of your past trauma. Are you sure? I know being non-binary is trendy now. Making the assumption that all non-binary people want to talk about in therapy is gender. Using words such as normal and regular as synonyms for cisgender, endosex and heterosexuality.

In the following sections I will briefly explain why each of these examples is microaggressive. Alternative tips will also be provide for how to ask more affirming questions to non-binary folx.

1. Misgendering

This is the most common form of microaggression that happens both within and outside therapeutic spaces. Misgendering is when language is used that does not correctly reflect the gender with which the person identifies. This can include using a person’s “dead name” or name given at birth when the client has specifically requested that the clinician not do so. Additionally, misgendering emerges with the misuse of pronouns, whether the client is present or not. Non-binary folx experience misgendering countless times throughout the day. This can occur on the phone, in an email, while “politely” holding the door for someone, and so many other interactions. McLemore’s (2014) study indicated that non-binary folx, and people who had taken fewer steps in the transition process, were most likely to be misgendered.

What can a therapist do when misgendering happens? Firstly, I encourage folx to not make any assumptions about honorifics (Mr., Mrs., Mx.) and routinely check in with clients about pronouns. Secondly, it’s helpful to practice not using gender language and this may require an accountability buddy, which is something I continue to engage in myself. Thirdly, avoid using passive language such as: “X identifies as” and “X prefers” as this robs the person autonomy over their own identity. Lastly, make a brief apology, correct yourself, and set an intention to gender a person correctly two or three times in a follow-up sentence. 

2. If you’re not a man, woman, or trans, then what are you?

This microaggression both invalidates and insults a non-binary persons lived experience. Gender is a construct, made up to control and classify people. Many non-binary folx reject the construct of the gender binary entirely. Asking a person, “what are you,” is cruel considering the fact that we are all simply humans. A more affirming question here could be, “how would you classify your gender identity and/or gender expression?” and “who are you, in terms of your gender?” Additionally, you may ask the client, “Would you be willing to share with me your experience exploring your gender and where you find yourself today?” With each of these suggestions, you allow the client the opportunity to self-identify and open up a dialogue about the client’s lived experience. As clinicians, it’s important that we do not restrict our client’s ability to explore. Above all, I encourage all therapists and wellness providers to center curiosity. 

3. That (insert gender identity or neo-pronouns) sounds made up.

Woah! This one hurts to type. I like to remind folx that gender inherently is a fabricated classification system. Though for many non-binary, transgender, and gender expansive people, out lives are only just beginning to feel like our own. New terms for gender identity continue to emerge daily. A client once said in a group session, “I bet there are as many gender identities as people in the world, because we all experience life differently.” I couldn’t agree more with this comment. It would be more helpful to say something like, “I have never heard of the gender identity or pronouns you just mentioned, would you be willing to talk to me about how you define this gender identity or pronouns?” Or you may elect to offer to do research on your own time outside of session to spare your client from having to educate you, the clinician. 

Though new terms like gendervague and genderfuck continue to emerge, the definitions of each of these terms will vary depending on who you ask. Neo-pronoun, or new pronouns, also continue to emerge as an outlet for non-binary folx to replace their name with a non-gendered word. Some common examples of neo-pronouns include: 

  1. fae/faer/faers
  2. xe/xem/xyr
  3. ey/em/eir
  4. ze/zim/zir
  5. ne/nem/nir. 

If you’re anything like me, you’re probably going to need some practice using these in a sentence. Find a friend to practice with or try out this helpful website.

4. Did you have the surgery?

Eek! It’s important to note that there are numerous gender affirming medical procedures that gender expansive people can pursue. There is no ONE surgery that all non-binary folx undergo. For many non-binary folx, there is no interest in pursuing gender affirming medical procedures. While others may elect to engage in one or many gender affirming medical procedures. 

As a clinician, I urge you to first ask yourself whether you ask your endosex, cisgender and heterosexual clients about their medical history. If you do not, then ask yourself why you feel entitled to ask your non-binary client this question? Two affirming questions could include: (1) what forms of transition are part of your path; and (2) have you considered gender affirming medical procedures to affirm your gender identity and/or gender expression?

