Mental health is public health 

At the end of the twentieth century, a new public mental health approach emerged globally, which declared the importance of mental health in overall well-being. As described by the United Nations Human Rights Office, this approach has two foundational beliefs: (1) “there is no health without mental health”; and (2) “good mental health means much more than the absence of a mental impairment” (United Nations Office of the High Commissioner for Human Rights). This approach suffered marginalization and criticism in the public health domain due to divides in policies and practices between physical and mental health. Among youth around the world, mental health has been a pressing challenge known to cause a heavy burden of diseases and other health concerns, including substance abuse, violence, poor sexual and reproductive health, and lower educational achievements (Patel et al. 1302). Yet, this burden has not yet been adequately addressed, not even in high-income countries (Patel et al. 1302). 

Many of these mental health issues have been exacerbated in the COVID-19 pandemic, particularly among marginalized communities. There is emerging data suggesting that transgender individuals have been struck by a myriad of mental and physical health difficulties in the face of the global pandemic, particularly because trans communities have been disproportionately impacted by contextual changes in the pandemic (e.g. loss of gender-affirming spaces, loss of gender-affirming care, heightened percentage of employment loss, etc.). As a result, the risks for mental distress (including body-related distress) are likely to be elevated in recent years (Brownstone et al. 434).

In both 2017 and 2020, The United Nations Human Rights Council (UNHRC) addressed the “global burden of obstacles” in mental health and called for the need to set a global agenda for mental health that is human-rights based (UNHRC 19). The present article contributes to these efforts in trying to promote the full integration of human rights and access to health by generating new understandings of mental health experiences among non-binary transgender college students—a group that is often excluded from clinical research. I aim to produce a new kind of knowledge to fill this gap and answer the questions: What is it like to experience an eating disorder as a non-binary trans person? What is the relationship between transness and eating disorders? By using a critical psychology approach and qualitative methods, the results put lived experiences at the forefront, allowing readers to learn from these participants’ real-life narratives. 

Existing research on eating disorders among trans people 

The existing literature on this topic has revealed a concerningly high prevalence of eating disorders and other behavioral adaptations among trans people, in an attempt to change their bodies (“Emerging Trends” 562; “Community Norms” ). Despite these important findings, non-binary individuals are frequently excluded from studies on this matter. As such, is unclear whether existing findings are relevant to this population. Moreover, non-binary people are not given outlets to share their experiences, nor provided with support systems or treatment plans tailored to their specific needs. Among the small portion of literature that includes non-binary trans participants, researchers argue that body dissatisfaction and eating disorder symptomatology is pervasive. One study demonstrated that nearly 70% of their sample of transgender adults indicated body dissatisfaction—higher than any other queer subgroup that they studied (lesbian women and gay men) (Bell et al.). A recurrent finding across studies of trans communities is that eating disorders are attributed to both broad social factors, as well as transgender-specific experiences (Mitchell et al. 1295; Romito et al. 50). Despite this critical finding, there are sparse treatment recommendations targeting trans and gender-non-conforming groups specifically. More research is needed to determine possible treatment and coping mechanisms. 

The present study 

To fill the research gap at hand, I conducted a qualitative research study in the Spring of 2022, addressing the experience of being non-binary and having an eating disorder. Over the course of four months, I researched this topic, studied qualitative methodology and critical psychology, interviewed two participants, analyzed the data, and drew conclusions from this work. The participants in this study were two students enrolled at Bard College in Annandale-On-Hudson, New York, both of which were 22 years old at the time of our interviews. To ensure the confidentiality of these participants, I have omitted any individual-identifying information and will use pseudonyms. I did not aim to produce generalizable knowledge about the entire transgender community; instead, I sought to highlight two real-life stories in great depth, with the understanding that these experiences may be applicable to a myriad of queer individuals. 

