Gender identity & expression: Societal expectations and impacts on self-image

Presented by:

  • Schuyler Bailar, Educator, Author, Advocate, and Founder at LaneChanger
  • Cait Scafati, Primary Therapist at Within Health

Transgender, nonbinary, and gender-expansive people face unique challenges related to body image and eating disorders due to societal expectations and standards related to gender identity and presentation. These expectations can lead to feelings of gender dysphoria, which can, in turn, contribute to negative body image and disordered eating behaviors. Not to mention, systemic oppression is a form of ongoing trauma that significantly increases the risk of eating disorders as well as other mental health conditions.

Defining gender identity and expression

Though people often conflate gender identity with gender expression, they are different. Gender identity is your internal self and personal sense of gender, a complex biopsychosocial relationship between body, identity, and sociality. For example, if a person is a trans man, that is their gender identity. Children as young as four years old may already have a stable sense of their gender identity.

Gender expression is different than gender identity in a few key ways. Namely, that it is how we communicate our gender. It consists of our mannerisms, how we act, how we look, and what we wear. Gender expression is constrained by society and how society identifies these cues, and it can vary over time and across cultures. To continue the example above, a person can identify as a trans man, but they may wear a dress, paint their nails, or wear makeup, which may be considered a feminine gender expression.

Another related term is biological sex, which typically refers to the gender someone was assigned at birth. However, the term can be misleading because it implies that there is only one way to define biological sex, that it is binary, and that it is simple and straightforward. The reality is, biological sex has many major components that come together in a variety of different ways, and it’s not always linear. Therefore, the preferred term for biological sex is “assigned gender at birth” since biological sex is unclear and can also provoke transphobia.

How societal gender standards contribute to eating disorder risk

Everyone, including cisgender people, is subject to gender standards and the gender binary, regardless of their gender. 

For cisgender folks, societal gender standards, such as feminine and masculine ideals, can contribute to body distortions, increasing the risk of an eating disorder like anorexia nervosa or bulimia nervosa.

Transgender and nonbinary people experience an extra layer of pressure and influence. Due to the systemic oppression and transphobia that exists to deny trans identities, trans people must fight to claim their identities and the validity of their genders in the first place. Many trans people feel that they won't be recognized as themselves if they aren’t the “ideal” man or woman. This results in heightened gender pressure and an increased risk of eating disorders.

Gender dysphoria vs. body dysmorphia

Gender dysphoria and body dysmorphia are often very different, although often mistaken for one another.

Gender dysphoria, which affects many transgender and nonbinary people, refers to an incongruence between a person’s gender identity and their assigned gender at birth. It refers to a misalignment of identity. Gender-affirming treatment, such as hormone replacement therapy or surgery, can relieve gender dysphoria.

Conversely, body dysmorphia is rooted in dislike, a lack of self-worth, and the intent to control one’s life. It’s related to body image and body distortions as opposed to gender, and it affects people with body dysmorphic disorder and sometimes other eating disorders. People with body dysmorphia may be convinced that there is something wrong with a body part, such as their nose, stomach, or chin, and even if they have cosmetic surgery to “fix” the problem, the dysmorphia remains. Treatment for body dysmorphia involves various types of psychotherapy as opposed to medical procedures.

How gender dysphoria and body image distortions contribute to ED risk

Eating disorders are complex medical and psychological conditions affected by many biological, sociological, and psychological factors. However, some factors can increase the risk of developing an eating disorder, such as:

  • Trauma
  • Perfectionism
  • Body image dissatisfaction
  • Limited social networks
  • History of anxiety disorder
  • Teasing/bullying
  • Appearance ideal internalization

Transgender and nonbinary people may have a heightened risk for many or all of these risk factors. Systemic oppression and transphobia can cause complex and long-term trauma, body image dissatisfaction, profound anxiety, and depression. In addition, it can lead to bullying, teasing, and severe violence like sexual and physical assault. 

Moreover, many trans individuals may internalize gendered appearance ideals and feel pressure to “pass.” For example, trans women may feel pressure to have an “ideal” feminine appearance, including a small waist and curves in specific areas. Similarly, trans men may feel pressure to have a muscular and lean physique. These expectations can lead to body dissatisfaction, gender dysphoria, and a desire to change their body through disordered eating behaviors like extreme dieting, over-exercising, self-induced vomiting, using diuretics, fat burners, and laxatives, and beyond.

This may especially be true for transgender and nonbinary people who face barriers to gender-affirming care and cannot access hormone replacement therapy or gender-affirming surgeries. Without access, they may continue to struggle with gender dysphoria, body image dissatisfaction, and a desire to change their body through disordered eating patterns.