Types of Transitions

With respect to transitions, they are not necessary to be a non-binary person. They are also not necessary for binary transgender people either! However, there are three distinct types of transition that could be a part of a client’s gender journey: (1) social transition, (2) legal transition, and (3) medical transition.

Firstly, social transition is in reference to the ways in which a person identifies and presents their gender in public. Some aspects of social transition include, choice of clothing and/or makeup, changing one’s name, selecting pronouns, tucking, packing, binding, and coming out.

Secondly, legal transition is in reference to the ways in which a person actualized their gender through updating legal documents. These documents can include a person’s name, social security number, birth certificate, passport and driver’s license.

Lastly, medical transition is in reference to the various procedures available to folx to actualize their gender. Some common procedures may include surgery, hormone replacement therapy (HRT), vocal training, laser hair procedures, and fertility preservation. 

Other considerations

Please respect your client’s right to privacy as non-binary folx are often encountering invasive questions related to their body from all directions. Historically and through stereotypical media portrayals of gender expansive people, transgender and non-binary bodies have been labeled perverse, odd, and unusual for far too long. If you don’t ask your endosex, cisgender and heterosexual clients about their body parts, then why do you feel entitled to do so with non-binary clients?

Furthermore, I urge you to validate and normalize the response of “I don’t know” from a client in your care. I have found that this can be challenging for client’s to say as there are so many societal pressures to have answers. As a result, modeling and normalizing that not having an answer is acceptable can be incredibly validating to non-binary clients. 

Also, it is important to mirror the language of your client when discussing aspects of the client’s physical body. I suggest asking, “how will we refer to the insert body part?”

5. How are you non-binary if you aren’t androgynous?

Just like there is no one way to look like a cisgender woman or man, there is no right way to look non-binary. This question is incredibly harmful as many non-binary folx experience imposter syndrome. Additionally, most non-binary folx experience discomfort or dysphoria due to being perceived as a cisgender person. Being androgynous is only one way in which the vastness of non-binary gender expression is embodied. Many non-binary folx experience and express their gender more fluidly. 

Instead of reinforcing a false narrative of how to be a non-binary person, consider empowering your client. You may ask, “how do you embody and affirm your gender?” Or you may ask, “what makes you feel most like your fully embodied self?” Sometimes these questions will open a door of exploration and other times clients will find themselves unable to answer. If your client has no answer, I would invite you to ask them if they’d be willing to explore this with you. Furthermore, I will sometimes offer to lead a client through a creative arts or visualization exercise. This offers the opportunity for the client to move away from traditional language and engage their playful imagination. 

6. It sounds like your (insert gender identity) is a product of your past trauma.

Ouch! Whether or not there could be truth to this statement, no one can go back and rewrite their history. Instead of focusing on how the past may or may not have caused a person to become gender expansive, why not focus on the now? So many non-binary folx feel disempowered and therapy is an intentional space to reclaim that power. Getting caught up in the what ifs of the past prevents clients from becoming more assured of themself in the present.

It can be powerful to validate a client’s past lived traumatic experience. I also encourage you as a clinician to assist your non-binary client with cultivating self-esteem. You might say something like, “Your past experiences have shaped the person you are today, and I am so grateful for the opportunity to know the person you’re becoming (or you have become).” Embolden your client to lead the conversation and connect to their past, if and only if that’s their own desire. Otherwise, continue to center the here-and-now of their gender journey. 

7. Are you sure? I know being non-binary is trendy now.

This comment is loaded for a variety of reasons. Firstly, many folx are currently exploring their gender and identifying as non-binary for many may be the first step on that journey. Secondly, some experience gender as an aspect of self in constant movement and evolution. Thirdly, whether or not being non-binary is trendy or not, we need to reclaim our gender expansive history. 

