Understanding Eating Disorders in the LGBTQIA+ Community

LGBTQIA+ Webinar

Our panel of experts discuss the prevalence of eating disorders within the LGBTQIA+ community, how sexuality and/or gender identity impacts the development of an eating disorder, as well as LGBTQIA+-informed eating disorder treatment.

Learning Objectives:

  • Understand how oppression related to sexual and gender identity may impact the development and maintenance of eating disorders
  • Increase knowledge of ways to work with eating disorders and when to refer
  • Increase understanding of the importance of multidisciplinary treatment as well as support communities when working with LGBTQIA+ clients with eating disorders

Our Panelists:

Dr. Steffanie Grossman, Licensed Psychologist

Malak Saddy, RD, LD/N, CEDS-S

Noelle Carmen, host and moderator

Understanding Eating Disorders in the LGBTQIA+ Community Podcast, Video, and Transcript

CARMEN 00:00I’m Noelle Carmen, and today we are talking about eating disorders among the LGBTQIA community. With us today are – please forgive me if I say this name incorrectly – Malak Saddy. Did I say that–
SADDY 00:00Yeah.
CARMEN 00:01–right? Okay.
SADDY 00:31Yeah. Yeah.
CARMEN 00:31Points for me. Uh, she is a registered dietician specializing in eating disorders. And we also have Dr. Steffanie Grossman, a clinical psychologist here in the Dallas area who specializes in eating disorders and working with the LGBTQ+ community. Please know, we will send their contact information to you all along with all of their private practice information, um, in a follow-up email with also all of your CE information as well. Um, before we begin, I wanna invite all of you to please ask all the questions. Um, we hope you walk away with lots more information than you had walking in, um, and also action items under your belt so that now you can move maybe into a different space, even if it’s just about asking more questions. Um, okay. So let’s begin the conversation. I– first of all, I wanna make sure we’re all on the same page. So let’s just start at the top of the conversation. Can you give us just an eating, eating disorder general definition in terms of– give us your 30 second pitch on eating disorders? Um, who wants to start?
SADDY 00:31I’ll go– I’ll, I’ll chime in here first. Okay. I’m gonna try to do it in 30 seconds.
CARMEN 00:32Wait. I’m counting.
SADDY 01:46Yeah. Um, but I– you know, when I think about eating disorders, I think of the most common, the four types of eating disorders that we might typically see, which is anorexia, bulimia nervosa, um, binge eating, um, and ARFID. I think it’s becoming more common that we’re seeing also clients with atypical anorexia as well. And when I am thinking of eating disorders, I am thinking of, um, a person who struggles with their relationship with food and body image. Um, there’s a lot of guilt and shame, whether we’re engaging in restrictive behaviors or binging behaviors, um, and trying to compensate for that guilt and that shame, whether that’s through exercise, through purging, through laxatives, diet pills, um, or other, uh, behaviors. And, and so, uh, I think it’s extremely important when we’re working with our clients with eating disorders that we have that multidisciplinary team working together with, um, a dietician who spe– who specializes in eating disorders with a therapist who specializes in eating disorders, a psychiatrist, a medical doctor.
CARMEN 01:52Um, honestly in my private practice, I will not see a client if they are not seeing a therapist because I cannot do the work around food, um, if that trauma in those internal pieces are not, um, being worked on and healed. And so I think when we’re able to collaborate and come together and stay in our lane, we’re– I mean, ethically, we’re treating our clients with, um, the best care. And so, um– so yeah, I think it’s a lot more than just the food. Um, and, you know, for me, I always kind of rely on my cues if I am internally– I mean, I am so in touch with my body. Something like, if I start sweating, I turn red. If I wanna start crying, I’m like, “Hey, Malak, this is where, you know, our therapist needs to join in because it’s going in from, um– you know, it’s, it’s moving away from the food piece to a little bit more of that therapeutic piece.” I, I know that was not 30 second–
SADDY 01:53No, no.
SADDY 03:03–stuff, but you–
CARMEN 04:01No, no, no. That’s okay.
CARMEN 04:02No, that’s why we’re here. Dr. Grossman, your thoughts.
SADDY 04:03Yeah. So I think Malak made a really good point when it comes to noticing that difference between food and the kind of that self-worth part. So when I think of an eating disorder is going to be someone coming in that we have that relationship that’s really disjointed with food, where food takes on such an emotional relationship, anyone with eating disorder’s coming in and has an emotional relationship with food. But it’s never just about the food. It’s what about food or body has become for them. So a lot of times, we’ve seen disorders really are developing as a sense of control. Like, when someone say has had trauma or even like a series of small traumas that they might not identify as traumas, but are, or even just kind of growing up in, like, a culture where there’s such a strong focus on body, on diet, and this is how you need to look to be viewed as okay, um, that– almost like that portion of, like, figuring out how we eat to make our body look a certain way becomes just all encompassing. It takes so much energy and becomes the priority and that isolation part. Um, and so I think kind of just an overview of eating disorders would just be that, like, that really emotional relationship with food that’s not just about food and more about self-worth.
CARMEN 04:03We– so we are– we are– I knew we were gonna already start in with the questions. But, um, uh, piggybacking off of all of what you’re saying here, um, the question is I have several students that don’t meet the weight requirements to be diagnosed with anorexia. Why do they have to meet predetermined numbers to be diagnosed and treated? Dr. Grossman loves–
GROSSMAN 05:31So this question– yeah, no. I love it. ‘Cause what we’re talking about actually in that is, like, even the idea of sizeism playing out, right? So that idea of oppression with regard to weight, um, but a neat thing. So in the last year DSM– so there’s been some updates, but this most recent DSM, um, they actually changed some of the requirements for anorexia. So now it’s no longer it has to be that 85% or below, but you can be underweight and still just have it be where it’s mild, moderate, severe, etc. Um, and so it still has that frustration that we still incorporate body, um, like, actual weight into anorexia nervosa itself that’s stated– so if I have a client that’s coming in that isn’t, um, meeting that threshold, what we’ll do is we’ll put them into basi– so as Malak had said, atypical anorexia. So that’s going to be, um, basically the new version of eating disorder not otherwise specified. It’s now become feeding eating disorders. In the community, it’s been kind of fun, like, with the acronym of like FEDs, which is like, huh, with, like, eating disorders. Um, but so it’d be the FEDs not otherwise specified. Um, and so there is that, that way to kind of have that be still a diagnosis. Uh, a junkie thing about that that’s frustrating is with lot of these pieces, we’re not seeing that weight is going to be actually the part that determines medical consequences. And so to have it be where weight is such a dictator for actually getting the diagnosis that lets you receive that treatment from insurance things of that sort is just it, it really highlights an area of oppression that I think the community is really trying to change. I love that question, and it’s so frustrating.
CARMEN 05:31Especially, I mean. I think, like, even just the terminology of atypical anorexia. Like what the heck is atypical about if anorexia is anorexia? Then why do we even have two? And, you know, typically, unfortunately, when a diagnosis of atypical anorexia is coming up, it’s because our clients are in larger fat bodies. And so they’re already as– you know, Dr. Grossman said, you know, they’re already oppressed in giving that, that label, and that diagnosis just adds honestly further trauma and is incredibly frustrating. I mean, hopefully when it is revised, that would be looked at. I mean, what the DSM-IV had amenorrhea for Pete’s sake. Like, so even men who, you know, uh, you know, had anorexia couldn’t even be diagnosed because the amenorrhea, like, come– you know, so. And–
GROSSMAN 05:33So– oh, sorry. Go ahead.
