February 26, 2021

Sand Chang, PhD on Gender Diversity in Clinical Practice

CREDN Conference presenter Sand Chang discusses gender diversity in eating disorders treatment and the need for more competent care.

Sand Chang, PhD is a Chinese American genderfluid/nonbinary/femme psychologist, gender therapist/specialist, and trainer living in Oakland, California. They will be presenting Do No Harm: Centering Trans and Nonbinary Experiences in Body Positive Movements and Eating Disorder Treatment at the upcoming Columbia River Eating Disorder Network Conference on April 23rd-24th.

We spoke with Sand about how they got started in this work, why confronting personal biases is important for all practitioners, and what areas of improvement are needed in the field. 

Tell us a bit about your background and how you became interested in the treatment of eating disorders?

I always say, “Research is me-search” and believe that all of our clinical or academic interests have some root in our own struggles or experiences. When I was younger, I struggled with compulsive exercise and restriction, but never met full criteria for a diagnosable eating disorder. That led me to focus my dissertation on eating disorder symptoms, not full syndromes, as well as connections to perfectionism, view of self as independent versus interdependent, and Chinese American identity. Much later in my career, I found Health At Every Size, and this has completely changed how I practice. I’m part of a wonderful community of Body Trust providers, and now I see how much eating disorders work is connected to a larger movement of body liberation, one that is connected to decolonizing the body in multiple regards.

Eating disorders have traditionally been seen as a cisgender problem approached from a heteronormative lens. What are some of the ways these stereotypes can affect treatment, or be barriers to access and change?

Eating disorders assessment and treatment are all centered on the experiences of white, western, cisgender, heterosexual women. The thing is, research suggests that trans people are at a much greater risk of having an eating disorder. Our treatment models do not center the people who might need help the most. The ideas we have about who has an eating disorder or is likely to develop one need to be seriously overhauled. Eating disorders professionals need to step into accountability and do better when treating trans people, and that means challenging their conceptions about gender as well as not trying to make trans people fit into a treatment model that was never intended for anyone outside of dominant culture.

What are some ways you have seen the COVID-19 epidemic and periods of quarantine impact those struggling with diet, body image issues and disordered eating?

This pandemic has been incredibly challenging for those with a past or current eating disorder. We have been going through a collective trauma, and any trauma increases the need to locate means of coping and survival. For a lot of folks, this has meant relying on disordered eating strategies to cope with a sense of loss, fear, hopelessness, and lack of control. It has meant not having our regular routines or social supports available to help regulate our nervous systems. The media hasn’t helped. The fatphobia that has been rampant across social media (e.g., talking about the “COVID 15”) is violent as well as insulting. This kind of messaging suggests that in the midst of people dying that we should all be concerned about our weight or BMI. That comes from a place of absolute privilege and ignorance. The media has also spread misinformation about fat people being at a higher risk of dying from COVID. It’s important to call out that if there is indeed any truth to this, it’s not due to having a larger/fat body; it’s due to the fact that fat people face weight bias and discrimination when seeking health care and are therefore more likely to get subpar treatment.

Why do you think it is important for practitioners regardless of specialty or professional background to be aware of biases (personal or systemic) in regard to the treatment of transgender, gender diverse and non-binary clients?

As practitioners, we all have ethics codes that instruct us to not only “do no harm” but to promote good for all our clients. However, practitioners often fall short of this ideal and do serious harm when working with marginalized communities. What many people don’t realize is that enforcing cisnormative or binary gender norms hurts everyone. It’s a form of body surveillance and subjugation that contribute to disordered eating for people of all genders. Practitioners have to truly examine and interrogate what biases and assumptions they have, including whatever gender norms they were indoctrinated with by their own families and cultures.

Where do you feel more energy is needed to address transgender, gender diverse and non-binary health, especially in relation to body image and disordered eating?

We have to stop assuming that disordered eating is simply about weight control or weight loss. We have to take into account systemic oppression and poverty that leads to food scarcity. We have to take into the minority stress that people who aren’t legible within the gender binary face on a regular basis. And providers have to stop making trans identity or gender dysphoria mutually exclusive with the existence of an eating disorder. Too often I’ve seen or heard of providers promoting the idea that the eating disorder must be treated first before a trans person can receive gender-affirming medical interventions. This is sometimes so extreme that medically necessary medications (i.e., hormones) are withheld while people are in eating disorders treatment. This is simply not okay.

Is there anything else you want to share about your upcoming presentation or your work in eating disorder treatment?

I’m just really honored to be invited to be part of the event and that this space is carved out for such an important topic. I’m really looking forward to bringing this conversation into as many spaces as possible!

Learn more about the Columbia River Eating Disorder Network Conference