Gender diverse people have existed throughout history such as the First Nations, two spirit and Hijras, who are officially recognized as a third gender in India. Additionally, you may want to learn more about the transgender history in the U.S. and globally as well as the history of trans health care in the United States. And if you haven’t already started, it’s never too late to explore your own gender identity and gender expression in greater depth.

8. Making the assumption that all non-binary people want to talk about in therapy is gender.

There are certainly a vast number of people seeking therapy at this time to explore their gender. Then there is a large number of non-binary folx who are more confident in who they are and are seeking therapy for alternative reasons. Many non-binary folx express in consultations that their previous therapist would only ask questions about the client’s gender identity. This stifles our clients ability to be fully human and process the vastness that is the human experience. 

Instead of assuming that non-binary and gender expansive clients want to discuss gender, perhaps you will ask what they would like to focus one. I, like many therapists, offer an intake questionnaire, which serves to allow the client to self-determine goals for therapy. Some clients are seeking an affirming provider with or without lived experience, but with the purpose of processing depression, anxiety, trauma, substance use, life transitions, and so much more. I can’t stress enough how important it is to allow your client to have control over their therapy goals. It also helps to add to your intake forms a place to add pronouns, salient identities, and chosen names. 

9. Using words such as normal and regular as synonyms for cisgender, endosex and heterosexuality.

This is a prime example of systemic microaggressions. We have all been socialized in a world that assumes heterosexuality and cisgenderism as the baseline. There is nothing odd, unusual, or irregular about being gender expansive. For most, actualizing their non-binary gender identity and/or expression is a liberating experience. In short, this example upholds systems of oppression that harm everyone.

I recommend that all therapists engage in implicit bias exercises to identify the ways we internalize gender, gender roles, and gender expectations. The following three books are incredible resources: 

  1. A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients
  2. The Queer and Transgender Resilience Workbook: Skills for Navigating Sexual Orientation and Gender Expression
  3. You and Your Gender Identity: A Guide to Discovery

As clinicians, we can only go with clients where we have dared to venture ourselves. 

I microaggressed my client – What do I do?

As humans, we all have the ability to harm. Apologies are opportunities to take accountability; however, refrain from lengthy apologies. When apologizing, center the harm and avoid providing an excuse for your intentions. I have and continue to make mistakes as a therapist. I welcome these experiences as opportunities to deepen the therapeutic relationship. Therefore, these instances are opportunities to collaborate and empower our clients to identify their needs. 

I am also a fierce advocate for therapists engaging in their own therapy and supervision. These can certainly be expensive endeavors, but so important for our own growth both personally and professionally. For example, seek out or create peer supervision groups. Obtain adequate training from folx of lived experience with regards to providing affirming care to TGNC clients. Lastly, please Please PLEASE avoid advertising yourself as a gender affirming provider until you’ve gained specialized training. 

References

Bergner, D. (2021, July 23). The Struggles of Rejecting the Gender Binary. The New York Times. https://www.nytimes.com/2019/06/04/magazine/gender-nonbinary.html?auth=login-google

Chang, S. C., Singh, A. A., & dickey, l. m. (2018). A Clinician’s Guide to Gender-Affirming Care: Working with Transgender and Gender Nonconforming Clients (1st ed.). Context Press.

Hoffman-Fox, D. (2017). You and your gender identity: A guide to discovery. Skyhorse Publishing.  

Indug. (2018, October 29). India’s Relationship with the Third Gender. UAB Institute for Human Rights Blog. https://sites.uab.edu/humanrights/2018/10/29/indias-relationship-with-the-third-gender/

Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: The experience of transgender identity development. Journal of Homosexuality, 61(12), 1727–1758. https://doi.org/10.1080/00918369.2014.951262

McLemore, K. A. (2014). Experiences with Misgendering: Identity Misclassification of Transgender Spectrum Individuals. Self and Identity, 14(1), 51–74. https://doi.org/10.1080/15298868.2014.950691

Nadal, K. (2013). That’s So Gay!: Microaggressions and the Lesbian, Gay, Bisexual, and Transgender Community (Perspectives on Sexual Orientation and Diversity) (1st ed.). American Psychological Association.

