Development of a gender-affirming care protocol in eating disorder treatment settings

ABSTRACT

Transgender and gender-expansive (TGE) individuals suffer from eating disorders (EDs) at disproportionate rates relative to their gender-conforming counterparts. While literature on EDs in TGE populations is growing and evolving, best practice guidelines are scant. A framework for providing gender-affirming care (GAC) in an ED treatment setting was developed by integrating findings from a focused literature review and insights from leading experts. Following synchronous and asynchronous training, the protocol was implemented in a virtual ED treatment setting with a national reach serving patients ages 6–24 years. This paper offers a summary of best practices and approaches for providing GAC in ED treatment settings. The use of GAC practices has the potential to address underlying issues and inequities in treatment delivery and outcomes. We encourage ED treatment providers to consider the adoption/adaptation of GAC best practices to more effectively meet the needs of TGE patients. More research is needed to better understand the influence of individual and collective GAC practices on specific ED treatment outcomes.

Clinical Implications

• This paper outlines guidelines and best practices for providing GAC for TGE individuals undergoing ED treatment in a multi-disciplinary setting by developing a comprehensive and multi-disciplinary GAC protocol.

• The protocol’s guidelines draw from existing research and experts with lived experience to outline the fundamental elements of GAC specific to ED treatment. They can serve as a roadmap and centralized resource for ED professionals.

• The use of GAC principles has the potential to standardize practices, facilitate a higher quality of care delivery, and improve clinical outcomes for TGE individuals.

Background

Eating disorders in transgender and gender expansive communities

Eating disorders (EDs) disproportionately impact transgender and gender-expansive (TGE) individuals. A recent report found that over half of TGE adults endorse a lifetime history of engaging in ED behaviors, and 28% meet diagnostic criteria for an ED (Uniacke et al., 2021). TGE individuals often endure high levels of bullying, discrimination, trauma, and abuse, and high rates of body dissatisfaction. Duffy et al. (2019) assessed suicidality in a large sample of college students and found that of the TGE students with past-year ED diagnoses, 75% reported past-year self-injury and suicidal ideation. Past-year suicide attempts were 24 times higher in TGE individuals with EDs relative to cisgender women with EDs, and 21 times higher in TGE individuals with EDs than TGE people without EDs (Duffy et al., 2019). Providing access to gender-affirming care (GAC) is endorsed as best practice across settings and is especially imperative in ED care given its protective influence on the intensity of gender dysphoria (Calzo et al., 2020), body satisfaction, ED symptoms severity (Testa et al., 2017; Uniacke et al., 2021) and suicidality.

Factors contributing to the development and maintenance of eating disorders in transgender and gender expansive individuals

There are several reasons TGE individuals may suffer from EDs in relation to their gender experiences. A growing body of research identifies stigma, discrimination, and body dissatisfaction as significant risk factors in developing ED behaviors for TGE individuals (Calzo et al., 2020). Transgender and gender-expansive youth may also engage in ED behaviors to delay or prevent the development of secondary sex characteristics during puberty or to shape their body to align more closely with their gender identity (Geilhufe et al., 2021). Other reasons for elevated ED risk include lack of access to gender-affirming healthcare providers, internalization of gendered body ideals, and heightened social stigma, particularly for TGE individuals who have more visibly nonconforming gender expressions (Galupo et al., 2021; Zamantakis & Lackey, 2021). Eating disorder behaviors may also serve as coping mechanisms for emotional distress and minority stress, the stress experienced by minoritized individuals due to discrimination, prejudice, and stigma (Geilhufe et al., 2021). This stress is further compounded for people with multiple marginalized identities, including TGE individuals who are disabled, fat, neurodivergent, and/or people of color (Geilhufe et al., 2021; Gordon et al., 2016). Threats to safety may also contribute to the onset and maintenance of ED behaviors. In one study assessing safety among TGE youth, participants reported concerns about increased bias and discrimination, violence against TGE people (including threats to personal safety), rollbacks of rights and supportive policies, safety in personal relationships, and the visibility of a marginalized identity (Veldhuis et al., 2018). Such concerns and exposure to state-sanctioned violence towards TGE individuals may also increase experiences of internalized transphobia and hopelessness (Tebbe et al., 2022), which may lead to disordered eating behaviors and must be considered in conceptualizing a plan for ED treatment.

