Social Work Ethics, Eating Disorders, and Diverse Gender Communities

by Kaelin Kennedy and Noell L. Rowan, PhD, LCSW, LCAS, CCS

     Recent revisions to the National Association of Social Workers Code of Ethics exhort social workers to rise up against social injustice, stating, “Social workers must take action against oppression, racism, discrimination, and inequities, and acknowledge personal privilege,” according to Standard 1.05b of the Code, as quoted by Dr. Allan Barsky (2021). We are called to recognize oppression, take a stand for the underserved, and treat clients with respect and dignity.

     These ideals are inspiring, and yet for many social workers in clinical practice, they can present an ethical dilemma. This conflict between our profession’s commitment to social justice and our employment in practice can be especially strong in eating disorder treatment.

     Eating disorders are often conceptualized as an illness of the privileged. The prototypical eating disorder client is a wealthy, white, young, thin, cisgender woman (Sonneville & Lipson, 2018). Yet, this stereotype obscures how oppression makes individuals and communities more vulnerable to eating disorders. In fact, eating disorders may affect gender minority individuals at up to double the rates of their cisgender counterparts (Nagata et al., 2020). Although research is limited, the existing literature indicates that the transgender and non-binary communities experience increased prevalence of eating disorders, both in youth and among adults (Diemer et al., 2015; Coelho et al., 2019). Trans and non-binary clients may also experience disorders marked by greater impairment and exponentially increased risk of suicide relative to their cisgender peers (Simone et al., 2020; Duffy et al., 2019).

     Despite this increased risk, treatment for eating disorders in gender-diverse clients appears deficient, with clients reporting that treatment providers often do not understand diverse gender identities and how they affect eating disorder presentation (Duffy et al., 2016). Indeed, eating disorders may follow a different course in gender-diverse individuals, one that requires a different plan for treatment. Many gender diverse individuals report that the stress from their minority gender identity and dysphoria is entangled with their eating disorders (Coehlo et al., 2019). Some use food restriction and compensatory behaviors, such as purging, to minimize gendered features, whereas others may use the eating disorder as an avoidant method to cope with minority stress and gender-related victimization (Coehlo et al., 2019; White Hughto et al., 2017).

     Perhaps because the eating disorder and gender distress are often intertwined, researchers have found that gender affirming care may significantly alleviate eating disorder symptoms. Testa and colleagues (2017) found that gender affirming medical interventions for gender-diverse individuals with eating disorders may significantly alleviate their body dissatisfaction and, thus, their eating disorders. Qualitatively, clients report that culturally competent care under medical transition reduced their eating disorder symptoms and severity (Duffy et al., 2016; Ålgars et al., 2012).

     What does this mean in terms of social work practice? First, social workers must recognize the heightened risk that eating disorders pose to gender-diverse clients and increase screening and prevention efforts in gender-diverse community spaces. Second, education for social work treatment providers on trans experiences and culture is vital, and practitioners may adjust eating disorder treatment practices to better incorporate this culture. These adjustments may include accounting for gender dysphoria in treatment philosophies and changing nutrition goals to suit clients’ identified gender, as well as consulting endocrinologists and other medical transition experts. Third, expanding research on eating disorders in gender-diverse clients is crucial. Little is known about how gender diversity interacts with different eating disorder diagnoses, especially over the long term, and these gaps in the literature make it difficult to apply evidence-based practices to these clients.  

     The National Association of Social Workers Code of Ethics promotes six ethical principles in the practice of social work: service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. All six principles call social workers to serve this oppressed but resilient group of clients. These services cannot be delivered without competence and cultural sensitivity in trans issues and healthcare, respect for the self-determination and dignity of gender-diverse clients, and integrity toward clients’ vulnerable confidences in a transphobic world. Clients report that they often struggle to establish truthful relationships with their providers about their gender identity, calling attention to the importance of establishing strong relationships with these clients, who have so often been harmed by societal stigma.

     The most recent revisions to the NASW Code of Ethics include social workers taking action against oppression and inequities and the recognition of clients as experts in their culture (Barsky, 2021). Ultimately, social workers are called by our Code of Ethics to improve practice and competence with transgender and diverse gender clients as a matter of social justice. By advocating for better treatment and visibility for this oppressed population, we can alleviate suffering from eating disorders and champion social justice for underserved diverse groups.

References

Ålgars, M., Alanko, K., Santtila, P., & Sandnabba, N. K. (2012). Disordered eating and gender identity disorder: A qualitative study. Eating Disorders, 20(4), 300–311. https://doi.org/10.1080/10640266.2012.668482

Barsky, A. (2021, May). Ethics Alive: Special report on the 2021 revisions to the NASW Code of Ethics. The New Social Worker. https://www.socialworker.com/feature-articles/ethics-articles/special-report-2021-revisions-nasw-code-of-ethics/

Coelho, J. S., Suen, J., Clark, B. A., Marshall, S. K., Geller, J., & Lam, P. Y. (2019). Eating disorder diagnoses and symptom presentation in transgender youth: A scoping review. Current Psychiatry Reports, 21(11), 107. https://doi.org/10.1007/s11920-019-1097-x

Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 57(2), 144–149. https://doi.org/10.1016/j.jadohealth.2015.03.003

Duffy, M. E., Henkel, K. E., & Earnshaw, V. A. (2016). Transgender clients' experiences of eating disorder treatment. Journal of LGBT Issues in Counseling, 10(3), 136-149. http://dx.doi.org.liblink.uncw.edu/10.1080/15538605.2016.1177806

Duffy, M. E., Henkel, K. E., & Joiner, T. E. (2019). Prevalence of self-injurious thoughts and behaviors in transgender individuals with eating disorders: A national study. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 64(4), 461–466. https://doi.org/10.1016/j.jadohealth.2018.07.016

Nagata, J. M., Ganson, K. T., & Austin, S. B. (2020). Emerging trends in eating disorders among sexual and gender minorities. Current Opinion in Psychiatry, 33(6), 562–567. https://doi.org/10.1097/YCO.0000000000000645

Simone, M., Askew, A., Lust, K., Eisenberg, M. E., & Pisetsky, E. M. (2020). Disparities in self-reported eating disorders and academic impairment in sexual and gender minority college students relative to their heterosexual and cisgender peers. The International Journal of Eating Disorders, 53(4), 513–524. https://doi.org/10.1002/eat.23226

Sonneville, K. R., & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. The International Journal of Eating Disorders, 51(6), 518–526. https://doi.org/10.1002/eat.22846

Testa, R. J., Rider, G. N., Haug, N. A., & Balsam, K. F. (2017). Gender confirming medical interventions and eating disorder symptoms among transgender individuals. Health Psychology, 36(10), 927–936. https://doi.org/10.1037/hea0000497

White Hughto, J. M., Pachankis, J. E., Willie, T. C., & Reisner, S. L. (2017). Victimization and depressive symptomology in transgender adults: The mediating role of avoidant coping. Journal of Counseling Psychology, 64, 41–51.

Kaelin Kennedy is currently earning her master's in social work at the University of North Carolina Wilmington. She is the intensive outpatient intern at the Chrysalis Center for Counseling and Eating Disorder Treatment.

Noell L. Rowan, PhD, LCSW, LCAS, CCS, is Professor and Associate Director of the School of Social Work, University of North Carolina Wilmington, where she founded and oversees the Substance Use Disorders and Addictions Certificate Program within the graduate social work program. Her substantive research and practice areas include work with persons with addictions, older adults, and members of the LGBT populations.