Singh, A. A. (2018). The Queer and Transgender Resilience Workbook (Skills for Navigating Sexual Orientation and Gender Expression) (1st ed.). New Harbinger Publications.

Spatrisano, J. (2019, August). Microaggressions Towards Gender Diverse Therapy Clients and the Mediating Effects of Repair Attempts on the Therapeutic Process (No. 13903396). ProQuest LLC. https://www.proquest.com/openview/628748913234c0faf3ae03f578067f7c/1?pq-origsite=gscholar&cbl=18750&diss=y

Stryker, S. (2017). Transgender History, second edition: The Roots of Today’s Revolution (Seal Studies) (2nd ed.). Seal Press.

Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications for clinical practice. American Psychologist, 62(4), 271–286. https://doi.org/10.1037/0003-066x.62.4.271

Sue, D. W., & Spanierman, L. B. (2020). Microaggressions in Everyday Life (2nd ed.). Wiley.

Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the Gender Minority Stress and Resilience Measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. https://doi.org/10.1037/sgd0000081

Two-Spirit. (n.d.). Indian Health Service: The Federal Health Program for American Indians and Alaska Natives. Retrieved August 28, 2021, from https://www.ihs.gov/lgbt/health/twospirit/

Yee, N. & Gonzalez, M. (2021). History of Transgender Inequality in Health Care – THINQ at UCLA. Medium. https://medium.com/thinq-at-ucla/history-of-transgender-inequality-in-health-care-77e5370fd939

At the Intersection of Fat & Trans

fatphobia

I am a fat, queer, able-bodied, neurotypical, white, and cisgender femme person (note: cisgender = my gender is congruent with the gender I was socially assigned). I’m well aware of societal expectations for the way my body should look, to express my gender consistent with white womanhood, and to engage in romantic and sexual relationships in a certain way. I also know that the bar for being seen, respected, and accepted for who I am would be sky high if I was a fat, autistic, disabled, polyamorous, transgender feminine person of color.

Most of the research conducted with people who are fat and/or trans has been with white, able-bodied humans, so any negative impact I discuss related to fat trans folks is likely even more detrimental for people of color and for those with chronic illness and/or disabilities. I write this as a person with privilege who aims to learn more, and educate others about systems of oppression and power, while also advocating for human rights and dignity. I am personally familiar with experiences of fatphobia and sexism, and I have a specialty in counseling trans and gender nonbinary (TGNB) people.

Weight Stigma, Fatphobia, & Microaggressions

When you see a slim person jogging down the road, do you think, “good for them!?” When a slim person walks along the beach in a bikini, do you think, “ugh, they shouldn’t be wearing that!?” When you notice that a slim friend has gained weight, do you say, “oh wow, you’ve gained weight? What are you doing?” I’m guessing most of us don’t, so why would it be OK for us to judge or comment on fat bodies? The short answer: it’s not OK. Basically never. Just like it’s never OK for us to comment on trans and gender non-conforming bodies.

The National Eating Disorders Association (NEDA, 2018) defines weight stigma as discrimination or stereotyping based on a person’s weight (also referred to as sizeism). Weight stigma is known to increase body dissatisfaction, which is a leading risk factor for disordered eating. NEDA clearly states, “the best-known environmental contributor to the development of eating disorders is the sociocultural idealization of thinness.” Many people who struggle with body image and disordered eating got messages along the way that shamed their bodies and/or food choices, suggesting they weren’t good enough just the way they were.

Fatphobia, the fear and/or hatred of fat bodies, is an extension of sizeism. Many of us have learned not only that thin is the ideal, but that being fat is to be avoided like the plague. We are constantly exposed to messages that thin = good and fat = bad (e.g., TV and movies, comments from our parents, health & wellness marketing, conversations with our friends, and health insurance companies offering wellness discounts). Brené Brown’s research found that a) appearance and body image and b) being stereotyped and labeled are two of the 12 most common triggers for shame (Brown, 2007). This hatred and fear of fatness becomes internalized and spreads like wildfire in the ways we talk about ourselves, evaluate ourselves compared to others, and judge others’ bodies and food choices.  Three questions you might ask yourself to examine your weight bias are: 1) Do I engage in negative body talk? 2) How do I feel about bodies of different sizes? and 3) How do I feel about the concept of weight gain for myself? (Chastain, 2018).