Treatment experience for transgender and gender-expansive individuals

Transgender and gender-expansive individuals often report negative experiences with providers, fear of disclosing their gender identity, and ineffective or harmful treatment practices (Holt et al., 2023), and these negative experiences are especially pronounced for those who experience multiple marginalization (Agénor et al., 2022). Misgendering (using incorrect gender pronouns) and deadnaming (using a person’s birth-assigned name rather than asserted name) in medical records are common sources of distress for TGE individuals, and can also lead to lower healthcare utilization and avoidance of care (Alpert et al., 2022; Thompson, 2016). In a focus group led by Alpert et al. (2022) on TGE adults, following a review of their own records, all participants reported being misgendered and feeling subsequent feelings of “shame, embarrassment, frustration, anger, disappointment, and a sense of emotional exhaustion.” Participants reported that “misgendering in the EHR was common even by providers with whom they had built rapport, including providers who had used their name and pronouns correctly during the clinical encounter.” In a study of TGE young adults receiving ED treatment, 40% chose not to disclose their gender identity to their providers, and 19% of participants reported it being extremely difficult or impossible to find providers who specialized in both treating EDs and providing GAC, and none of the participants reported having a positive experience with ED treatment (Duffy et al., 2016). Additional reports of harmful ED treatment practices include inattention to structural barriers, exclusive ED stereotypes, the use of modalities that have not been adapted for TGE individuals, and inadequate gender literacy training for treatment providers (Hartman-Munick et al., 2021). A study on a large sample of TGE school-aged individuals found that 33% of respondents reported discrimination in healthcare settings within the past year alone, including providers refusing to use accurate name and pronouns and outright refusal of services due to TGE identity, and 50% of respondents reported having to teach their medical providers about TGE care (James et al., 2016). These data underscore the need for robust training and guidance for ED care providers (Ramos, 2021).

Influence of family support

Families are often active participants in the treatment of children and teens with EDs (Lock & Le Grange, 2015). Family members will have varying levels of support and acceptance along the journey of their child’s gender identity development, thus underscoring the importance of a GAC approach from both the treatment team and caregivers. The support of just one affirming family member has been shown to significantly reduce the risk of suicide and improve long-term mental health outcomes in TGE individuals (Malpas et al., 2022). Specific to ED behaviors, family rejection increases the odds of weight-control behaviors by 42% and binge eating by 22% (Paceley et al., 2023). As such, the inclusion of family in treatment and supporting family on the acceptance journey can be important for optimal treatment outcomes. Exploring the benefits of involving chosen family may also be helpful and more salient for TGE patients (Paceley et al., 2023).

Aims of this paper

While GAC guidelines exist across several professional organizations, such as the American Psychiatric Association, American Academy of Child & Adolescent Psychiatrists, and the American Academy of Pediatrics, little guidance is available that is specific to ED treatment professionals (Coleman et al., 2022; American Psychological Association, 2024; Adelson, 2012; Rafferty et al., 2018). Given the particularly unique ways in which gender identity and eating and body modification behaviors can intersect (Geilhufe et al., 2021), It is crucial to provide concurrent treatment of both gender distress and/or dysphoria and ED symptoms through collaboration with a team of providers with expertise in GAC. Solely addressing ED symptoms can not only be distressing for the patient but can also exacerbate co-occurring psychiatric issues and render treatment ineffective, particularly in cases in which the patient is experiencing gender dysphoria (Geilhufe et al., 2021). In the rapidly evolving field of gender care, updated resources are important for ensuring the well-being and affirmation of TGE individuals (Hellner et al., 2021).

This paper aims to describe one ED treatment program’s comprehensive approach to providing care to TGE individuals that is consistent with existing GAC guidelines and tailored specifically for ED care in a multidisciplinary setting. To strengthen and standardize the delivery of GAC, we decided to create a program-specific protocol—a collection of specific directives and instructions—to ensure that best practices in providing GAC, as well as knowledge specific to caring for TGE individuals with EDs, were applied consistently and reliably across many roles and professions working together in one treatment program. We hope to provide a replicable model for creating similar protocols in other large, multidisciplinary ED treatment settings. Our protocol combines evidence-based practices and subject matter experts’ experiences and centers a trauma-informed, holistic approach and sensitive communication strategies.