SADDY 06:59No, I was gonna say, hopefully, we’re moving away from those–
GROSSMAN 07:46Mm-hmm.
SADDY 07:47–those aspects.
GROSSMAN 07:49So, so amenorrhea to what Malak is mentioning just in case there’s someone in the audience that doesn’t know is basically the loss of menstrual cycle. And so if you were in a body that was supposed to be having a menstrual cycle, so acknowledging even that, where it’s kind of, like, already, um, one, stigmatizing, like, cis men, but also stigmatizing trans folks who say– or intersex folks, right, who don’t necessarily have, like, that met with that piece. Like, we took that out. Um, and so that was a really good part because even a lot of people that were underweight, um, when it came to being in that criteria wouldn’t lose their periods. And so then they weren’t diagnosed, which still makes no sense, right, ’cause we want the people to get treatment.
SADDY 07:50And I think so–
GROSSMAN 07:51So this– oh, go ahead.
SADDY 08:28Sorry. I was just gonna, like, kind of re– I think so often, um, unfortunately because our society views eating disorders as this glamorized thin ideal that we think of eating disorders in that sense, and it is absolutely not that. Eating disorders affects every gender, race, ethnicity, um, religion. It does not matter who you are. Eating disorders– and I truly believe that 99% of the population, including myself have experienced some sort of disordered eating patterns because of diet culture and the wellness society that has been pushed on us, you know. And so, um, I think it’s super important to, to recognize that it doesn’t matter who– like what we think it looks like is not actually that, you know.
CARMEN 08:29You know, so this piggybacks right into my next question, because when I was talking to Dr. Grossman, uh, before we came on, I was like, “Okay, so one of the questions I’m gonna ask was, in general, how do eating disorders present?” And she said, “Wait, wait, wait, Noelle. Hold on. Back up just a little bit, because there’s so much stigma around identifying eating disorders and talk about them.” And I said, “Great, let’s talk about the stigma. I feel like that’s a really important conversation to have.” So, uh, Dr. Grossman, can you dive right into– talk about that piece, the stigma piece.
SADDY 08:30Yeah, absolutely. So when I heard that question kind of– and, Malak, I love that you mentioned that kind of what eating disorder look like. Eating disorders, again, impact everyone. And so I think such a great point that highlights that stigma is like some of the parts we were talking about with regard to diagnosis. But it wasn’t even until this most recent diagnosis that– or most recent, um, DSM, so the diagnostic statistic manual where we make the diagnosis from, that it was actually where binging disorder was considered an actual disorder. Prior to that, it was in the diagnose– diagnosis for further research, considered more than not otherwise specified. And what we’ve seen now is now that that’s actual diagnosis, that is the most common type of eating disorders. But prior to that, you would have a B where if someone was experiencing binges or binge eating disorder and what it now is– because it wasn’t a diagnosis A, they wouldn’t necessarily be able to, to get assistance from treatment, from insurance, from– and then to a big part about having disorders actually be an actual classified disorder, is it makes the way for you to actually have a B where there’s funding for research to treat this. As well as you just stigma-wise, people would come in and they’d be like, “Well, I binge, which is so distressing and has so much guilt and shame and all these pieces.” But because it wasn’t a valid diagnosis kind of, quote-unquote, “it wouldn’t feel real.” It would feel like, “Well, this is just me. It’s not actually a disorder that I’m experiencing. It’s not that ED voice.” So now that people with eating disorders hear, like, voices, but we try to separate the person from the disorder and help it be where that war inside their head becomes more about the war against eating disorder rather than the war against themself. Um, but even just thinking about how eating disorders present in such different ways, um, when it comes to symptoms, body types, all these pieces, it is not just a disorder that impacts women. It’s frequently the stereotype.
CARMEN 09:11Yeah. I’ve been practicing for over 12 years and never ever have I seen a case or a client that is exactly the same. And that’s why treatment needs to be so individualized. But we have to respect our clients’ lived experience and what they’ve been through, um, when we’re treating and coming at it again from a collaborative, um, aspect of multidisciplinary team. And so I think, yes, there’s a lot of similarities. Sure. But I– again, yeah, I don’t– what has worked for some has not worked for others. I think of environment resources, all those different aspects that come into play, um, you know, that could be various culture, religion, um, uh, that can play into recovery, so.
GROSSMAN 09:48Can you break this stigma down for us, um, in a– in a more understandable way? Okay. So we are kind of talking about this in a general way. Understood. Where, where do we go wrong, um, even as clinicians in terms of understanding the stigma? Um, certainly, that is a very important thing that we need to understand when looking face-to-face at our clients, right? So can you break that down into, um, more boots on the ground examples?
SADDY 11:32Mm-hmm. So someone walking in the office, like, for– like both of us, when it comes to therapy, when it comes to the dietetics aspect, if someone isn’t aware that eating disorders can impact anyone– it might be someone walks in that isn’t necessarily the gender or the size or the whatnot that we expect. And they might be struggling so much with– keeping in mind, anorexia is the number two lethal mental health disorder of all mental health disorders, right? The only disorder that kills more people is opioid use disorder. Other than that, anorexia is second most. And so say if someone walks into the office and because of the stigma about expecting what eating disorder, like, looks like, we might not ask those questions about, “Hey, what’s your relationship with food? How do you feel like when it comes to that number on the scale? How do you feel about, say, if someone says good food, bad food? Do you have foods that you avoid? How often do you think about food?” Right. ‘Cause someone with an eating disorder, that’s all they think about. It’s constantly in the back of your mind, right? It’s there for every presentation, every test, every conversation, before you go to bed, when you wake up. And so if we miss that, based on that stereotype, based on that stigma, we potentially just had someone walk out the office that may or may not die soon after.
CARMEN 12:14Yeah. I’ve had a client who, um– I actually recently just saw her. She was telling me that she went to see her therapist. She told her therapist that she had a history of an eating disorder. The therapist told her, “Oh, you don’t look like you have an eating disorder.” They were doing this via video. The woman asked her to stand up and lift up her shirt to see if she could see skin and bones. So I know this feels ridiculous, but we are– this just happened last year. This isn’t, like, something that happened 5 or 10 years ago. So I think most important is that eating disorders don’t have a type.
GROSSMAN 12:43Mm-hmm.
SADDY 13:48And so my number one thing is please do not comment about somebody’s body size, shape. If you want– even just as, as humans, there’s no reason that we need to, like, compliment somebody based upon their weight. Um, and so what I would suggest is, like, compliment on the head up. You know, “Dr. Grossman, your hair looks awesome today.” Like, I’m not referencing any sense of, you know, uh, of size, um, or what– you know, just kind of keeping it neutral. And this is the thing is our society is no longer obsessed, unfortunately, with a thin, thin ideal. It’s, it’s obsessed with, um, uh, the, the female obedience. Stay in the corner, mess around. And even not just honestly feeling just humans. Stay in the corner, play with your diet pills, look at the scale, associate your worth, and don’t you dare get ahead because if you do, that feels uncomfortable. So how can I profit off of your vulnerabilities and insecurities? And so I think it’s super important for us to understand also those messages that we’ve received, you know, um, that have made us feel like it’s normal or okay to tell somebody, “Oh, you’ve lost so much weight, and you look good.” That just should not be coming up, honestly.
