Trans kids are vulnerable to eating disorders. This therapist knows what they’re going through.

This story was originally published by The 19th.

Penny Gautreaux has spent her career helping people in crisis. But facing her own took a village.

A licensed social worker and therapist, Gautreaux struggled with an eating disorder for 24 years. As a transgender woman, dysphoria tied to her gender made it worse. She was hospitalized twice for being undernourished. She was, as she puts it, gearing up for a third round of hospitalization when the people in her life stepped in.

Her own therapist gave her an ultimatum: no more appointments unless she got help. Gautreaux’s long-time partner, spurred by this professional warning, “all but carried” her to a treatment program, Gautreaux said. Seeking help was a long time coming: her disordered eating had begun when she was 11.

Transgender youth are particularly vulnerable to eating disorders, or EDs. Dysphoria plays a role, but the risk is compounded by other factors like depression and discrimination. The risk is highest for adolescents and young adults: Trans college students are up to four times as likely to have an ED diagnosis as their cisgender peers.

For Gautreaux, her disordered eating had to do with her family.

“There were people in my family who felt that my size was going to be a deterrent to my future, and so I was put on severe diets,” she said. “Most families think they’re helping, because we live in a culture that’s fatphobic.”

The situation worsened when she came out as trans and was kicked out of the house. From 17 to 24, she was what she described as “on-and-off” homeless — often sleeping in her car or staying with friends. That made things worse. When she had to choose between buying food or putting gas in the car to have air conditioning in the summer heat, she chose gas every time. That wasn’t just survival, she said; that was her eating disorder at work.

For many LGBTQ+ people, Gautreaux’s story is familiar. LGBTQ+ people are more likely to have an eating disorder than cisgender and heterosexual people. Studies have found a wide variety of reasons why, including more exposure to bullying, which can lower self-esteem. LGBTQ+ people also tend to experience more severe symptoms and longer delays between ED onset and treatment, research has found. Due to discrimination and stigma that can separate them from their families, they are also more likely to fall through the cracks of the social safety net and struggle with homelessness and addiction.

After her therapist’s ultimatum, Gautreaux sought help at the Emily Program, a comprehensive eating disorder treatment program, which provides care in seven states across the country: Georgia, Minnesota, North Carolina, Ohio, Pennsylvania, Washington state and Wisconsin. Gautreaux entered in 2019 as an intensive in-person patient, then received virtual care during the pandemic. She graduated a year and a half later. The day she left, she pledged to come back as a clinician.

That promise held. Now, as a clinical manager for the Emily Program’s treatment center in Lacey, Washington, Gautreaux helps people who were in her shoes not too long ago. She wants others to know that help is available — and that it works.

“The only thing I wish I’d done differently is I wish I’d gotten help sooner,” she said.

The Emily Program treats people at any age; patients range from six to 86. And treatment works. What worries Gautreaux and others in her line of work is the increasing ED risk factors for young LGBTQ+ people — and the things they’re exposed to every day in politics and on social media aren’t helping.

More and more trans youth face barriers to receiving gender-affirming care, due to politics. The Trump administration has taken a whole-of-government approach to blocking the care. In response, many hospitals have stopped treating young trans patients, including in states where gender-affirming care is protected by law.

Gautreaux said that the rise of anti-trans politics will only exacerbate high rates of eating disorders among young LGBTQ+ people. Many studies have found that anti-LGBTQ+ state bills and federal policies hurt the mental health of LGBTQ+ youth. Over time, those effects add up, she said.

“The more signals you get that you are worthless, the more likely it is that you will start to agree, and once you start to agree, something like an eating disorder or other things — addiction, self-harming behavior — anything like that becomes more likely,” she said.

Social media is adding more fuel to the fire, said Jillian Lampert, executive director and senior vice president of strategic engagement and experience at the Emily Program.

“It’s really intense,” she said. “The work we do clinically is helping people to understand, yes, even if you see it on a TikTok every day, or even if you see it on that person’s Instagram and you’re following them, it is still a digitally altered world, that person is editing their video. They have lighting, they have makeup.”

Young girls are particularly vulnerable, Lampert said, as well as trans people who may only find community online. Engaging with ‘what I eat in a day’ videos or posts sharing diets can lead algorithm-driven social media feeds to serve up more content like it. That just brings people further down the rabbit hole, she said.

Part of Meta’s recent $17 billion settlement with states over teen social media addiction involves restricting content promoting eating disorders and limits on social comparison features like beauty filters. This matters for LGBTQ+ people — several studies have found that LGBTQ+ youth spend more time online and on social media than straight or cis people their age. Sometimes it’s the only place to find community.

"The work we do clinically is helping people to understand, yes, even if you see it on a TikTok every day, or even if you see it on that person’s Instagram and you’re following them, it is still a digitally altered world, that person is editing their video. They have lighting, they have makeup.”Jillian Lampert

Researchers have also found that trans adolescents spend even more time online than their cisgender peers. And for trans youth, body image can be delicate.

That’s because of gender dysphoria, a medical condition that causes distress when one’s gender identity doesn’t align with their body.

Lampert recalled working with a young patient who began binge eating and hiding food soon after starting puberty. Once the family was connected with a therapist, it became clear that the adolescent was struggling with gender dysphoria.

“Mom had no idea,” she said, referring to the patient’s mother. “The thing driving the eating [disorder] was the dysphoria.”

Once the patient came out, changed their name and was able to transition, the eating disorder went away, Lampert said.

Put together, this makes gender-inclusive care for eating disorders all the more important. Even small signals in doctor’s offices can help put LGBTQ+ patients at ease. Gautreaux remembers how hard it was for her to seek treatment. She was “a complete mess” that first day, she said. But when she walked into the Emily Program’s office, she noticed a small Pride flag.

That flag gave her some reassurance: at least she didn’t have to worry about her identity being the problem.