General findings 

Overarchingly, the participants described an important relationship between their eating behaviors and gendered body concerns. The two participants described severely restricting their diets in order to achieve different body ideals both proactively and reactively. Parker shared that they restricted their diet to retain the image of their pre-pubescent self and control their stature and muscle mass. They cited a persistent fear that eating a healthy amount would masculinize their body. Ollie described a similar restriction in order to hold off features they felt were feminine (e.g. larger legs or hips). These narratives contrast the conventional body concerns of cisgender participants with eating disorders—which typically surround the desire to be skinny—as the participants in the current study pointed to gender-related characteristics as central to their restrictive diets. This pattern is echoed in previous research with binary trans samples (Romito et al. 50), but this work extends the conversation to include non-binary participants. My findings also illustrate that one’s distress around their body can fluctuate greatly across different circumstances and that vehicles for gender expression are malleable. This gives rise to many options for dealing with distress about one’s body, detailed in the following section. 

Specific coping mechanisms 

I drew many themes from these interviews (e.g. control & agency, effects of transphobia, etc.), but in this article, I will shed light on the participants’ options for dealing with their body concerns and support systems, largely because these aspects of the trans/eating disorder experience are not prioritized in current literature. The participants cited various ways that they could respond to or mitigate their body concerns, some of which directly connected to the body, while others worked along the lines of gender expression. Between both interviews, three overarching options were discussed: (1) eating practices, (2) clothing, hair, and makeup, and (3) medical transition. The notable support systems included (1) the trans community, and (2) friends/family. I found that these systems are effective coping mechanisms for both eating disorder-specific stressors, as well as trans-related stressors. 

Eating practices 

For both participants, a central aspect of their restrictive eating behaviors dealt with the feeling that they had mastered control over their food and their bodies. Their behaviors led to significant physical and mental harm, but the feelings of agency prolonged their willingness/need to restrict their food intake. For both participants, eating disorder recovery did not come from releasing control; instead, the participants learned to derive new types of control over their eating through cooking (Ollie and Parker) and veganism (Ollie). For Ollie, eating with an ethical stance allowed them to shift from thinking about their intake on an individual level—rooted in thoughts about their body and weight—to a moral-based mission. Learning how to cook for themself became an exciting process for Parker. As they began to share their meals with their friends, they derived control from determining exactly what they would make and how they could make it, and they learned to be proud of the finished product. Each of these factors contributes to how cooking was one aspect of Ollie’s and Parker’s healing. 

Clothing, hair, and makeup 

The two participants collectively voiced that clothing, hair, and makeup were modes for responding to their body concerns. Clothing, hair, and makeup are all resources that Ollie and Parker utilized to alter their presentations without acting on their bodies directly. Although these factors may not have entirely “fixed” their body concerns, experimenting with new types of clothing, hairstyles, and makeup allowed the participants to be playful with their expressions, promote a positive relationship with their bodies, and alter others’ perceptions of them. 

Medical transition 

Among the other options for combatting discomfort with their body, Ollie spoke about the prospect of embarking on a medical transition, specifically with hormone replacement therapy (HRT). During a brief portion of our conversation, Ollie said that if they were to begin HRT, they felt confident that the fat redistribution would take effect (i.e. that testosterone could reduce the amount of weight that sits around their hips). Medical transition (hormones, surgery, etc.) is an opportunity that they thought a lot about and saw as a prominent option for combatting discomfort with their body, although there were many financial and familial barriers that prevented them from seeking it. 

Support systems: Trans community

Both participants cited being involved in the trans community as a protective factor against harmful sentiments about gender, as well as instrumental for combatting their body concerns. The participants spoke about how it took being around a supportive trans community to truly figure out what sorts of gender expressions they gravitate most to. In terms of alleviating their discomfort with their hips, Ollie shared that virtually all of their pants are second-hand from their trans friends and partners. They explained that clothing shopping induced considerable distress, presumably because of the necessity to acknowledge uncomfortable aspects of their body and subject themself to vulnerability in trying new clothes on. So, getting clothing advice and pre-owned clothing from other trans people who similarly sought out masculizing features made a huge difference in their life. Additionally, Ollie relayed that having real-life contact with a community whose perspectives are frequently silenced was instrumental in combating transphobic and fatphobic rhetorics, and subsequently, decreased the factors that contributed to their distress around their body. 

