"That's not at all what I needed" trans adults' perspectives on trans-affirming primary care and eating disorders.

Transgender and gender diverse adults, referred to collectively as trans, experience eating disorders (EDs) at high rates and struggle to find primary care providers (PCPs) knowledgeable in both gender-affirming care and EDs. Most research regarding healthcare experiences of trans people with EDs focuses on specialized treatment. This qualitative study explored the experiences of trans patients with ED symptoms in trans-affirming primary care, which offers clinical support for gender affirmation in the context of interpersonally gender-affirming primary care services. Twenty-two participants were recruited via social media to participate in focus groups (n = 5). Researchers utilized thematic analysis. Participants reported gender-affirming and non-affirming experiences, experienced unwelcome comments from providers regarding bodies and gender, encountered barriers to disclosing their ED symptoms, felt transition-related medical care supported recovery but did not always resolve their ED symptoms, felt they had to self-advocate, and wanted their providers to recognize them as whole people (beyond their ED and transness) who experience joy. Importantly, despite being trans-affirming, participants critiqued trans-affirming primary care as perpetuating weight stigma and binary gender norms. Participants recommended providers receive ED training, implement universal ED screening, and explore how sociocultural norms regarding weight and gender negatively impact trans health outcomes.

Transgender Patient Preferences When Discussing Gender in Health Care Settings.

Importance: Transgender (trans) patients report frequent discriminatory and harmful experiences in health care settings; gender-affirming, competent health care improves trans individuals' health and well-being. Objective: To identify factors influencing trans patients' decision-making regarding sharing gender-related information with providers (clinicians, health care organizations, health care systems) and trans patient preferences for gender-related questions, as well as the subsequent impact on health care experiences. Design, Setting, and Participants: A qualitative, interpretivist phenomenological study was conducted via telephone or video (using Zoom) in English and Spanish from August 10 to September 11, 2020. Participants were recruited via trans-specific social media groups and email listservs. Interviews were transcribed verbatim and analyzed from October 2020 to January 2022 using thematic analysis by a majority trans research team. Main Outcomes and Measures: Semistructured interviews explored patient health care experiences and preferences. Results: Participants included 27 trans and/or nonbinary adults (mean [SD] age, 30.9 [10.4] years; range, 21-69 years) from 13 US states. Four themes were identified: (1) impact of provider behaviors, (2) engaging in relational risk assessment, (3) receiving affirming vs medically competent care, and (4) "how are you going to fit [me] into your system?" The first theme reflected the impact of provider actions, including level of flexibility in care and interpersonal interactions, ability to explain medical relevance of gender-related questions, and preparedness to work with trans patients. Second, respondents weighed a variety of implicit or explicit safety cues when deciding whether and how to share information with providers. Third, participants spoke at length about affirming and medically competent care, noting that they have had to prioritize one over the other. Last, participants reported their needs often being at odds with health care system norms and standards of care. Conclusion and Relevance: In this qualitative study of trans patient preferences when discussing gender-related information with providers, it was found that equitable, gender-affirming, and competent health care requires flexibility and responsiveness to patient preferences. It requires provider humility and engagement, as well as institutional policies that support competent and gender-affirming spaces. Future research could identify additional roles that providers, administrators, and systems can play in ensuring competent care for trans patients.

Healing from weight stigma in community: A thematic analysis of a group intervention for large-bodied individuals.

Discrimination against and negative beliefs about large-bodied individuals, known as weight stigma, is pervasive and harmful. While previous research has focused on the negative consequences of weight stigma, the present study aims to highlight the lived experience of large-bodied individuals while also exploring the process of healing from harmful experiences of weight stigma. Ten adult (9/10 White, 8/10 cisgender women), large-bodied individuals recruited via snowball sampling through a nonprofit, grassroots, eating disorder advocacy organization participated in a 10-week, counselor-facilitated support group with the shared goal of healing from the impact of weight stigma. Researchers used reflexive thematic analysis to analyze video recordings and transcripts of group sessions to answer the following question: how did participants make sense of their weight stigma experiences and engage with the process of healing in community? Four primary themes were generated: (a) Community is Essential, (b) Storying, (c) Deprogramming and Changing Mindset, and (d) Expansive Healing. These results underscore the impact of weight stigma in the lives of large-bodied individuals and provide insight into how clinicians might support such individuals engaging in collective healing from these painful experiences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Teaching How to Avoid Overreliance on BMI in Diagnosing and Caring for Patients With Eating Disorders.

