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Table 3 Supporting provider comments on barriers to successful care experiences among gender minority patients seeking and receiving eating disorder treatment

From: Provider perceptions of barriers and facilitators to care in eating disorder treatment for transgender and gender diverse patients: a qualitative study

Discrimination and microaggressions

“…the boss that I left from, they were also an older male, who was very open about sexuality but when it came to gender and pronouns…they refused, because it wasn't grammatically correct. Like, we helped a lot of patients come out to their families and created a safe space but when it came to that (gender), there's no tolerance.” (P16)

“…we're like, okay, this person needs to go to this specialist…they need to have their gastro system looked at more carefully…the doctor on our team was like, ‘I mean, we can send them there and that's the only place we can send them but it's gonna be rough’, and then you try to help the client through it…prepare them what to say, how to navigate, what to expect. Like literally like you have to send them into an unsafe space…in Arkansas we don't have a lot of choices…there's only one or two doctors in all of the state…so when they need a specialist, it's really risky for them as far as their identities.” (P10)

“…there's a piece of legislation in this state it's called the Conscience Clause. So, essentially, it gives people (providers) a pass (on religious or conscience grounds)…we've had clients that said, ‘this person seemed okay or they were the only one that took my insurance, I had appointments,’ and then the person is telling him, ‘I need to refer you out because I don't have enough experience to treat you.’ They're back in the same place of, ‘I've been vulnerable (disclosed gender ID) and that person told me, I can't help you.’” (P17)

Provider lived experience and education

"I think a much more fundamental issue is the lack of diversity within our fields…especially for the kind of treatment that I do in inpatient residential settings, where you're really living with your carers (sic)… you're not seeing somebody once a week for an hour. I think especially in that context, for the people around you not to be reflective of your experience, is a huge problem. It doesn't matter how well educated they are, it doesn't matter how well intentioned they might be, it doesn't matter how many seminars they might have taken, there's a fundamental difference in having some level of lived experience of the nuances that come along with whatever you might be talking about and just learning about something in an academic way." (P25)

Other patients and parents

“I think, unfortunately, all levels of their care can be impacted, especially if they're male…or if they identify as male. It also makes it tricky, because I work with other clinicians at the residential part of our company and housing is really difficult with these particular patients because parents of [other] adolescents do not feel comfortable with a patient in their say, daughters, room who's heterosexual for all we know. They are 12, but you know, who knows? But then there is a 13-year-old that is transitioning, they find that out, then they cause a ruckus!” (P16)

“My patient that I worked with for a while talked very specifically about someone who had this ‘Back the Blue’ poster in her picture [in telehealth video group therapy] and me saying to him, 'so you're probably very fair about what those assumptions are, but we don't 100% know. And just because she has someone in her life, who is a police officer, doesn't mean that she doesn't accept you as you are. So, I get it, and I get why you're wary and let's also try to be fair, and if she says anything, let me know, because we're going to squash that very quickly and it's not okay.'…it's challenging.” (P02)

Institutions of higher education

"So our board…they hold a lot of power. The politics of my state have a big impact…we wanted to put out a statement, during some of the events that have been happening over the last couple of years, making sure that our students knew that we were welcoming of all people, specifically, our gender minorities…and we were not allowed…it's really run by the views of the board [of the university] and what messaging they want us to put out. So, we've got people that push and advocate but when it comes down to even little things, like changing the paperwork that our clients see when they come in so it's not, 'identify yourself as male or female'…it took a lot of time for us to get that approved.” (P10)

Family-centered care

“…a different nonbinary client…this person is only 11 years old…I kind of helped them go through that process of like telling their family and telling their doctors and everything like that. But that was incredibly difficult. And mom just emailed me and is still using the incorrect pronouns…apparently, they're using a completely different name now, and mom is still using the old one…and I think, working with families in this population…like this person is 11…I find really, really challenging because it's like, I don't want to step on these parents toes in any way, but I also want to advocate for my client.” (P07)

“some of the values and attitudes of family members…parents and family just kind of emotionally cut them off…a sense of personal rejection…so you've got that compounded on their sense of identity confusion that they've gone through on that, and trying, again, to be accepted by others…all the negative self-talk that goes on with an eating disorder, it just seems like it's compounded or exponentially higher, with an individual who is transgender…there have been other family situations or support systems where their partners have been very supportive…you need a support system in eating disorder recovery.” (P09)

Gender-centered care

“…a lot of treatment facilities are female only. That's going to be a big, big issue…I've worked in a clinic where we accepted a transgender male….and this client who was transgender, transitioning from a female to a male, he kind of felt, you know, like an outcast, an outlier because even though he had female body parts he identified as a male and a lot of the things that we were teaching and the discussions about the body that we were having you relate to more so as a woman, so that was kind of difficult for him.” (P21)

"So, I think even for cis males who have eating disorders, I know that most, if not many of them, would probably feel very uncomfortable in most treatment centers, just because of how gendered most treatment and the content of treatment tends to be…anybody who's not at least female identifying would probably have a similar experience. Layer on top of that the relative lack of comfortableness in most healthcare settings, for somebody who's not cisgender and who probably is not straight either. The lack of sort of general competency in those realms…lack of welcomeness in those kinds of settings…I think that also then magnifies that disconnect for people coming into treatment…I don't think we're doing a great job." (P25)

“There was one point where I was filling in over there just because they moved us around to where people were needed the most. We had a client that was trans that identified as female, and they had them on the male unit, which even at that point, being as ignorant as I was compared to now, I would say, to me, that didn't seem quite right. And I asked about it and essentially, they were saying, this is the best fit [for the patient] based on how it was going. There were a lot of issues with that.” (P05)

Traditional therapeutic techniques

"You have providers trying to press acceptance of one's body shape and weight, or managing eating style without understanding gender dysphoria, and one's already complicated relationship with their body could actually exacerbate gender dysphoria. So, by having tried some of the typical interventions, like looking at a mirror and telling yourself positive things isn't going to work…it would be like the antithesis of your identity to have to be forced to accept certain parts of your body." (P15)

“…exposure, meal outings and going out in the world and eating…going certain places or clothing shopping…they might not feel fully comfortable. You know, getting looks from people or getting questions and, ‘why are you in the women's section?’…’why are women in the men’s section?’… things that are even as seemingly simple as picking a dressing room when you're out in public trying to do those shopping exposures, I can see all of that being not impossible, but just an additional barrier for us to have to consider when trying these different therapeutic interventions.” (P11)