February 26, 2020

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, trainer, and current Clinical Director at Octave Health Group in San Francisco. 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 at Lewis & Clark College on April 25th.

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.

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