Protocol development process overview

Setting

This protocol was developed and designed for use within a virtual ED treatment program serving patients ages 6–24 years across the United States. This treatment program provides an enhanced version of family-based treatment. Members of the care team include therapists, dietitians, medical providers, and peer and family mentors. Peer mentors are individuals who have recovered from an ED and provide support directly to the patient. Family mentors are individuals who have supported their child through an ED and provide support directly to caregivers or other support persons involved in the patient’s treatment. Patients and/or caregivers typically meet with providers weekly. Other forms of support, including group therapy, may also be incorporated depending on patient needs. More details on this treatment approach and outcomes can be found elsewhere (Hellner et al., 2021; Steinberg et al., 2022).

Development process

The goal of creating a GAC protocol was to provide comprehensive instructions and recommendations for providers in all aspects of caring for and interacting with TGE patients. While many pre-existing practice guidelines are primarily written for clinicians, we also made the decision to include guidance for other support staff who have direct patient interactions (e.g., admission specialists and practice managers), with the hope of increasing non-clinical organizational competence and, consequently, patient experience. Protocol development was informed initially by a focused review of the literature. Search terms included the following: terminology, gender-affirming care, screening and assessment tools, safety considerations, best practices for charting and documentation, medical and nutrition considerations, social change in working with caregivers, and gender-affirming therapeutic modalities. Next, findings were synthesized and expanded to make them directly applicable to the treatment setting. The initial draft of the protocol was reviewed by three external stakeholders from the fields of medicine, nutrition, and psychotherapy, who all hold TGE identities. Next, internal stakeholders were identified to review the protocol and offer feedback. Internal stakeholder disciplines included psychiatry, medicine, dietetics, therapy, and experts by lived experience. Multiple rounds of revisions were performed to ensure that the protocol was relevant to a diversity of TGE experiences and aligned with the treatment program’s existing operating procedures.

Training and implementation

The implementation of our GAC protocol began with a series of direct communications and synchronous didactic training to the provider team at large, followed by discipline-specific training for therapists, dietitians, peer mentors, and family mentors. Separate training sessions were also held for the treatment program support staff. In addition, four optional consultation sessions were held for staff who had questions or were seeking additional support. It is important to mention that training in this ED-specific GAC protocol followed the completion of foundational training for all providers about gender identity, gender expression, and best practices for communication (e.g., use of pronouns, mirroring patient language).

Positionality

The first author led the research, development, and authorship process, and they describe themselves as transgender and intersex; they have training in program development through a public health framework, and their primary focus is gender-affirming ED care. The second author is a cisgender woman with training in public health epidemiology and dietetics and has extensive experience working with TGE individuals. The third author is a cisgender woman who has received extensive training in providing GAC and has direct experience providing ED care to TGE patients, along with expertise in treatment development.

Summary of protocol

The following section offers a summary of of the protocol such that it may be applied to other ED treatment settings.

Grounding principles & rationale

The protocol first summarizes the treatment program’s rationale and approach toward providing GAC in a series of grounding principles. These principles included the firm stance that gender care is a part of ED care, that our providers have a duty to uphold the safety of our TGE patients, and the importance of respectful, empathic, and non-judgmental patient communication. We suggest that any ED clinical care guidelines developed for serving TGE individuals begin with grounding principles to state the program’s approach to GAC and the alignment of GAC with organizational values. The protocol also provides a clear rationale for creating a protocol specifically for TGE patients with EDs. This rationale provides a summary of literature reviewed earlier in this paper on the connection between diverse gender identities and EDs, including the role that gender dysphoria may play in the development of disordered eating behaviors. It also summarizes relevant data on outcomes of TGE individuals with EDs and other areas of particular relevance to behavioral health care, such as rates of suicidality and self-harm. The goal of providing this summary and rationale is to ensure that all providers and support staff clearly understand the importance of providing GAC as part of ED treatment. Furthermore, it also enables providers and support staff to provide education to patients as part of clinical care.

Language and documentation

The protocol lays out policies and approaches to language and documentation practices. The protocol provides a list of specific language for providers to use in clinical interactions and documentation in TGE patient charts or about TGE issues, including a list of language that should not be used in documentation. The list also includes definitions and rationale for the selected language. These language guides were created based on recommendations that consistent usage of inclusive language is vital in creating a supportive environment for TGE individuals (Calzo et al., 2020). Terminology includes common gender identities along the gender spectrum (e.g., non-binary, gender-expansive) and common terminology associated with transition (e.g., gender dysphoria, gender expression.) Additionally, terminology distinguishes sex from gender as best practices include refraining from pairing gender with sex (e.g., non-binary individual rather than non-binary male) and refraining from using pronouns at all in charting but instead using the term “patient” or “client” (e.g., “Patient reports increased motivation for recovery.”; Calzo et al., 2020).