Physicians tend to rely on diagnostic criteria, which can influence patients' access to care by legitimizing need for care, connections to appropriate clinicians, and insurance coverage for indicated interventions. This article considers potential unintended but foreseeable negative consequences, including iatrogenic harm, of using body mass index (BMI) to distinguish typical from atypical anorexia nervosa, despite both illnesses sharing the same behaviors and complications. This article also suggests teaching strategies to help students learn to avoid overreliance on BMI in eating disorders care.

How Should We Approach Body Size Diversity in Clinical Trials?

Regulatory and ethical considerations mandate that minorities affected by health disparities be included in research. Despite concerns about clinical outcomes for patients with obesity, clinical trials have reported few data about participation of and outcomes for such patients. This article examines the lack of body size diversity in clinical research participants and reviews the evidence and ethical arguments for including larger-bodied patients. Drawing on examples of improved gender diversification of trial participants, this article suggests that similar benefits would be likely from inclusion of body diversity.

Women's refusal to be weighed during healthcare visits: Links to body image.

The purpose of this mixed methods study was to assess the relationship between body image and refusal to be weighed by a healthcare provider among women in the United States, including examination of their reasons for refusal. Between January 15 to February 1, 2021, an online mixed-methods cross-sectional survey assessing body image and healthcare behaviors was administered to adult cis-gender women. Of the 384 respondents, 32.3 % reported refusing to be weighed by a healthcare provider. After controlling for SES, race, age, and BMI in multivariate logistical regression, the odds of refusing to be weighed were 40 % lower for every unit increase in body image score (positive body appreciation). The most common reasons for refusing to be weighed were having a negative impact on emotions, self-esteem, or mental health (52.4 %). Higher body appreciation decreased the odds of refusing to be weighed among women. Reasons for refusing to be weighed ranged from shame and embarrassment to lack of provider trust, personal autonomy, and concerns about discrimination. Identifying interventions and alternatives such as telehealth to provide healthcare services that are weight-inclusive may mediate these negative experiences.

"You Don't Look Anorexic": Atypical anorexia patient experiences of weight stigma in medical care.

Eating disorders (ED) and weight stigma pose significant healthcare challenges. Patients at higher weights, like some with atypical anorexia (AAN), may face increased challenges due to weight stigma. This study analyzed patients' lived experiences with weight stigma in healthcare. Thirty-eight adult patients with AAN completed in-depth, semi-structured interviews regarding healthcare experiences. Guided by narrative inquiry approaches, transcripts were thematically coded. Across the illness trajectory (ED development, pre-treatment, treatment, post-treatment), patients reported that weight stigma in healthcare contributed to initiation and persistence of ED behaviors. Themes included "providers pathologizing patient weight," which patients reported triggered ED behaviors and relapse, "provider minimization and denial" of patients' EDs, which contributed to delays in screening and care, and "overt forms of weight discrimination," leading to healthcare avoidance. Participants reported that weight stigma prolonged ED behaviors, delayed care, created suboptimal treatment environments, deterred help-seeking, and lowered healthcare utilization. This suggests that many providers (pediatricians, primary care providers, ED treatment specialists, other healthcare specialists) may inadvertently reinforce patients' EDs. Increasing training, screening for EDs across the weight spectrum, and targeting health behavior promotion rather than universal weight loss, could enhance quality of care and improve healthcare engagement for patients with EDs, particularly those at higher weights.

"How Do I Exist in This Body That's Outside of the Norm?" Trans and Nonbinary Experiences of Conformity, Coping, and Connection in Atypical Anorexia.