GROSSMAN 14:20And even noticing too what you have in your office and how that even kind of–
SADDY 14:21Yes.
GROSSMAN 15:31–creates the stereotype in some ways. So if someone walks into an office and they see a bunch of diet sodas around, or if every single picture is of someone, like, of the same particular body type, right, when it comes to particularly again, challenging that ideal, um, that that’s something that someone with an eating disorder, or just someone in general, that’s looking around be like, “Oh, I respect this person. This is someone empowering privilege.” Um, that’s just something to be aware of what you have.
SADDY 15:34Let’s dive even deeper now and talk about, um, the internal struggles. If you got– if you can give us some, some pictures of what that looks like in terms of– give us examples of the diminishments of self-worth or distorted body image or self-trust. Some of these really, um– these very deep internal conflicts, um, that are around eating disorders.
GROSSMAN 15:34Mm-hmm. Well, I always like to think of when it comes to, like I mentioned before, like, that ED voice. So folks with an eating disorder often feel like it’s kind of a war inside their head, right? Like, that’s like a– like a visual that we get really frequently. And so just when it comes to thinking about– like, if you are having this constantly, like, in the back of your mind, like, it’s hard to focus with what people are saying. It’s hard to be able just to be present. It’s hard– and that in itself can hit at self-esteem, right? That part of eating disorders are so often about control. And so if you’re feeling so out of control– and then eating disorders too, what we like to say is that they’re gonna keep on taking over until basically you disappear. Um, so you never actually feel like you reach what you’re going for ’cause eating disorders keep moving in that way. It just becomes wearing and draining and isolating. Like, you can’t focus on what’s around you. Food is something that frequently is present when it comes to, to different social gatherings. All those parts will just pulls you out, which then when we think about that cycle of, “I now have no friends, or I have, like, kind of, like, that perceived version of no friends. I have less friends. I’m more isolated.” And it just pulls us down more.
CARMEN 15:58And it isn’t– I mean, I, I think oftentimes too, will sometimes hear is people will try to re-relate eating disorders to addiction. And there are– I mean, eating disorders– sure, there might be some crossovers and aspects of it, but you need food to live. You need food to live, and you need to eat it three times a day. And so as, you know, Dr. Grossman just said, you have to think that constantly. We’re having this conversation. If a client of mine was here, what they would be is that, “Oh my God, Malak, your face is so fat. Like, why is it so round? Oh my God, you need to sit up stuff like slouching. Did you really eat that, um, taco burrito for breakfast this morning? Why would you do–” so it’s this constant rumination of calories, food, self-image. And so even though we’re engaging in this conversation, it’s this, like, chatter that just doesn’t stop, and it’s exhausting. And like we said, when you have to eat three times a day, three to six times a day, that’s a lot, you know.
GROSSMAN 16:27Let’s jump in now to eating disorders among the LGBTQIA community. Before we even do that, let’s quickly go through some very basic definitions again so we’re on the same page. We’ve fundamentally talked about eating disorders, you know, covered that whole topic in what, 20 minutes here. Um, and now, um, let’s just talk about things like sex, gender, gender expression, sexual identity, gender dysphoria, and body dysphoria. Um, let’s just jump in. So, so, uh, Dr., Dr. Grossman let’s start with sex.
SADDY 17:27Yeah, absolutely. So sex is going to be the anato– or what you’re assigned at birth, or, say, if you don’t have a birth certificate, just based on your chromosomes, your genitals, so anatomy of birth, right? Um, I like to always point out– so there’s a stigma or kind of that binary that people think that is just female, male, that’s actually not true. There’s actually a good chunk of states that you can even have in your birth certificate intersex. So that’s when you’re born with, um– basically when it comes to anatomy. So again, like, the chromosomes, genitals of multiple genders or multiple sexes in that way. So not just female, not just male. We might have chromosomes of one particular sex. And then when it comes to the genitals, it might be another. And so that’s actually something I, again, really highly like to point out is again, that’s birth certificate for a lot of folks. And so knowing that that’s something that, um, is really present. Uh, so that’s gonna be sex. So that’s what you’re assigned at birth, sex assigned at birth.
CARMEN 18:24And, you know, I think it’s confused with gender, right. Don’t–
GROSSMAN 19:01Exactly.
CARMEN 19:48Yeah.
CARMEN 19:51Okay.
GROSSMAN 19:51Not to confuse your gender. So sex is what you’re assigned, right? That’s again, the chromosomes, genitals, anatomy, so anatomy-based. Gender is going to be who you identify, how you identify. So that’ll be– so things like– and it’s just some umbrella terms, for example, would be transgender, cisgender. I like to point out that cisgender would be if the sex– using myself, for example, sex assigned to birth. So if you look at my birth certificate, if you were to talk to my doctor, if you were to talk to my family, what I assigned to birth was female. I identify as a woman. So my sex aligns with how I identify. So that’s cisgender. So when your sex aligns with how you identify, so cisgender woman. Um, so another identity might be transgender. And for some folks, that identity is more of an umbrella identity. So someone might identify as a trans man or a trans woman or someone who’s non-binary. Um, but basically that’s going to be when someone says– um, or when someone has– or where their identity is not aligning with what they were assigned at birth with regard to sex. So kind of just that umbrella term.
CARMEN 19:51Um, when it comes to gender expression, that again is not gonna be the same as gender, not gonna be the same as sex. So gender expression is how I present myself. So that might be more feminine, more masculine. It’s gonna be things– like you mentioned hair earlier, how you wear your hair, the clothing you’re wearing, how you walk, how you talk. So everyone has again, a sex, a gender, and then that gender expression, and that– all of those can be really flexible, right? They can be a spectrum. And then finally sexual identity or sexual orientation is gonna be who I’m attracted to. So that can be things, for example, heterosexual. That can be, um, bisexual, lesbian. Like for my identity pansexual, so attracted to folks of all genders. Um, that’s gonna be again, who I’m attracted to? So each person has all four of those on a different scale. Like they don’t necessarily have it where you– if you have this one, you’re automatically right here. A lot of them are just spectrums that can shift over the lifetime or over the day.
GROSSMAN 19:52And I wanted to jump right into, because I know it was is important, gender dysphoria versus body dysmorphia.
GROSSMAN 20:51Mm-hmm.
CARMEN 21:45Before we get into the conversation, let’s make sure we’re understanding that.
GROSSMAN 21:52Yes. And this is so important when understanding, working with eating disorders among trans folks, non-binary folks, among gender expansive folks. So gender dysphoria is going to be when someone is experiencing significant distress about their sex assigned at birth or their sex not aligning with their gender. So potentially might be say– some examples are, if I was someone who say was assigned female at birth, but I know that I’m drawn to more masculine clothing. I like to hang out with the boys. I really like– I know that, like, my– see potentially– and this is not for all folks, right? But say, if my genitals really do not match me. Or if I know that I am really wanting, like, like, a belonging where I’m like, “I need my penis. Like, I know that I should have. Like, that’s something that’s important to me.” Um, it’s going to be just where you are not aligning. Like, it’s not congruent with what you were assigned. Um, and so that for some folks can be really distressing, right? I always like to mention that not everyone who identifies as non-binary transgender expansive is experiencing gender dysphoria because gender dysphoria is something we work to decrease. And we’ll talk about for eating disorders that can often play a role in that, um, so something like really important for this conversation.