We can’t talk about stigma and fatphobia without also talking about microaggressions, which Sue (2010) defined as “commonplace verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative insults to a target person or group.” The very nature of microaggressions is that they are often unintentional and unacknowledged slights, leaving the recipient to process those thousands of tiny moments that invalidate that person’s very existence.

For example, when someone says to a friend who has lost weight, “wow, you look great,” it is thinly veiled as a compliment that covers up the deeper diet culture judgment, “your body is more desirable now that it is thinner.” When someone watching you eat X food says, “I don’t eat X – it’s bad for you,” what it really suggests is, “be careful eating that food – you wouldn’t want to become fat and/or unhealthy. In fact, the conflation of weight with health and “concern for health” is one of the more common ways that people (especially health providers) justify weight-related microaggressions. Sadly, what often gets in the way of health for fat folks is the very structural oppression they face by those who believe people are unhealthy because they are fat (Lee & Pausé, 2016).  

At the Intersection of Fat & Trans

When we talk about the above concepts in relation to fatness, they also hold true for other identities that experience oppression, e.g., race, gender, ability, sexuality, etc. TGNB folks experience transphobia, cissexism, cis-heteronormative expectations, and pressures to fit into (white) binary understandings of gender, i.e., what it supposedly means to be a man or a woman. Because TGNB people are often valued based on how well their bodies “fit in” to these expectations, it follows that they would also be held to standards of body size, shape, and weight. Adding weight stigma to the other pressures that a TGNB person experiences along with their own struggles with their body is like a shaken soda bottle of oppression waiting to explode.

Here are several ways that a TGNB person might experience the cumulative and harmful effects of sizeism and fatphobia in the context of their transness:

  • A trans masculine person eats as little as possible to shrink his body and appear more androgynous by reducing the width of his hips & the size of his chest
  • A nonbinary person hesitates to go to the gynecologist for worsening pelvic pain, because when they initially brought it up, the doctor said the pain was weight-related.
  • A transfeminine person fears going out on a date, because she can’t blend enough with her large belly.
  • An agender person has to search endlessly for affordable clothing that both fits their large body and also feels congruent with their gender.
  • A genderqueer person wants to fly without drawing attention to themself, but they face ridicule when going through the security body scanners and then are looked at with disgust while walking down the airplane aisle due to their body size.
  • A trans woman’s doctor does not refer her to get treatment for her Anorexia, because he reasons that restriction might help her to lose weight.
  • A trans adolescent is extremely uncomfortable in their body due to the compounded effects of going through puberty as a fat person.
  • A pregnant trans man gets mistaken for being fat and doesn’t get the emergency medical care he needs (note: an article was recently published about this exact situation at usatoday.com).
  • A trans person arrives for their consultation appointment for gender affirming surgery, but the armchairs in the waiting room are too small for them to fit, the exam room table cannot hold their weight, and they soon find out that the surgeon has a maximum BMI requirement.
  • A trans college student gets the courage to go to the gym and build muscle for his upcoming top surgery, but then is fat shamed by other students at the fitness center.

It is so crucial to be mindful of the ways in which weight stigma and fatphobia intersect with the policing of trans and nonbinary bodies. Don’t trans folks already have enough to worry about with their internal struggles to find peace and affirmation with their bodies? Why do we pile on societal constructions of what they should and shouldn’t look like, that they should and shouldn’t eat, and pressures to modify their bodies to be more feminine (i.e., thin and curvy in the “right” places) or masculine (i.e., thin and muscular)? Why do we expect TBNB people to not only modify their bodies to societal standards, but to do it without developing an eating disorder or increasing hatred toward themselves? We need to do better in making space for TGNB folks of ALL sizes, shapes, expressions, and food preferences. Everybody and every body is worthy of respect and human dignity.