Addressing eating disorders (EDs) within trans and nonbinary (TNB) populations is a growing concern, as TNB individuals are two to four times more likely to experience EDs than cisgender women. This study explored the lived experiences of TNB people with atypical anorexia by examining how gender identity impacted experiences of ED illness and (potential) recovery. Nine TNB adults with atypical anorexia were followed for one year and completed semi-structured, in-depth, longitudinal qualitative interviews at baseline, 6 months, and 12 months. Interviews were coded using Braun and Clark's thematic analysis procedures. Four themes, along with subthemes, emerged regarding the intersection of gender identity and ED experiences: (1) Conforming, (2) Coping, (3) Connecting, and (4) Critiquing. In Conforming, participants highlighted how societal pressures around gender contributed to ED vulnerability. In Coping, participants explained that their EDs represented attempts to cope with the overlapping influences of body dissatisfaction, gender dysphoria, and body disconnection. In Connecting, participants described ED recovery as a process of connecting to self, others, and communities that welcomed and affirmed their diverse identities. In Critiquing, participants described how current ED treatment settings were often unwelcoming of or unprepared for non-cisgender patients. Overall, participants viewed their EDs as intricately linked to their gender identity and experiences of social pressure and discrimination. This study suggests the need for targeted ED prevention and intervention efforts within TNB communities, and the ethical imperative to meaningfully address the needs of TNB patients in ED treatment settings.

Conceptualizing eating disorder recovery research: Current perspectives and future research directions.

BACKGROUND: How we research eating disorder (ED) recovery impacts what we know (perceive as fact) about it. Traditionally, research has focused more on the "what" of recovery (e.g., establishing criteria for recovery, reaching consensus definitions) than the "how" of recovery research (e.g., type of methodologies, triangulation of perspectives). In this paper we aim to provide an overview of the ED field's current perspectives on recovery, discuss how our methodologies shape what is known about recovery, and suggest a broadening of our methodological "toolkits" in order to form a more complete picture of recovery. BODY: This paper examines commonly used methodologies in research, and explores how incorporating different perspectives can add to our understanding of the recovery process. To do this, we (1) provide an overview of commonly used methodologies (quantitative, qualitative), (2) consider their benefits and limitations, (3) explore newer approaches, including mixed-methods, creative methods (e.g., Photovoice, digital storytelling), and multi-methods (e.g., quantitative, qualitative, creative methods, psycho/physiological, behavioral, laboratory, online observations), and (4) suggest that broadening our methodological "toolkits" could spur more nuanced and specific insights about ED recoveries. We propose a potential future research model that would ideally have a multi-methods design, incorporate different perspectives (e.g., expanding recruitment of diverse participants, including supportive others, in study co-creation), and a longitudinal course (e.g., capturing cognitive and emotional recovery, which often comes after physical). In this way, we hope to move the field towards different, more comprehensive, perspectives on ED recovery. CONCLUSION: Our current perspectives on studying ED recovery leave critical gaps in our knowledge about the process. The traditional research methodologies impact our conceptualization of recovery definitions, and in turn limit our understanding of the phenomenon. We suggest that we expand our range of methodologies, perspectives, and timeframes in research, in order to form a more complete picture of what is possible in recovery; the multiple aspects of an individual's life that can improve, the greater number of people who can recover than previously believed, and the reaffirmation of hope that, even after decades, individuals can begin, and successfully continue, their ED recovery process.

How we research eating disorder (ED) recovery impacts what we know (perceive as fact) about it. In this paper we aim to provide an overview of the ED field's current perspectives on recovery, discuss how our methodologies shape what is known about recovery, and suggest a broadening of our methodological "toolkits" in order to form a more complete picture of recovery. To do this, we (1) provide an overview of commonly used methodologies (quantitative, qualitative), (2) consider their benefits and limitations, (3) explore newer approaches, including mixed-methods, creative methods (e.g., Photovoice, digital storytelling), and multi-methods (e.g., quantitative, qualitative, creative methods, psycho/physiological, behavioral, laboratory, online observations), and (4) propose a potential future research model with a multi-methods design, incorporating different perspectives (e.g., increasing recruitment of diverse participants, including supportive others in study co-creation), and a longitudinal course (e.g., capturing cognitive recovery, which often comes after physical). In this way, we seek to expand our picture of what is possible in recovery; the multiple aspects of an individual's life that can improve, the greater number of people who can recover than previously believed, and the reaffirmation of hope that, even after decades, individuals can begin and continue their ED recovery process.