CARMEN 21:52But say– so if someone is– like, realizes that, “You know what? As long as, like, my presentation– like, my presentation matches who I am.” Um, potentially for some, not all, potentially surgery, if I’m getting voice therapy, if I’m– that in itself might alleviate gender dysphoria to where that’s not something I have anymore, right? So not every transgender person has gender dysphoria. Um, and noting too, when it comes to the body dysmorphia, the difference between those is if someone has gender dysphoria about a particular body part, say, for example, just chest dysphoria, right? Someone’s like, “I know that this does not fit me. This is not me. My breasts just, like– I just– I just think they bring me so much dysphoria and discomfort.” That right there, if it’s aligning with their gender does not necessarily mean that there’s body dysmorphia. Body dysmorphia is basically gonna be your brain is activating in a way where you’re seeing your body different than actually how it is. So say, if someone looks at you, they’re gonna see a whole different you than what you are seeing when you look in the mirror ’cause your brain’s activating different. So that’s gonna be where they’re not seeing their body accurately.
GROSSMAN 21:56Someone with gender dysphoria, say, if, like, that person– body dysmorphia is like, “You know, my chest is too large. My–” and it’s more based on body dysmorphia where they’re not seeing the chest accurately. That’s very different than someone who has chest dysphoria, who’s like, “I know– like, my chest is actually what I’m seeing, but it is not fitting me. It is does not align with me. This is not who I am.” Those are two really different things. And so if– when you’re working with someone who’s trans non-binary gender expansive, that’s really important to tease apart with eating disorders because it can be one really invalidating and damaging, if say, we’re thinking that that’s body dysmorphia, but it’s actually gender dysphoria, so that invalidation. But also too, you potentially aren’t gonna actually get the eating disorder into remission or into recovery because we’re not actually going for– this person isn’t aiming for an ideal, right? That– like, the thin ideal, the body ideal isn’t necessarily matching with this person. It’s more– they’re just wanting society to see them as the end. They’re wanting to feel like themself, and it’s not something that they’re seeing differently. So those are two really important distinctions. Um, and one of the reasons that when you’re working with someone, um, who identifies as trans and you’re seeing that dysphoria versus that dysmorphia is really important to have clinicians who can tease those apart and understand, um, those different lenses.
GROSSMAN 23:00I think it’s worth just saying and acknowledging even among the LGBTQIA community, this is confusing. Um, there’s a lot of definitions. There’s a lot of overlap. So in terms of feeling overwhelmed as we go through these things, totally valid, um, right, Malak?
GROSSMAN 23:59A 100%. And I think–
CARMEN 25:08Yeah.
SADDY 25:27–that’s why it’s not necessarily about a competency. It’s about humility. It’s about that we– it’s a lifelong process that we are learning and growing, and we’re going to make mistakes. And how do we, um, be curious rather than assume, honestly?
CARMEN 25:28Mm-hmm.
SADDY 25:28Okay. Jumping into the next part of the conversation, when we are– we’ve talked about the, the queer community. Now let’s talk about eating disorders among the LGBTQIA community, define who we’re talking about. What does this mean?
GROSSMAN 25:43Mm-hmm. And really fast, just kind of with that term, I always like to point out, so when we’re saying the word queer, like, there’s a little bit of, like, a kind of take back. That word at one point, it was more derogatory. I know there’s a lot of queers now. They’re like, “Nope, this is an umbrella term.” And so just to make note that that can apply to both sexual identity as well as gender identity. So some folks identify as queer with relation to gender. Some folks identify as queer with relation to sexual orientation. Some folks identify queer with relation to both. Because keeping in mind, everyone, again, both has that sexuality or that identity as well as a gender identity. Um, so just kind of make a note of that if people are like, “What’s that term?”
CARMEN 25:44Mm-hmm.
GROSSMAN 26:01Um, so when we’re thinking about– how I perceive the LGBTQ+ community is going to be really anyone who identifies as that. My role is not to say you are someone who is part of this community versus not. Um, and so when I think about that, if someone comes to me and say that they’re part of the community, I believe them with that one, right? So that can be someone who’s gonna be someone who say usually potentially is a sexual identity minority, right, who identifies as not cisgender. Um, we also have folks who come in who identifies as asexual, um, who identify– like, I know some friends who are poly, who identifies as part of the LGBTQ community based on that, right? And so poly–
SADDY 26:34Can you define poly–
GROSSMAN 26:35Yeah.
CARMEN 27:10–just for us. Yeah.
GROSSMAN 27:11Yeah, totally. So polyam– so someone who, um, engages in polyamorous relationships. Um, so that would be– so when we think about monogamy, like, one person has one partner, and that’s their person, right? Poly relationships are going to be consensual relationships where people have multiple partners, right. It’s gonna be, again, the part about that is consensual. So all folks involved in the relationship are aware of what’s going on, and they’re all great with that. Um, and so the– some of those folks also identify themselves as LGBTQ+ just briefly touching back too with the word asexual. So what that’s going to be, is that’s gonna be someone who potentially when it comes to thinking about, um, so sex itself, so not sex identity, but, like, sexual intercourse, sexual relationships, romantic in that aspect, um, they might not need quite as much of that physical interaction, that sex, as say someone who potentially doesn’t identify as that. And asexuality is a complete spectrum, right? Like, that’s, like– a lot of these pieces are just spectrum of if someone identifies as that identity, that’s who they are, right? Um, so a lot of– like, again, like LGBTQ+ folks, if they say they’re part of that community, that’s what we’re talking about.
CARMEN 27:12I think when I’m working also with, with some of my clients, especially when we’re talking about body image and our relationship with our bodies, you know, um, society has given us a lot of body or beauty standards of what a– what femininity looks like, what masculinity look– what– you know. And so, you know, when– as we’re exploring, you know, some of our identities and stuff, it’s also exploring, like, what of those standards that maybe society has given do you like or do you want? If I wanna wear my hair short and still be fem, I can. If I wanna wear a dress, but have– like, shave my– I can still be feminine in those ways that it doesn’t– that– yeah, there isn’t a sense of an ideal. And so I think it’s also important. I think, right, working with our clients to help also understand, like, is it– where– when we’re thinking of what beauty looks like, is it because you genuinely think that that’s– or is it because what society has told you, “This will make you look more feminine. People will accept you more if you’re– if you look a certain way.” So how do we decipher between the two? So, for example, I can choose to get Botox and fillers, but not shave my arm– like, armpits. You know, those both can coexist, um, and I can still be feminine.
GROSSMAN 27:13Mm-hmm.
SADDY 28:15The research shows that there is a higher prevalence of psychopathology, which is attributed to increased stress within the queer community. Um, can we talk about this increased stress as it relates to eating disorders?
GROSSMAN 29:22Totally. So when we think about this, like, um, I want to–I know I’m like, “I love this stuff,” y’all.
CARMEN 29:24Yes.
