Trans-Affirming Primary Care Providers' Perspectives on Addressing Disordered Eating in Primary Care Settings

Background and Purpose: Eating disorders are serious conditions with one of the highest mortality rates out of any mental illness. Transgender and gender diverse (trans) communities experience eating disorders at higher rates than their cisgender peers yet are often unable to access treatment. Trans-affirming primary care providers (PCPs), who provide medical support for gender affirmation in an interpersonally gender-affirming environment, are important facilitators of healthcare access for trans people and play a crucial role in early identification and treatment of health concerns. However, research has found that trans adults with eating disorders do not feel their PCPs are equipped to meet their healthcare needs. Research on PCPs’ approaches to disordered eating is limited, and even less is known about how they address eating disorders among their trans patients. This qualitative study addresses this gap by exploring trans-affirming PCPs’ perspectives on eating disorders among their adult trans patients.

Methods: Virtual semi-structured interviews were conducted with 22 trans-affirming PCPs from across the United States from June 2024-March 2025. Participants were primarily physicians (82%) trained in Family Medicine (91%). Participants were recruited via list servs, phone outreach to trans-affirming primary care clinics, and the division of family medicine at a large hospital system. Interviews focused on their experiences assessing and supporting patients with disordered eating, the factors (i.e., logistical, training) that informed their approaches to addressing disordered eating, and their ideas to improve care. The coding and analytic approach (Reflexive Thematic Analysis; Braun & Clarke, 2022) was guided by queer phenomenology (Ahmed, 2006).

Results: Thematic analysis suggests that trans-affirming primary care providers typically lack the interdisciplinary and care coordination support to effectively address eating disorders. Despite serving sizeable populations of trans patients with disordered eating, their understandings of eating disorders were often informed by their lived experience and societal beliefs rather than formal training. Providers described trans-specific challenges including: 1) scarcity of accessible trans-affirming eating disorder treatment, 2) uncertainty regarding how to discuss eating disorders in the context of gender transition, 3) the difficulty of supporting patients to attain gender-affirming surgery weight requirements without triggering or exacerbating disordered eating. Stigma related to eating disorders and body size contributed to their reticence to address disordered eating. PCPs found that providing gender-affirming hormones was a tangible way they could support their patients’ eating disorder recovery. Integrated interdisciplinary support that enabled them to effectively address eating disorders was typically only available in college, specialty (e.g., HIV management), or adolescent medicine clinics.

Conclusions and Implications: Findings highlight the importance of integrated interdisciplinary support for capacitating trans-affirming primary care providers to address and manage eating disorders, given the numerous barriers trans patients face accessing eating disorder treatment. Implications for social work policy include advocating for continued access to gender-affirming medical care, expanding awareness about eating disorders among social workers in integrated health settings, advancing weight inclusive approaches to gender-affirming care, expanding trans inclusive treatment options, and mandating insurance coverage for the full spectrum of eating disorder treatment (e.g. outpatient options) rather than inpatient care only.