Content note for eating disorders, sexual abuse, gender incongruence and dysmorphia
A discussion came up in a clinical consultation group I’m involved with about the number of trans people who have disordered eating. I reeled off some thoughts are not always considered, so I’m repeating them here.
It is well known that trans experiences often co-occur with some form of neurodiversity (Sensory Processing Disorder, autism, ADHD etc). So I’m going to start with these, less often thought about, reasons for eating issues and then afterwards I’ll talk about the two things people might assume – body dysphoria and trauma.
As our relationship to food, whether disordered or not, is complex and multidetermined, trans people may be having many-layered and complex responses to food and eating, some aspects of which can be missed.
Is it a sensory issue?
Many trans people have sensory issues, that can be an aspect of different kinds of neurodiversity. This can be around food texture, smell or taste, but it might also be around sound – e.g. the sound of someone else eating, people talking or the noise of cutlery and crockery. Some neurodiverse people get overwhelmed when their senses have too much to do, so it’s not the sounds and tastes and thinking about communication individually are problems, but all together they could be too much.
When these problems are out of the person’s awareness and go unresolved, or are even minimised or denied by caregivers, they can develop into stress reactions and avoidant or problematic behaviours around food or eating.
We need to start taking sensory difficulties and overwhelm seriously. If someone can only eat bland food whilst alone in a room with non-metallic cutlery, that’s cool – we should never have to do a thing that is painful, and for people with sensory differences, things that seem quite benign to neurotypicals can be agony. If hearing others eat or clanking plates and cutlery can be masked by soft music, a person should not have to sit down to a meal without that adjustment. Noise cancelling headphones can also be very helpful in this case. If a person can’t manage to talk or listen whilst also eating, that’s okay. If they can cope with food texture just fine at home but it’s too much in a noisy restaurant, that’s okay too. If they want to smother everything in very hot sauce because that’s a good sensation, that’s a great sensory fix. If they cannot eat sticky food with their fingers, or deal with bones, pips and gristle, we just have to believe that matters.
For some people eating is always going to be a sensory challenge no matter what and all we can do is find ways to support them to cope with that challenge. Sensory issues and overwhelm often get worse at times of stress, so there may be days our clients cope with eating and days they just can’t.
Is it related to interoception?
Many neurodiverse people have problems with interoception, their ability to know what their body is telling them. Not knowing when we are hungry or full may be part of overeating or undereating. During childhood, this may have made it harder for caregivers to get a child to eat or to not overeat. If this then became a battleground there can be extra emotional difficulty here, with issues of guilt and shame, and feelings of being controlled by others around food.
Is it a stim?
Stimming, or self-stimulatory behaviour, is common in neurodiverse people. It can be benign, such as sucking, chewing, hand-flapping, rocking, humming or spinning, or self-injurious, such as hair-pulling, cutting, hitting self, or skin-picking.
Neurodiverse people may have a greater need to seek comfort through stimming. They may also have been discouraged from some relatively harmless stims (think about which is more harmful: thumb-sucking or smoking. Now think about which is more socially acceptable for adults to do). Eating can be a kind of stim – a self-soothing sensory experience. This, of course, can be completely benign but can also develop into something potentially more harmful, such as eating to the point of unwellness. It may have been more socially acceptable to stim using food than to fidget, fiddle, rock, or flap as a child.
Recognising what stimming is and what it does for the nervous system can sometimes allow someone to find alternative stims if eating has become an issue. Stim toys you can safely chew are available on the internet, for example. I have had clients who wear these around their neck and have let the people around them know about their need to use these to soothe themselves.
Some trans people use their relationship with food to manage feelings of physical incongruence (previously called dysphoria) they feel with their body or to change the shape of their body. In young people, eating issues can develop out of a desire to delay or halt puberty.
In the UK, trans adolescents have recently been denied the kind of bodily autonomy other teenagers have in law by the Bell v. Tavistock ruling. Trans adults are denied autonomy by UK gender clinic waiting lists that are up to 5 years – this despite robust clinical evidence that transition healthcare is life-saving and overwhelmingly helpful.
It is imperative that we help trans people, especially teens, feel a sense of bodily autonomy. Understanding the difference between dysphoria and dysmorphia is vital as part of this. Trans people don’t misperceive their own bodies, as in dysmorphia, nor is it about hating their bodies, although if unalleviated, feelings of hatred can develop. Trans people know well the physical reality of their bodies, the problem is their brain telling them their bodies should not be like that. Unlike dysmorphia, it cannot be cured by psychotherapy – the clinical evidence for this is well established.
Uninformed clinicians might get dysphoria and dysmorphia muddled up and focus on trying to make the trans person accept their body, a practice that simply does not work for trans people and can increase their distress.
But on top of this, trans bodies are sites of violence and aggression. Trans children, like other kids that are marginalised, vulnerable and isolated, are highly likely to have been sexually abused because of that vulnerability. Sadly, predators take advantage of difference and social isolation. Whether or not they have “come out” as trans, differences in behaviour and socialization are often apparent and trans people frequently report being excluded as children. Trans kids are more likely to be bullied, attacked and abused in other ways throughout life too. And their bodies are aggressively mislabelled, policed and treated with invasive curiosity. A trauma history can exacerbate this, with people, including therapists, wrongly assuming trauma “causes” trans feelings when the opposite is true – being a gender diverse person in a transphobic world can lead to trauma.
Trans people are also more likely to have been homeless or lived in poverty, and this can bring its own complex issues regarding food. Food and eating can become the means to gain a sense of control amid these different forms of violence, marginalization, and coercion.
Questions for therapists to ask
Do you have any sensory difficulties around food or eating? Sounds, tastes, smells, textures? Do you ever feel overwhelmed at mealtimes? Do you have problems telling when you’re hungry or full? Is the sensation of eating soothing for you, as in a stim? A trans person may not be diagnosable as neurodiverse but still have certain specific sensory issues or issues with interoception which create challenges around food and eating.
It can be helpful for some clients to think about what food symbolized in the home, what mealtimes were like (if they happened at all) and whether food became related to emotion, love and affection, control, struggle or conflict. What other family members’ relationship is with food can sometimes be enlightening, too. Sometimes eating is a part of an entire family’s emotional landscape and food become a symbol for care, affection, emotional regulation, control, conflict and much more.
Having said this, while it can be helpful for clients to make sense of the landscape that exists for them around food, it is not always helpful to stay focused on eating. Eating issues are often best resolved through addressing underlying stresses and traumas. For many trans people accessing trans related healthcare and progressing through transition will be as helpful as any ED specific treatment.
So, therapists need to be prepared to advocate for their clients to be referred for transition healthcare and not obstruct that healthcare if the client identifies a need for it, and that requires therapists to unlearn one of the most abiding myths about trans people, the idea that they are deluded or will regret transition – when in fact, regrets are incredibly rare and trans healthcare (for those that want it) is well evidenced.