GROSSMAN 29:40So there was a presentation, uh, by Chiu Meyer. I can’t– um, I’m blanking on the first name, but it was a wonderful presentation once upon a time. Um, and he actually has done too, where there’s like a– and anyway, a bunch of assessments. I’ll give research, um, resources at the end. But there’s the, uh, the minority stress theory. And they took it and specifically made it about the gender identity, minority stress theory model. And it’s really neat. And I think it gives a really good conceptualization of understanding how eating disorders can play in as well as, like, different ways that we think about making sure our clients are getting into recovery from eating disorders. That can be really important. Um, so when you break that model down– and I jotted it down ’cause I don’t necessarily have that memorized, memorized, but I love it. Um, so if you see me looking down– um, where it says that. So with this model, we have, like, when you experience so some of these external factors of discrimination, rejection, victimization, or for specifically gender identity, as well as to when we think about sexual identity, that non-affirmation of that identity. So say if someone, like, walks in, you know, and they– their incorrect pronouns are used, right? Or say if someone walks in and they’re holding a partner’s hand, but they’re not taken seriously as partners because of who’s on their hand, those are all stressors, right? Those are external stressors.
CARMEN 29:46And we have those internal stressors because it’s leading to them, so we have that internalized transphobia, internalized homophobia, the negative expectations of, “If I’ve already been misgendered–” and so, like, someone, when I say that not using your correct gender or your correct pronoun, or if I’ve been taken not serious. Like, my family won’t acknowledge my partner as partner, I start to expect that that’s gonna happen. Um, what that ends up leading to then is some of those negative mental health and physical health outcomes. And what we’ve seen is that, um, the ways that we can prevent that or the, the buffers to that is going be community connectedness and pride. And so when we think about, like, really wanting to make sure that our clients who identify as LGBTQ+ have that strong social support, where they have that safety, where they are allowed to develop that pride internally, where they have that community, it’s just– it’s vital. Um, and when you think about all these pieces, so all those stressors that are happening makes complete sense. And eating disorder might come in to give that sense of control. So lot of times eating disorders are going to be about, like, again, controlling your environment in some way, right, controlling that. You know, I know that I cannot necessarily– I control, like, that my parents are accepting me, that my family accepts me, that I can walk the street without being afraid. But one thing I can control is what I’m eating. I can control what I’m looking like. I can control– and so that focus becomes about that, right?
GROSSMAN 29:47And so when you think about that developing, just to give that sense of almost just, “This is something in my power,” until it’s no longer in your power, right, and it becomes this disorder that’s really running them up, makes complete sense if that’s developed. Same thing when it comes to thinking about gender identity. Um, if someone’s using the eating disorder, as I mentioned before, to really be able to challenge some of that– um, the gender dysphoria, so, like, decreasing, again, like, chest size or, or like you see a lot of times– so trans men, we have a high rate of eating disorders, particular with anorexia purging behaviors, given that when you have anorexia, what can potentially happen is, you know, your chest size decreases, your body– like, like, you lose some of that hourglass shapes. Your body becomes more androgynous. You might lose your period, which is really, really traumatizing for some trans men, right, um, because that’s just when you think about that body piece there, and that, that in the aspect with that, it can be a way to control those parts. Or flip side, someone, say, who identifies as non-binary or trans woman, where there might be some more binging behaviors or using your body to almost try to figure out how to almost conceal some of those curves that people usually would identify as being more feminine in that way or, um, being more masculine in that way, starting to kind of try to create them. Um, we just see that that’s really, again, the perfect storm for eating disorder development.
GROSSMAN 30:53Even on my– so on my– um, on the telehealth system that I use, I always have my pronouns. Um, they’re au– they’re automatically on there. And on the– when I have a new client come in, um, there’s a new client form that I ask preferred pronouns. So I’ll take a look, uh– or just pronouns, um, that is there. So I– I’m, I’m looking at it before to also make sure that when I meet, um, with that client, I’m also being respectful. So that is something that’s helpful. And I honestly think that everybody should be, um, like, including, including that, um.
GROSSMAN 32:09And I think too just– thanks for pointing out, Malak. I wasn’t really paying attention to the discussion. Every time it pops on my ADHD, it makes me look, and then I look away. But another part, too, when it comes to pronouns that’s really important is so– especially as someone who’s cisgender where– like, in my expression, like, most people, when they view me, they assume that I’m she/her. That’s been something that’s happened in my world, right? But so by me actually saying that, even though you’re assuming my pronouns – and they tend to be correct – by me putting she/her as my pronoun, it’s actually advocating for people that might not have a B where it’s quite as like, quote-unquote, obvious. And so it almost takes away this, like, this power of if I’m going in– say, if someone’s trans, and they’re like, “You know, I’m really scared about saying my pronouns,” to have someone who is of a privileged identity where there’s that assumption being made about them already coming in and saying their pronouns first. That right there is leading the way to not have a B where this person who’s marginalized has to stand out to be actually themselves. And so putting pronouns is a big way of advocating. So I say, do it on, like– if you see my signature, it’s on the bottom of my signature. It’s on my Zoom. It’s on my, my, um, my little business card back in the day when we used in-person business cards. Um, it’s on my website. Um, but it’s just a way of advocating also and making more normal that you cannot assume pronouns. So that’s a big part of, of kind of that discussion on the side now, um. Yeah.
SADDY 33:21Yeah. Can we do a side note and take some of these questions? Are you good–
GROSSMAN 33:54Yeah. Yeah.
CARMEN 35:09–with that?
GROSSMAN 35:14Yeah.
CARMEN 35:14Okay. I don’t mean to derail the conversation, but there’s some good–
CARMEN 35:15–stuff here. Uh, one of the questions. I have more LGBT male identified gay students with a negative body image. Please discuss the image a gay person might receive– perceive? Sorry.
SADDY 35:17Well, so what we see when it comes to, uh, gay men with eating disorders that gay men with just as, like, the population, like, when we compare, like, the percentage of men with eating disorders to the percentage of men who are openly gay within the population, there is a huge percentage of men who have eating disorders who are queer, um, who are gay. And so we see a very high rate of eating disorders among gay men. Um, and I think someone– like, if I was seeing that kind of correctly pop up– it’s down a little bit, but I haven’t fully gone through. But there’s different within the gay men community or the gay male community with that piece. We have different just, like, within, like, all communities, right, but kind of different stereotypes that occur, difference, like– some folks might be going for more of, like, that really, like, more, like, fit muscular body. Someone mentioned bears. So bears potentially are gonna be folks that come in and have more, like, almost like that burly style. Um, so there’s a lot of different perceptions within, like, when it comes to body image types within, um, gay men’s community. Um, and so it’s hard to kind of, like, just say, like, this is exactly, like, what some– just within, like– I think Malak was saying too, within the communities where it’s almost like you can have different styles within. Um, but to note with that, there is a very high eating disorders among gay men. Yes, yes, yes. That’s, like, the high number.
CARMEN 35:17And I think when I think about body image and, um– you know, I think of the body positive, even community in aspects of that. That is also kind of in a sense of its own spectrum. You know, we can feel– I– you know, we can– I can sit in the aspect of feeling like I’m a hot mess. I can also be body– like, body kind– or treat my body with kindness, body acceptance, body neutrality. Like, it doesn’t have to feel like that. You know, when we’re working with our clients that we have to take them from this place to accept and love every bit and ounce of your body, that what we’re also just working on in the beginning, especially is, like, how do we just sit in that acceptance? Like, I might not like how I look, but also, I still have to feed myself. I still have to drink water. I still have to sleep. I still have to brush, like, those necessities of taking care of myself. I love looking at body image, honestly, like, with a scaling aspect. So it doesn’t feel like I always have to show up at a 10 every single day.
