Table 2 Supporting provider comments on barriers to accessing care among gender minority patients seeking and receiving eating disorder treatment

Stigmatization

"I mean, family, lack of support, abandonment, rejection… that's a huge barrier, because how can someone get the help they need if their family is not helping them when they have a health rejecting illness?" (P01)

"I think, just like, past experiences with past providers are like a huge barrier where patients have been like, 'oh, I went to this one person, and this bad thing happened. So, why would I ever put myself in that situation again’, which is totally valid." (P18)

Family support

“…I've had a lot of people say, it wasn't until college, that they could even consider having access [to therapy], because the family didn't want the shameful secret, or that their child was not masculine enough or not feminine enough from their perspective, or, you know, the family didn't allow access to therapy with someone who would be gender affirming, and that was a bad thing, because it would only encourage this like delusion.” (P15)

“…the family education piece…specifically with this population, is to make sure that the parents are educated on not only good recovery skills, but also, why it's made more difficult or challenging in a situation where there are some identity things going on…so much of an eating disorder is about identity…we have to approach it as a whole person…we also have to make sure that your child feels comfortable being who they are in their skin…I think that helps parents have a little bit more buy in to the process.’” (P29)

Financial factors

"…a lot of the times the parent’s kind of cut them off, especially as they start to transition, they have a lack of support from various areas, and that includes financial. Eating disorder treatment is really expensive…some of our transgender clients might have to discharge early due to financial reasons and that's very sad." (P03)

“We've had clients in program who have been seeking gender reassignment surgery and for whatever reasons, financial or otherwise, maybe they couldn't afford it, and it could be like, ‘I have to choose between eating disorder treatment, or looking the way that I feel is appropriate. And I think that people are going to kill me in my community, because they won't accept me the way I am. So, it's like my eating disorder will kill me, or my community will kill me. So if I want to fit in, I have to get top surgery, but I can't afford it and eat at the same time.’ So sometimes people are having to make some pretty difficult decisions.” (P05)

"There was one incident with insurance, where there was no option for trans or gender expansive expressions. It was male, female, that was it. Because on their birth certificate, it said they’re a female, the insurance company wanted a female name. The female name on their bursary gave coverage to this individual for any kind of treatment. This patient was very flexible, very understanding, but I could see that being a barrier for a lot of folks…really invalidating, triggering, discouraging, and just like screw it, it's not worth it." (P11)

Gendered clinics—cis female only

“I've only worked in facilities that were female only, but some of our sister facilities…were coed. So we would have clients who would come to the place and say, ‘I don't feel comfortable, X, Y and Z.’ So we say, ‘Okay, well, we can transition you to one of our sister facilities that's in Florida or California,’ but they don’t have resources to get to Florida or California. So, it kind of just puts them in a crunch.” (P21)

Scarcity of gender competent care

"One of the states I've worked in is not a very liberal state, and can be kind of dangerous, sending certain clients to certain providers…the state of Texas, living there and working with several trans clients, I wasn't scared, but I just felt for them and wanted to make sure that I was sending them to doctors that were educated and appropriate with this population." (P07)

"The state of Kentucky is not a super welcoming place for anyone who isn't a heterosexual cis white man…I will say we're located in the biggest city in Kentucky so, I do think because it's a metropolitan area, it's more accepting…tolerant. I don't know that folks are like, necessarily feeling actively positive about the trans population but I think they're certainly more open than in some of the rural, small towns. And like if you don't want…somebody to see you walking into the clinic, even if they're not coming here…it might be hard to have that privacy" (P11)

Religious communities

"It's a very conservative and a very religious community that is not LGBTQ affirming, that is not, in general, supportive of gender diverse individuals…So I think the barriers are both practical and financial…a huge way that people access services in this community is through like a religious or ecclesiastical provider. They provide the referral and sometimes payment for services. It gets very, very thorny there because the person that is basically in a position of power, that religious figure, to pay for those services and may only refer to people who are not necessarily gender affirming." (P27)

"So my practice is in a predominantly conservative, religious community…there are unique challenges to that for our populations that we're serving, because a lot of them are coming into our clinic, with beliefs about themselves that are quite negative or distressing to them personally…so, if they're living a life that they feel is outside of that, it's really eye opening [for them] to sit with someone and to have that person say, 'I think that you are still someone that can live your values and live your life, authentically and that's not such a black and white issue.'." (P29)