The Greater Impact

The impact of sizeism and fatphobia are pervasive and insidious. For example, adolescents who are teased for their weight are 2-3x more likely to consider and attempt suicide (Eisenburg et al. 2003). TGNB folks, especially transfeminine people and people of color, are significantly impacted by the pressure to fit into gender appearance ideals (i.e., white, light skinned, thin, & young with straight hair; Patton, 2006) that reflect the binary norms of femininity or masculinity.

Here are some ways that TGNB people are impacted by these pressures compared to cisgender people:  

  • Increased body dissatisfaction and frequent body checking
  • Risk of dissociation from or hatred of certain parts of their bodies
  • Increase in disordered eating or weight and shape control behaviors, including binge eating, fasting, vomiting, and laxative use
  • Weight loss to suppress secondary sex characteristics and/or
    • For transfeminine people, to achieve the thin ideal
    • For transmasculine people, to slow or stop the menstrual cycle
  • For TGNB people with a high BMI, even greater rates of body dissatisfaction and disordered eating
  • For transfeminine people, increased experiences of sexual objectification
  • Greater risk of mental health struggles due to the stigma of being trans and/or fat
    • e.g., desire for weight change increases reported history of suicide attempts and self-injury
  • Risk of negative social consequences, stigma, and safety concerns when physical features are not in line with societal expectations for their gender

(Algers et al., 2010, Algars et al., 2012; Diemer et al., 2015, Gordon et al., 2016, Hepp & Milos, 2002; Jones et al., 2016; McGuire et al., 2016, Peterson et al., 2017; Sevelius, 2013; Vocks et al., 2009; & Witcomb et al., 2015)

It’s not  surprising that trans folks are afraid to seek medical care from providers who often invalidate them while also imposing guidelines and hoops for them to jump through in order to seek some semblance of gender affirmation/congruence. When you’re fat, that fear increases. And don’t get me started on providers who recommend weight loss as a treatment for anything, regardless of gender. Would you pay to participate in a treatment program that had a 95-98% failure rate and led to most people going back to pre-treatment symptoms within 3-5 years? I hate to be the bearer of bad news, but if you have ever joined a weight loss program or gone on a fancy diet to lose weight, that’s exactly what you’ve done.

Though many TGNB people experience disconnect and dissatisfaction with their bodies, some reconnect with themselves and improve body satisfaction by altering their body, for example, through gender affirming surgery and hormones, body art/tattoos, and/or exercise. Gender affirming treatment, increased body satisfaction, and perceived social support from family, school, and friends help to reduce the risk of disordered eating (McGuire et al., 2016; Testa et al., 2017; Watson et al., 2017). Some find ways to reject the cultural ideals by creating their own unique gender expression, and those who have a more integrated gender identity are more likely to report social awareness, social acceptance, and body satisfaction (McGuire et al., 2017).

So What Can I Do?

Munro (2017) explains, “we live in a world that resists the notion of fatness as a facet of body diversity; as such, fat bodies are rarely represented in a positive light. Fatness is labeled as a disease and the treatment is eradication.” Social change movements for fat acceptance and body liberation are working to challenge and change this cultural mindset, but the journey is long and difficult – like transness, many are afraid of those who are different, those who do not fit the social norms, and those whose bodies challenge our internalized beliefs and fears.