GROSSMAN 35:31Mm-hmm. Yeah.
SADDY 36:43Next question. When a person is vocal about weight loss schools or their weight loss journey, how can I be supportive without being harmful, especially when they are specif-specifically asking for support? I recognize any comments about, uh, sorry, body image are inappropriate, but the typical response is, “You look great.” I hate this because it implies that they looked bad before the weight loss.
GROSSMAN 37:39Mm-hmm.
CARMEN 37:41So what is the verbiage action items around verbiage in a clinical setting?
GROSSMAN 38:08Yeah.
CARMEN 38:08Yeah. And I think that– oh, go ahead.
SADDY 38:13I was gonna– I mean, honestly, I don’t think that– like, you know, if somebody is asking for– or is, like, talking about their weight loss journey, um, that is kind of maybe separate than maybe noticing somebody who has lost weight. Personally– um, and this recently just happened to me. My uncle came back from overseas in Lebanon. He’s like, “Look, Malak, I had lost a–” I was like, “I’m–” like, “I still love you. Like, I don’t– you know, you’re still the same person, and I’m just really glad you’re here, and I can– and I see you, and I spend time with you.” So honestly kind of diverting and also reflecting that who he was– what– at whatever weight he was is still the same. And I– he’s still my uncle who I cherish those times with, you know? Um, and so just kind of redirecting that conversation and taking con-control of that. You know, “You’re still great. Um, when is the next time we can hang out?” So we’re moving away from associating their– the weight to their worth, um, and that they– it would be kind of treated differently, so. Um, and the same aspect too, if somebody– if you notice that somebody had lost weight, it’s just not a comment to, to necessarily discuss ’cause you also have no idea why or how they lost the weight, whether they have an eating disorder, if they’re going through a sickness, or if they’re depressed or– you just have no idea. So it’s best just not to make any reference about that. So yeah, I would kind of diverge that, that comment.
GROSSMAN 38:13It comes down to how close you are to them. Like, I’ve definitely had comment or conversations with, like, friends that I love, people I love with client, um, about when it comes to, like, that idea of, like, weight and how sizeism is played in. Like, so if someone’s like, “God–” like, I look great. Like, I’ve lost this weight. So kind of what Malak is saying that idea of, like, yeah. You know, like, I mean, a body’s a body. But how frustrating is it that when it comes to society right now that we have to really focus so much on weight loss. And, like, I’m so happy for you that you are happy with yourself. Like, tell me a little bit about kind of experiences with sizeism and actually start to have those conversations that help people realize, like– for example, even our society, it’s so frustrating with regard to even, like– I’ve had clients that have, like, been afraid to sit in chairs or when they go on planes. Like, small plane seats are– and it’s really frustrating. We have a society that really perpetuates where– like, not only just comments on weight, like, are normalized, but it is hard to be in a larger body in this society. Like, it is really hard to live in that. Uh–
SADDY 38:16I was just gonna say that that thing– sorry, just one quick thing, ’cause also, you had mentioned earlier too, about our office space and having, like– um, you know, whether it’s posters or also making sure that our, um, office space and our office chairs are size inclusive, that we’re not having that’s, uh– the railings, that we are aware of that. Do we have an elevator for our clients if they are disabled to be able to get to our office? Um, and is the door– can– is– are they able to fit through? I think that is so important to, um, make sure that we’re aware of, um, and, and not dismissing. So–
GROSSMAN 39:34Mm-hmm.
SADDY 40:28–uh, it’s really– yeah. And not having a scale just, like, laying out there if–
GROSSMAN 41:02Yes. Mm-hmm.
SADDY 41:03Like, none of that.
GROSSMAN 41:07Mm-hmm. Yeah.
GROSSMAN 41:09Let’s dive– sorry. Uh, let’s dive in and talk specifically– I know we’ve talked a little bit about gay men, but let’s talk about– give us some understanding, um, in terms of the different segments and what eating disorders look like in the queer community. Can you break that down for us? Give us examples, give us understanding and further action items with regards to addressing these different scenarios.
SADDY 41:10Mm-hmm. Well, I think that actually, like, one of those– I’m kind of reading on the side. A question that came up that actually goes along really well while you’re saying that idea, someone asked, like, “How do you assist with a person choosing between above average weight and unhealthy weight with regards to even, like, the idea of what particular part of the community you identify as when it comes to, like, gay or some people use word weight. Some people– like, all these different communities, right, um, within the gay men community as well as just, like, the LGBTQ+ community in general?” Um, a lot of times, like, when it comes to that, like, I think the idea of, like, almost highlighting some of these oppressive pieces is really important. Like, when you actually think about it, the fact that, like, within an already oppressed community, we have to fit into these binaries in so many ways to even be seen as valid, to have friends, to be viewed as– like, because we’re not changing it right away, right? Like, if someone comes up– a client comes up and says, “You know, like, Ugh, like, I feel like I need to, like, lose weight to be able to be a part of this community.” If I’m like, “You know what. No, your fine as is,” that is actually really dismissive because there is that stigma within the communities, right? Um, just, like, for example, too, with, like– I always like to point out within the LGBTQ+ community, the T trans folks non-binary folks are often honestly forgotten a lot of times. Like, there’s this, “We’ve made so much headway.” But trans folks really are lacking when it comes to some of that support. Like, like literally, like, laws that are being created, like, even in– so I don’t know where– like, I know there’s a lot of people in different areas. But in Dallas recently where we are at, they’re, I mean, kind of, like, the murders of trans women recently, like, within the past few years, high number. And then there’s even been with some of, like, the gay bars on the strip where there’s been some episodes where trans women have actually been told, “You’re not welcome in here ’cause you’re not matching with your ID.”
CARMEN 41:10Mm-hmm.
GROSSMAN 41:40And so there’s communities within communities that are often forgotten. Um, and so I think kind of validating that part of that frustration and that pain and that sadness of even to fit in with a marginalized community, that an ideal world would be so embracing, right, because, like, you know what it’s like to be marginalized, um, still has so many facets within it that you have to try to fit. So honestly, a lot of it is a discussion for me about– like, let’s talk about oppression even within an oppressed community, and let’s start to break this down and give some of that validity to how painful this experience is, um, and so kind of noting that. So when we’re talking about the idea of what an eating disorders, appear, like, within the communities, like, they’re really prevalent in a lot of ways. Um, I always like to state too, again– and I, I know we talked about this already. But particularly with trans people, like, making sure that when you’re talking about an eating disorder, we’re not just focusing on necessarily the idea of, like, the thin ideal or kind of that control aspect related to just body. Um, a lot of it really truly is to decrease the trauma of, like, not having your body align with who you are. And so those are such important pieces.