Clinical considerations for treating transgender patients

There are many clinical considerations for treating transgender patients. Still, first, it’s essential to understand the prevalence of people, especially young people, who identify as transgender or gender non-conforming and those who struggle with disordered eating and full-blown eating disorders. 

First, between 2% and 7% of youth and young adults identify as transgender, nonbinary, or gender non-conforming.1 These numbers are likely to be conservative since they’re based on self-report surveys, and many people aren’t comfortable coming out yet or still don’t have the language for how they identify. Moreover, transgender university students report disordered eating behaviors up to four times more than their cisgender peers.1,2 

Another thing to consider when treating trans patients is the fact that treatment has historically been focused on and accessible to white, cisgender women. And because of that, eating disorder treatment often pushes and encourages body acceptance and positivity. However, if someone presents in treatment with gender dysphoria and a body that doesn’t feel congruent with who they are, asking them to accept their body can cause distress and discomfort as well as cause distrust in the therapeutic relationship.

Lastly, it’s important to remember that there is limited availability of treatment providers with the lived experience of being transgender, nonbinary, or gender non-conforming. Because of this, cisgender providers need to be educated about trans issues, know how to create a safe and inclusive space for trans patients, and understand the unique challenges these patients go through.

Providing gender-affirming treatment

Providing gender-affirming therapy and treatment for trans and gender-expansive patients is essential to long-term recovery. Here are some ways to offer gender-affirming care:

  • Use trans-inclusive signage (e.g., trans flags, safe space stickers)
  • Ensure all paperwork is trans-inclusive (e.g., gender-neutral language, gender-inclusive pronouns, offer a way to include the name they use if different than the legal name, etc.)
  • Providers should disclose their pronouns
  • Avoid asking inappropriate or invasive questions
  • Use neutral language (e.g., hormones instead of estrogen)
  • Focus on body neutrality rather than body acceptance or body positivity
  • Offer ongoing internal training for staff
  • Have referrals available to affirming outpatient providers
  • Engage in ongoing advocacy work
  • Acknowledge the potential for trauma from previous treatment experiences
  • Hold the client as the expert but not as responsible for training others
  • Reflect the language that the client has and uses
  • Consistently reflect and work on unpacking your transphobia
  • Know what pronouns someone may use outside of 1-on-1 therapy so that you don’t accidentally out someone in a group setting

How to deal with a client who is unsure of their gender and pronouns

Not every transgender, nonbinary, or gender-expansive client you have will be sure of their gender identity and pronouns; they may start treatment at the beginning or middle of their journey and are still actively exploring their options.

Navigating therapy with an unsure patient doesn’t have to be challenging. Just like with other clients, you should reflect on the language that the client uses. You’ll want to ask the person what language works for them. If they’re wavering, you can create a conversation about that and ask how that’s going for them and what their journey feels like. You can ask if there is a pronoun or pronouns that feel good for them, but maybe they’re scared to admit that it feels good. Often, people need permission or space to say yes. And if they aren’t ready, that’s okay—don’t push them. Just make space over time for that conversation to continue.

You can also offer ideas to see how they land for the patient, like calling them by their name and not using any pronouns until the person has a better idea of what they’d like to use. You can also suggest exploring or experimenting with different pronouns by trying them on to see how they feel and adjusting accordingly.

If you wind up making a mistake, apologize without getting defensive or explaining yourself, and then move on. However, it’s important to realize that if you ask someone for their pronouns and then misgender them, that can feel like a betrayal and disruption of trust, so pay attention to your language and write down reminders in your notes. And if you find that you are consistently misgendering a client, you may need to take a step back and reflect. Do some journaling and try to unpack your own gender biases.

What to do if a client calls you homophobic or transphobic

If your patient calls your homophobic or transphobic, don’t jump to explain yourself, say you didn’t mean it that way, or get defensive. This communicates that your need to defend yourself takes precedence over your client’s pain—it can make them feel unheard. You need to prioritize your client’s experience, even if you are uncomfortable or it causes you pain. Pause in the moment, collect yourself, and tell your client you are ready to listen to their feelings and experience.

Although your emotions, anger, and defensiveness are valid, the actions that stem from these emotions might not be and can cause a rift in the therapeutic relationship. Genuinely listen to what your patient has to say, offer a thoughtful apology, and validate their pain, acknowledging your role in their hurt.

As a provider, regardless of your gender identity, you may make mistakes along the way, and that’s expected—it’s how you respond to these missteps and make changes that matter. However, putting in the work to create a safe and affirming space for trans and nonbinary patients can help minimize these risks, improve your ability to help patients heal, and communicate to your patients that you value and respect them.


  1. Perry, M., Watson, L., Hayden, L., & Inwards-Breland, D. (2019). Using body neutrality to inform eating disorder management in a gender diverse world. The Lancet. Child & adolescent health, 3(9), 597–598. 
  2. 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.