Here are some ways I believe we can work to support our fat TGNB friends and fellow humans:

  1. Don’t comment on someone’s body parts, body size, food choices, or changes in weight. Ever. Check in when you’re thinking of complimenting someone – is there any chance that the compliment is a veiled microaggression?
  2. Practice empathy and compassion for others. Many TGNB and fat folks may struggle to love and accept their bodies, which can be a source of significant pain. “Empathy is the antidote to shame.” (Brown, 2007).
  3. While you’re at it, why not practice self-compassion and be mindful of the way you talk to yourself? “The act of giving yourself some grace is the practice of loving the you that does not like your body.” (Taylor, 2018, p. 114)
  4. Don’t assume that a TGNB person wants their body to be in line with binary constructions of femininity & masculinity. People have every right to exist in their bodies in whatever way works (or doesn’t work) for them.
  5. Dig into fat positive movements and literature (note: while there are some body positive (bopo) spaces that address fatphobia, not all bopo spaces are as fat accepting as they should be). Recommendations include:
    1. Ragen Chastain, https://danceswithfat.org/ blog
    2. Sonya Renee Taylor, The Body is Not an Apology book
    3. Rachel Wiley, Nothing is Okay book
    4. Christy Harrison, Food Psych podcast
    5. Alison Rachel, Recipes for Self-Love book & instagram
    6. Some awesome humans on social media: bodyposipanda; mynameisjessamyn; jazzmynejay; alokvmenon; ihartericka; po.rodil; ashleighthelion, and tessholliday.
  6. Be critical of the way that mass media portrays TGNB people, fat people, and TGNB fat people. Then, “dump the junk” (Taylor, 2018).
  7. Read up on intersections of transness with various identities, including size, health, race, ability, spirituality, sexuality, etc. so that your TGNB friends don’t need to teach you about their experiences.
  8. Check the privilege you carry in the world, whether you are cis, white, straight, able-bodied, healthy, wealthy, Christian, slim, etc. or any of the various intersections of these.
  9. Seek out medical and mental health providers who are fat positive and work from a Size Acceptance and Health at Every Size (HAES) perspective (Bacon, 2008; Chastain, 2012).

A Final Note

To those who are trans and fat, I see you. You are worthy, even when society doesn’t always communicate that to you. Everyone deserves to have love and compassion for the vessel that gets them through this world, even when you don’t like all parts of that vessel. You deserve to dress and express in ways that make you feel good about yourself and in clothes that fit your body, no matter what size you are. You deserve to access gender affirming care from providers who view fatness as a descriptor rather than an epidemic. You deserve to be gentle to yourself on good days, on bad days, and on in between days. There are people out there who will love and accept you at all sizes, in all gender presentations, and for all of the beautiful intersections that make up your identity. You are worthy.

References

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Algars, M., Alanko, K., Santtila, P., & Sandnabba, N. K. (2012). Disordered eating and gender identity disorder: A qualitative study. Eating Disorders, 20, 300–311. doi: 10.1080/10640266.2012.668482

Bacon, L. (2008). Health at Every Size: The Surprising Truth About Your Weight. Benbella Books, Inc: Dallas, TX.

Brown, B. (2007). I Thought it was Just Me [But it Isn’t]: Making the Journey from “What Will People Think?” to “I am Enough.” Avery/Penguin Random House: New York, NY.

Chastain, R. (2012). Are health at every size and size acceptance the same? Article retrieved on 6/10/19 from https://danceswithfat.org/2012/09/28/are-health-at-every-size-and-size-acceptance-the-same/

Chastain, R. (2018). Three questions to work on weight bias. Article retrieved on 6/10/19 from https://danceswithfat.org/2018/06/12/3-questions-to-work-on-weight-bias/

Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57, 144-149.

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Hepp, U., & Milos, G. (2002). Gender identity disorder and eating disorders. International Journal of Eating Disorders, 32, 473–478. doi: 10.1002/eat.10090

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National Eating Disorders Association (NEDA) (2018). What is weight stigma? Definition retrieved on 5/20/19 from https://www.nationaleatingdisorders.org/weight-stigma.

Patton, T. O. (2006). Hey girl, am I more than my hair?: African American women and their struggles with beauty, body image, and hair. National Women’s Studies Association Journal, 18(2), 24-51.

Peterson, C. M., Matthews, A., Copps-Smith, E., & Conard, L. A. (2017). Suicidality, self-harm, and body dissatisfaction in transgender adolescents and emerging adults with gender dysphoria. Suicide and Life-Threatening Behavior, 47(4), 475-482. doi: 10.1111/sltb.12289

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