"I'm coming out!": An autoethnographic situation of sel/f/ves within queer fat chronically Ill identity.

In this article, we (two fat, white, queer, nonbinary, chronically ill critical social work scholars) explore the parallel processes of coming out as fat and coming out as other identities (queer, femme, neurodivergent, nonbinary, chronically ill, disabled). We begin by reviewing literature from queer theories, crip theory, and fat studies, addressing concepts of "coming out" and identity. Next, taking an identity-centered autoethnographic and autoarchaeological approach, we explore how the processes in coming out as fat-growing critical consciousness, positive social identity reclamation, community belonging-mirrored other coming out processes, fostering resilience in our lives. We perform this reflection on sense(s) of self within a queer critical intersectional approach, as we individually and collectively examine how our fat identities are situated within our gender, racial, class, ability, health, and sexual orientation contexts. We interrogate how these identities of fatness and beyond, both privileged and oppressed, interplay in our personal, professional, and health-related experiences, and interactions with others. Finally, building off of the theoretical work proposed by Hunger, Major, and Blodorn (2015), we integrate concepts of critical consciousness, positive social identity, and community connectedness into the social identity threat model (as applied to weight stigma), hypothesizing how these potential positive outcomes of "coming out" may moderate the relationship between the psychological stress associated with marginalized identity and the adverse physical and mental health outcomes commonly associated with oppression and minority stress.

Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature.

OBJECTIVE: Currently, there is debate in the eating disorders field regarding how to define atypical anorexia (AAN), how prevalent it is in community and clinical settings, and how AAN rates compare with low-weight AN. This systematic review assesses AAN literature from 2007 to 2020, to investigate: (a) the demographic characteristics of AAN studies, (b) the prevalence of AAN compared with AN, (c) the range of operational definitions of AAN and the implications of these definitions, and (d) the proportion of patients with AAN and AN represented in consecutive admission and referral samples. METHOD: PsychINFO, CINAHL, PubMed, Greylit.org, and ProQuest databases were searched according to methods for Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic reviews, yielding 3,184 potential articles. Seventy-five eligible studies were coded for sixty-one variables. RESULTS: Clinical samples predominantly included younger, female, white samples with limited diversity. In epidemiological designs, AAN was typically as common or more common than AN, and AAN rates varied significantly based on the population studied and operational definitions. In consecutive clinical samples, AAN was frequently less represented. DISCUSSION: Although AAN appears to occur more frequently than AN in communities, fewer patients with AAN are being referred and admitted to eating disorder specific care, particularly in the United States. Given the significant medical and psychosocial consequences of AAN, and the importance of early intervention, this represents a crucial treatment gap. Additionally, results suggest the need for fine-tuning diagnostic definitions, greater diversity in AAN studies, and increased screening and referral for this vulnerable population.