Support systems: Friends and family 

Unsurprisingly, having a strong network of friends and family was a positive factor in both of the participants’ lives. They described their friendships as safe havens, shielded against misperceptions, transphobia, and other harmful experiences imposed by cisgender classmates. The importance of having a tight-knit group of people could not be understated. In these groups, the participants did not feel the need to meet gender expectations or conform to anti-transgender ideologies. Instances of familial support (e.g. parents not pushing gender norms onto the participants even when school administrators attempted to) taught Parker from a young age that there are people who do not prescribe harmful sentiments about gender, and that when faced with such comments, they did not need to alter themself. 

Implications

The examination of the relationship between non-binary identity and eating disorders is of utmost significance, as the transgender community is often underrepresented in research. Although some aspects of this intersection have been brought to light, the co-occurrence and mutual impact of non-binary identity and eating disorders have yet to receive adequate attention and consideration. It is essential to recognize that these two experiences can not simply be understood as the combination of being trans and having an eating disorder, but that these factors may give rise to intersecting challenges, desires, or motives that lead to initiating and sustaining harmful eating practices. 

While it is encouraging to see a growing body of research documenting the high levels of distress and prevalence of eating disorders among transgender and gender-nonconforming individuals, it is also critical to showcase the various ways that these individuals have found relief, safety, and effective outlets for mitigating their body concerns. The present interviews provide insight into various coping strategies that the participants employed to combat stressors in their lives, including finding solace in the trans community, having support from friends and family, experimenting with clothes and makeup, taking food into one’s own hands via a passion for cooking or veganism, and more. Disseminating information about these strategies may positively impact other trans people. 

Moving forward, it is imperative that more research be conducted on this topic. We must work toward highlighting the experiences of transgender people with eating disorders because the factors leading to dietary modifications may be trans- or gender dysphoria-specific, ergo current clinical recommendations—based on cisgender samples—might require considerable adaptation.

Acknowledgment:

I would like to thank Professor Elena Kim for her continued guidance during each stage of this project. This research would not have been possible without her support.

Works Cited 

Bell, K., et al. “Eating Disorder Symptoms and Proneness in Gay Men, Lesbian Women, and Transgender and Non-conforming Adults: Comparative Levels and a Proposed Mediational Model.” Frontiers in psychology, vol. 9, no. 2692, Jan. 2019. https://doi.org/10.3389/fpsyg.2018.02692 

Brownstone, L. M., et al. “‘It’s just not comfortable to exist in a body’: Transgender/gender nonbinary individuals’ experiences of body and eating distress during the COVID-19 pandemic.” Psychology of Sexual Orientation and Gender Diversity, vol. 9, no. 4, Dec. 2021, pp. 434-445. https://doi.org/10.1037/sgd0000519 

Mitchell, L., et al. “The effect of misgendering on body dissatisfaction and dietary restraint in transgender individuals: Testing a misgendering‐congruence process.” International Journal of Eating Disorders, vol. 54, no. 7, May 2021, pp. 1295–1301. 

https://doi.org/10.1002/eat.23537 

Nagata, J. M., et al. “Emerging trends in eating disorders among sexual and gender minorities.” Current Opinion in Psychiatry, vol. 33, no. 6, Nov. 2020, pp. 562–567. 

https://doi.org/10.1097/YCO.0000000000000645 

Nagata, J. M., et al. “Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among transgender men and women.” Eating behaviors, vol. 37, no. 101381, April 2020. https://doi.org/10.1016/j.eatbeh.2020.101381 

Patel, Vikram et al. “Mental health of young people: a global public-health challenge.” Lancet (London, England) vol. 369, no. 9569, April 2007, pp. 1302-1313.

10.1016/S0140-6736(07)60368-7

Romito, M., et al. “Exploring transgender adolescents’ body image concerns and disordered eating: Semi-structured interviews with nine gender minority youth.” Body Image, vol. 37, June 2021, pp. 50–62. https://doi.org/10.1016/j.bodyim.2021.01.008 

United Nations Human Rights Council, Right of everyone to the enjoyment of the highest attainable standard of physical and mental health: Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, UN Doc A/HRC/44/48, online: 

https://documents-dds-ny.un.org/doc/UNDOC/GEN/G20/094/45/PDF/G2009445.pdf?Op enElement 

United Nations Office of the High Commissioner for Human Rights. “The right to mental health.” The Office of the High Commissioner for Human Rights. 

https://www.ohchr.org/en/special-procedures/sr-health/right-mental-health