CARMEN 43:19So if I’m thinking about– I’m working with a client who is coming in, and it’s true body dysmorphia where they’re not seeing their body as is, I’m gonna work with the client by challenging those thoughts, right? Like, CBT record is just gonna be something, what folk– like, so using those to, like, to help kind of dysmorphia, right? Um, it’s going to be doing things like focusing on, like, active– like, all of these– the techniques that I would use with that client might be very different than the techniques that I use with a person who’s coming in where it’s related to gender dysphoria. Because with this, my goal is to help the client see, so body dysmorphia, when the goal is to help the client see their body as is, right? We wanna decrease that body dysmorphia. We wanna get them to a space where they’re having more peaceful relationship with food, um, and they’re able to have a more peaceful relationship with body. Someone coming in who has an eating disorder and it’s more related to gender dysphoria, one of the goals is to help decrease that gender dysphoria, right? So if I’m just like, “You know what? Let’s just, like– let’s go back to, like, you know, just challenging the thoughts and, like, looking at, like, I’m not worthy. I’m not–” it really leaves out a big part of– your body literally is not aligning with who you know you are. And so we need to talk with them then about what are some ways that we can decrease that dysphoria.
GROSSMAN 43:19So, for example, again, like, I’ve had clients when it comes to, like, chest dysphoria, right? And, like, with that part, if that’s a piece for them that’s, like, really perpetuating some of the anorexic or restricting symptoms, what we might do instead is get a chest binder, right? So that way it has where the chest is able to be smaller without having to try to use restricting symptoms to do so, right? It might be getting them connected with an MD who specializes in hormonal replacement therapy, right, so HRT, um, so we have that gender affirmation through, um, pills that are gonna have it be where they don’t have to try to lose weight to lose their period, right, where that’s something that can happen in that way. So it’s really taking a look at what is actually driving the eating disorder and how do we actually go for that symptom rather than having it be, just, like, anyone coming in, our goal is just to, like, have it be where we get them back to a peaceful relationship with food, um, and where we get them just to a space where they feel, like, self-worth, where they’re feeling in control in other ways, because that– those symptoms are just very different with what they’re doing. Um, and so when we think about eating disorders in the LGBTQ+ community, the trans population is one that I really, really highlight as we need to look at it through a lens that’s super affirming and understanding and validating.
GROSSMAN 44:19Malak, I didn’t know if you had– if you had thoughts that you wanted to–
GROSSMAN 45:24No. I think honestly–
CARMEN 46:32–step over you on that.
SADDY 46:35No, no. I mean– yeah, no, Dr. Grossman, you’re doing an, an, an amazing job, um–
SADDY 46:37–explaining it and being so articulate. So I really appreciate it. I think from a dietary– from a dietician’s perspective when I’m working with my clients, I also am– and kind of a little bit back to what you had mentioned earlier, Dr. Grossman, is also realizing how, um, uh, the BMI is absolutely not something that is to be used to– um, it is entrenched in diet culture and fat phobia and racism and to, like, move away from that. So when I’m looking at my client, whether I’m refeeding them or stabilizing them with their weight, that I am making sure that I’m just nourishing them so that, that, that their labs are coming back, um, in a– in a normal place, that their hair isn’t falling out, that their nails aren’t breaking constantly, that I’m just looking at that, that, that place of stability. I’m not necessarily looking at also the, the BMI charts or anything like that, um, to see them just, just for who they are and that lived experience, especially when we’re using hormone the– like, there’s so many aspects that come into– to that with that food piece too, you know.
GROSSMAN 46:42Mm-hmm. And I think a big part too, is just thinking kind of, like, with Noelle, like, the idea of action items. Anytime that I’m referring a client to whether it be a dietician or an MD, I am literally calling ahead, and I am making sure that this person is aware of what pronouns are using or two– like, I have some clients that are like, “I don’t want this person actually using my pronouns within, like, a space where others hear me. So I want them to use, like, the pronouns of my sex. But when we get behind closed doors, I really, at that point want them to be able to use my name and me.” And so, like, it’s, like, making sure that you are doing these handoffs that consistently create safe spaces for people that have been marginalized and are really terrified. Um, and so kind of just when you think about action items, that being something really important too is, like, having your list of people that you contact when you’re referring these clients to the multidisciplinary team.
SADDY 46:42Absolutely. And also, not just, like, necessarily taking on a client just because you feel like you need to fill, like, your session slots. If you do not feel comfortable, making sure that you are referring out. You know, um, I think that is so incredibly important. I totally agree.
GROSSMAN 47:45Yeah. And noting too– um, just kind of keeping track of, like, the questions. One thing I like to point out, and I love– Malak, I’m loving that you’re bringing this up. So just I’m gonna kind of do a gentle correction if that’s okay. Um, but I love that you’re bringing this up ’cause I think it’s so– it’s a really powerful thing with regard to challenging that stigma. So with gender identity disorder, so that actually is no longer, um, a diagnosis in the DSM. The logic behind that is– so back in the day, when that was a diagnosis, um, it really stigmatized the idea of gender itself being, um, the thing that was wrong rather than, like, gender dysphoria. So when someone had that gender identity disorder, it could potentially keep them labeled for, like, forever, right? Like, they had a disorder just because they were trans rather than they have a disorder because they’re having, like, significant distress with something not aligning with their body. And so how I was mentioning before, we’re– not all trans people have gender dysphoria. You know, I might spike a time say, like, I have clients, they’re like, “Who, my dysphoria spiked when I got misgendered.” You know, so there might be moments, but it’s no longer this whole piece of, like, where we have to spend a lot of time in therapy doing this and all these parts. And so it really– the idea of gender identity disorder was kind of stigmatizing the, um, like, the gender itself. So I’m so appreciative that you brought it up. And I just wanna clarify that’s, like, a very, like, just informative peace.
SADDY 48:30Um, and two, just question above orthorexia. Um, so orthorexia for those that don’t know– um, so that’s– it’s not actually a DSM diagnosis who would go under the, um, the, not otherwise specified disorders. I’d be curious if down the road if it becomes one. And there’s actually a really good book by Jenni, uh, Jenni Schaefer called Orthorex– I think it’s actually– Almost Anorexic is the name of it. Um, but orthorexia is going to be when people have this really strong, like, good food, bad food, emotional relationship guilt associated when they don’t eat, like, quote-unquote, clean foods or good foods. And so it’s interesting because, like, society really perpetuate that part of, like, “Oh my gosh, like, let’s eat at the whole food store. This is fantastic. Like, we’ve got this.” When really, if someone becomes obsessive about it, what we’re doing is just creating a different type of emotional relationship with food where there’s a lot of guilt associated. Um, and so when it comes to that, it actually, in some ways might have similar pieces of, like, treating, like– so, like, thinking about, like, thought records, right? Like, that’s a big way– like, using CBT to help kind of, like, almost alleviate. Like, “Am I unworthy if I’m eating a food that isn’t kind of, quote-unquote, clean? Am I– what does this mean for me?” Like, what did, like, that clean eating kind of, quote-unquote, let– like, how did that become an identity? ‘Cause eating disorders, again, are about– they’re about food in the way that– obviously, food is involved, and the food part is what often leads to some of the medical complications. So we don’t have that nutrients, etc., but it’s really about, like, what it’s below it. So, like, my identity is something that I’m controlling through my body or through what I’m eating.