OBJETIVO: Actualmente, hay debate en el campo de los trastornos alimenticios sobre cómo definir la anorexia atípica (ANA), cuán prevalente es en entornos comunitarios y clínicos, y cómo las tasas de ANA se comparan con AN de bajo peso. Esta revisión sistemática evalúa la literatura de ANA de 2007 a 2020, para investigar: 1) las características demográficas de los estudios de ANA, 2) la prevalencia de ANA en comparación con AN, 3) el rango de definiciones operativas de ANA y las implicaciones de estas definiciones, y 4) la proporción de pacientes con ANA y AN representados en muestras consecutivas de admisión y derivación. MÉTODO: Las bases de datos de PsychINFO, CINAHL, PubMed, Greylit.orgy y ProQuest fueron buscados de acuerdo con los métodos preferidos para el reporte de ítems para Revisiones Sistemáticas y Metanálisis de Revisiones Sistemáticas, dando lugar a 3184 artículos potenciales. Setenta y cinco estudios elegibles fueron codificados para 61 variables. RESULTADOS: Las muestras clínicas incluían predominantemente muestras de femeninas, más jóvenes, y blancas con diversidad limitada. En los diseños epidemiológicos, la ANA era típicamente tan común o más común que AN, y las tasas de ANA variaban significativamente en función de la población estudiada y las definiciones operacionales. En muestras clínicas consecutivas, la ANA fue frecuentemente menos representada. DISCUSIÓN: Aunque ANA parece ocurrir con más frecuencia que AN en las comunidades, menos pacientes con ANA están siendo referidos y admitidos a la atención específica del trastorno alimentario, particularmente en los Estados Unidos. Dadas las importantes consecuencias médicas y psicosociales de ANA, y la importancia de la intervención temprana, esto representa una brecha de tratamiento crucial. Además, los resultados sugieren la necesidad de ajustar las definiciones diagnósticas, una mayor diversidad en los estudios de ANA y un mayor cribado y referencia a tratamiento para esta población vulnerable.

Typical-Atypical Interactions: One Patient's Experience of Weight Bias in an Inpatient Eating Disorder Treatment Setting.

This article examines one patient's experiences with weight bias in an inpatient eating disorder treatment setting with a focus on interactions between the patient and her primary therapist. These therapeutic interactions had multiple unintended consequences, including bolstering feelings of denial, modeling of disordered behaviors, and disrupting the therapeutic alliance. Additional instances of weight bias with other treatment professionals, including an inpatient nutritionist and psychiatrist, are briefly discussed. The article ends with several brief recommendations for how clinicians can more skillfully approach issues of weight and size in the therapeutic alliance in order to resist size-related oppressions rather than reinforce them.

Evidence-Based Prevention for Adolescent Substance Use.

Due to the significant consequences of adolescent substance use behaviors, researchers have increasingly focused on prevention approaches. The field of prevention science is based on the identification of predictors of problem behaviors, and the development and testing of prevention programs that seek to change these predictors. As the field of prevention science moves forward, there are many opportunities for growth, including the integration of prevention programs into service systems and primary care, an expansion of program adaptations to fit the needs of local populations, and a greater emphasis on the development of programs targeted at young adult populations.

Enactment of home practice following mindfulness-based relapse prevention and its association with substance-use outcomes.

INTRODUCTION: Mindfulness-based treatments have received increasing interest and empirical support in the clinical psychology literature. There are, however, no studies to date that have systematically examined treatment enactment, which is the amount and type of home practice participants incorporate into their daily lives. Because treatment enactment has been cited as a key aspect of treatment fidelity, this study examined the relationships between treatment enactment (i.e., home mindfulness practice) and alcohol and other drug (AOD) use and craving in the context of a larger study of mindfulness-based relapse prevention (MBRP). METHODS: Participants (N=93) in this secondary analysis had been randomized in the parent study to receive MBRP. AOD use, craving, and home mindfulness practice were assessed at baseline, post-treatment, 2-month and 4-month follow-up time points. RESULTS: MBRP participants significantly increased the amount of time spent in home mindfulness practice over the course of the study. Further, greater time spent in home practice was associated with less AOD use and craving at the 2- and 4-month follow-ups. Of note, the significant treatment gains in home practice faded somewhat at the 2- and 4-month follow-ups as participants returned to standard aftercare, which did not involve mindfulness-based practice. CONCLUSIONS: Participation in MBRP was associated with a significant increase in home mindfulness practice, and increased involvement in home practice was associated with significantly lower AOD use and craving over the course of the study. This suggests that treatment enactment, which entails building mindfulness practice into one's daily life, plays a key role in ongoing recovery following MBRP treatment. Teaching mindfulness skills for daily use versus for only in high-risk situations has the potential to boost the longevity of MBRP treatment effects. These findings also suggest that MBRP clinicians should target the post-intervention decline in home practice (e.g., with ongoing mindfulness practice groups) to maximize the benefits of mindfulness meditation in decreasing AOD use and craving.

Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial.

IMPORTANCE: Relapse is highly prevalent following substance abuse treatments, highlighting the need for improved aftercare interventions. Mindfulness-based relapse prevention (MBRP), a group-based psychosocial aftercare, integrates evidence-based practices from mindfulness-based interventions and cognitive-behavioral relapse prevention (RP) approaches. OBJECTIVE: To evaluate the long-term efficacy of MBRP in reducing relapse compared with RP and treatment as usual (TAU [12-step programming and psychoeducation]) during a 12-month follow-up period. DESIGN, SETTING, AND PARTICIPANTS: Between October 2009 and July 2012, a total of 286 eligible individuals who successfully completed initial treatment for substance use disorders at a private, nonprofit treatment facility were randomized to MBRP, RP, or TAU aftercare and monitored for 12 months. Participants medically cleared for continuing care were aged 18 to 70 years; 71.5% were male and 42.1% were of ethnic/racial minority. INTERVENTIONS: Participants were randomly assigned to 8 weekly group sessions of MBRP, cognitive-behavioral RP, or TAU. MAIN OUTCOMES AND MEASURES: Primary outcomes included relapse to drug use and heavy drinking as well as frequency of substance use in the past 90 days. Variables were assessed at baseline and at 3-, 6-, and 12-month follow-up points. Measures used included self-report of relapse and urinalysis drug and alcohol screenings. RESULTS: Compared with TAU, participants assigned to MBRP and RP reported significantly lower risk of relapse to substance use and heavy drinking and, among those who used substances, significantly fewer days of substance use and heavy drinking at the 6-month follow-up. Cognitive-behavioral RP showed an advantage over MBRP in time to first drug use. At the 12-month follow-up, MBRP participants reported significantly fewer days of substance use and significantly decreased heavy drinking compared with RP and TAU. CONCLUSIONS AND RELEVANCE: For individuals in aftercare following initial treatment for substance use disorders, RP and MBRP, compared with TAU, produced significantly reduced relapse risk to drug use and heavy drinking. Relapse prevention delayed time to first drug use at 6-month follow-up, with MBRP and RP participants who used alcohol also reporting significantly fewer heavy drinking days compared with TAU participants. At 12-month follow-up, MBRP offered added benefit over RP and TAU in reducing drug use and heavy drinking. Targeted mindfulness practices may support long-term outcomes by strengthening the ability to monitor and skillfully cope with discomfort associated with craving or negative affect, thus supporting long-term outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01159535

Mindfulness-based treatment to prevent addictive behavior relapse: theoretical models and hypothesized mechanisms of change.

Mindfulness-based treatments are growing in popularity among addiction treatment providers, and several studies suggest the efficacy of incorporating mindfulness practices into the treatment of addiction, including the treatment of substance use disorders and behavioral addictions (i.e., gambling). The current paper provides a review of theoretical models of mindfulness in the treatment of addiction and several hypothesized mechanisms of change. We provide an overview of mindfulness-based relapse prevention (MBRP), including session content, treatment targets, and client feedback from participants who have received MBRP in the context of empirical studies. Future research directions regarding operationalization and measurement, identifying factors that moderate treatment effects, and protocol adaptations for specific populations are discussed.

The comorbidity of substance use disorders and eating disorders in women: prevalence, etiology, and treatment.

Substance use disorders often co-occur with eating disorders in female populations. This review addresses the prevalence and etiology of this comorbidity in women. Thirteen peer-reviewed journal articles are reviewed. Conclusions are drawn concerning prevalence rates, theory, and implications for treatment. Current research supports distinct etiologies and growth trajectories for both disorders. Thus, comorbidity presents with unique challenges, and often, worse outcomes. Though comorbidity rates are high, little research has been done concerning treatment. Given the high prevalence rates of these comorbid disorders, a specific treatment needs to be developed that targets both disorders simultaneously.