GROSSMAN 48:46And when I think of, um, also orthorexia, even in a– if you have a client that is faith-based and stuff, um, in the Old Testament, God declared all foods or in the New Testament, sorry, Dod– God declared all foods clean after that. So even if they– if there is a little bit of a religious or a faith piece, uh, piece that we can kind of tie it into that. Um, uh, and then also when I look at– when I think about orthorexia, there’s, uh– you know, sometimes when– I’ll hear people say, “Well, oh, I do that,” or, “What’s wrong with that?” So what I would look at is how often it’s happening. And it’s to the point where it’s so hard to be flexible, that it’s– that if a meal isn’t perfect or doesn’t– only isn’t locally sourced or organic, that it is that I’d rather just not eat. And so there’s a sense of, like, if, you know, your– if that’s your preference, that’s something. But if that is– you know, when we’re so obsessed about that, that’s where it becomes more of an eating disorder ’cause I think there is, like, a health spectrum line, right? Like, where does it go from, um, you know, a disordered eating to an eating disorder to intuitively connecting to our bodies. Yeah.
GROSSMAN 49:57I’m aware of the time. And we haven’t even touched the tip of the– just the tip of the iceberg, right? There’s an important thing– uh, important idea I really want to address, um, because you’re talking about out it a lot, and we haven’t– we’re not gonna have time to dig down deep. But you’re talking about oppression. You’re talking about guilt. You’re talking about shame. You’re talking about trauma. And we understand these things, um, you know, in the umbrella of eating disorders. But I wanted to at least touch on how they are specific to, uh, the LGBTQIA community, which I, I feel like we could dive into just a little bit more. Um, who wants to take it?
SADDY 51:19Oh, totally. Well, and we can kind of bounce off. But, like, when we think about, like, literally internalized transphobia, internalized homophobia, and then to even just kind of putting things on top of that, we have internalized non-binary phobias when we think– even within the trans community, there’s often, like– just when it comes to kind of say, if you were someone that is identifying as, like, a trans woman, if you’re, say, a person who’s really masculine that there’s some stigma surrounding you. So there’s all these different pieces or how they them is even still pretty, like, stigmatized. Um, so the community experiences at left and right, right, whether it be, like, from folks who identify as not part of the LGBTQ+ community or within it too, which is really hard. Um, but where some of that internalized homophobia, internalized transphobia can really have a B where eating disorder symptoms become a way of coping with that, right? Like, I feel that I am bad. I am wrong. Something is wrong with me. I’m not connecting. And then that part of, like, focusing on that food, focusing on that body, focusing on– but this is a way that I can feel okay until it takes over, can be something that comes up so often. Um, so when we think, again, about that– even that stress model that internalized, like, homophobia, internalized transphobia part is something really present that can– like, the coping part of the eating disorder can kind of come in.
CARMEN 52:22Yeah. But it feel like there’s sometimes, like, there’s, like, the anxiety, depression, or self-esteem that’s, like, manifesting. And in order to find that way to, to, to cope with that, because that feeling is so uncomfortable and uncomfortable to sit with, we can use food, drugs, sex, uh– you know, it can be anything. When obviously with eating disorders, it’s specifically around food and body image. And so when those feelings become so uncomfortable, which is absolutely understandable, um, it’s– that’s where, you know, the eating disorder starts to, to become– I also think of biological, environmental, social environment. So when I think eating disorders is that kind of honestly perfect storm of all these little items that just come together, um, to, to create this. I mean, it’s not a perfect– I mean, it’s not perfect, but yeah. Sorry.
GROSSMAN 53:02We aren’t gonna be able to cover all of this in this one-hour webinar, obviously. But I did wanna give you the opportunity to specifically address action items as we move forward in all of these– all of these topics regarding the queer community. Um, Dr. Grossman.
SADDY 54:08Yeah. I mean, my biggest takeaways would be, again, like I mentioned, that part of– when you are clinician and you are making those referrals, making sure that you are making them as safe as possible, like, calling ahead, making sure, again, that everyone is affirming in a way that is super loving, letting people know– like, don’t assume partner. This person might be– like, if they’re okay with it walking in, like– when it comes to even, like, say, if you have two partners, same gender, like, if you are wanting to make sure that they have a safe space and you’re not too familiar with that person yet or having your list, making sure you’re calling ahead. Um, other pieces is just because we have such, um, again, that high rate of eating disorders within this community, making sure you’re making it as safe a space as possible to be able to open up all of these identities or hidden identities. No one has to come out to you. And so you might miss that this is a person who’s at particularly high risk for an eating disorder. So doing everything you can to create that safety, right? Like, whether it be, like, having something, like, rainbow or something when it comes to the trans pride flag in your office, like, just, like, colors in that way, right. Having pronouns on, like, your website, having a B where you indicate someone that’s an affirming space, keeping aware of your art, things of that sort. Um, but really making sure, like, in paperwork too, that you are inviting people to open up. And then also with kind of with that in mind, I always like to say too, if you’re someone that uses insurance or super bills, um, whether it be in network, out of network, that one of the things I always like to do when it comes to clients, if they’re coming in and, again, creating that safe space, that I will talk with them about, “I need to use your legal name on here for the purpose of insurance. But please know that is something that, like, I am acknowledging as this might be painful. And what can I do? Let’s talk about this. I will not be using this anywhere else.” Really making sure that person knows you’re safe because then they’re gonna be more willing to explore with you some of these parts to open up to let you dive in with them to find recovery.
CARMEN 54:54I honestly completely agree. I think the only thing I would add is just, like, knowing yourself and knowing when– like, like I said, this is– this is not something that we’re competent in, that you’re constantly learning, and, and you’re growing. Um, if you don’t feel comfortable, like, refer out. There’s nothing wrong with that. You are providing that client with the best care. Um, and, and, and going– seeking these trainings, seeking, um, information so we can continue to learn and provide the best care. The other thing too, is that, uh, especially, I would say with the eating disorder piece is, again, the specialty part that if we’re not– that can cause more harm, again, ’cause– because society has given us all these messages, and we think, like, “I’m not hurting somebody by telling them, ‘Oh, like, oh, you’re not fat. That’s okay.'” Like, that– we’re also reinforcing that fat phobia. So–
GROSSMAN 55:14Mm-hmm.
SADDY 56:54–just know what you feel comfortable with, trust your gut, and refer out when those things happen, continue to seek those educations and, and those trainings.
GROSSMAN 57:41Dr. Grossman, Malak Saddy, thank you so much for being here. Thank you so much for sharing your expertise. This was a wonderful conversation. And again, just the tip of the iceberg, I wanna thank everyone for participating for asking questions. Please know that you will receive an email, uh, by tomorrow, um, also with all of your CE information and access to these wonderful panelists. I hope everyone has an amazing day. Uh, Dr. Grossman, did you wanna say something?
SADDY 57:41Yeah. I was gonna say– sorry, Noelle.
CARMEN 57:51No, it’s okay.
GROSSMAN 58:20I’ll, I’ll send to Noelle too. There’s actually a really awesome Facebook page–
GROSSMAN 58:22–that focuses eating disorders among non-binary and trans folks, and it’s for clinicians. I’ll send Noelle a few resources that she can attach to hopefully to that CEU and so that we all have some additional pieces also, um.
CARMEN 58:25And there’s an eating disorder support group too, that’s free that we can send as well.
GROSSMAN 58:25Specifically for LGBTQ+ folks if you have–
SADDY 58:36Yes.
SADDY 58:42Yeah.
GROSSMAN 58:43Mm-hmm.
SADDY 58:43Oh, thank you, everyone. Have an amazing day and an amazing weekend. Bye.

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