Language guidance also extends to gathering essential information about a patient’s physical, mental, and social well-being. Information gathering includes clinical interviews, screenings, assessments, and questionnaires. Thus, the protocol includes a review of all interview guides, screenings, assessments, and questionnaires. Modifications were made to interview, screening, assessment, and questionnaire materials to ensure that language is gender inclusive. For example, additions were made of open-ended response fields or changing question response options to allow multiple selections for demographic questions (“select all that apply”). These approaches allow for a more accurate understanding of a patient’s identities and experiences (Geilhufe et al., 2021). Particular attention was also paid to questions and lines of questioning that have been historically gendered. For example, questions about menstrual health were adapted to be preceded by a question of whether the patient has a uterus. If the patient does not have a uterus, skip logic is then used to bypass further questions about menstruation (Geilhufe et al., 2021). Care was also taken to ensure that screening and assessment tools validated among TGE populations were used, such as the Eating Disorder Examination Questionnaire Short Form (Duffy et al., 2021).

Clinical documentation—a gender care note

It is important to have a location and process for clear documentation of characteristics and aspects germane to a TGE patient’s identity and environment, particularly in the context of multidisciplinary care. A Gender Care Note was developed for use within electronic health records as an enclave for holding information on a given patient’s asserted gender identity, pronouns, asserted name, safety and privacy, environment and support system, and gender-affirming medical care. The Gender Care Note is meant to be completed during a provider’s initial meeting with a patient or by any other member of their treatment team shortly upon disclosure of TGE identity. The note is meant to be a ‘living document’ so that it can be amended to reflect changes in gender, care plan, or personal circumstances relevant to the patient’s gender identity.

One challenge of several ED treatment settings is the provision of care in multiple contexts—individual, family, and/or group. These multiple contexts can provide challenges to providing affirming care to patients who may not be open about their identities to their families or others in their community, including their treatment community. The Gender Care Note outlined in the GAC protocol allows providers to document the use of multiple pronouns (e.g., she/they or he/she/they) or changes in pronouns based on context. The Gender Care Note section of the protocol also provides a scripted prompt for providers, such as “Is there one of those pronouns you prefer me to use most of the time?”, “Are there different contexts where you use one pronoun over the other?”, “How do you let others know which pronoun they should use on a given day?”, “Are you planning to share your name and/or pronouns with peers?”, “How might staff support you if misgendering occurs?”, and “If we use your birth-assigned name and pronouns in certain situations such as family sessions, would you like to check in before and after to process how that feels and re-orient ourselves?”. The fields included in the Gender Care Note could easily be tailored to any treatment setting (Guss et al., 2019; Vincent, 2018). For example, for patients who may participate in family, individual, and group sessions, the note may include a section for pronouns to use in each of these sessions.

The Gender Care Note also provides space to clearly document with whom providers can share the patient’s gender identity and/or pronouns (e.g., family members, external providers, future referrals) as well as, conversely, anyone with whom the patient does not want their gender identity and/or pronouns disclosed. Again, prompts and scripts are included in the protocol to aid providers in explaining privacy limitations for those under legal guardianship for whom other parties may have access to medical records (Thompson, 2016). Relatedly, a Gender Care Note may include information about the patient’s environment and support system. Patients may identify any affirming relationships and significant non-affirming relationships. These questions also afford the provider an opportunity to evaluate access to affirming community or online resources, and thus identify potential support needs.

Documentation on any medical care that the patient is receiving or has received to affirm their gender identity is also documented in the Gender Care Note. This section of the note indicates whether the patient has accessed puberty blockers, gender-affirming hormone therapy, or is planning to have gender-affirming surgery while in care, as such interventions can be impacted by ED acuity and nutritional status. Information is collected regarding the name of the medication, dose, frequency, date initiated, and prescribing provider. For patients planning to have gender-affirming surgery, the note includes the type of procedure(s) and date of procedure(s). For patients who have already undergone gender-affirming surgery, information collected about procedures can inform medical care or treatment recommendations provided by the ED treatment team. For example, patients who have undergone an orchiectomy may merit closer attention to bone mass density.

Safety assessment

As part of the treatment program’s standard safety assessment, the GAC protocol also recommends that providers conduct an assessment of other threats to TGE patient safety, such as harassment, discrimination, and known risks to the patient’s safety within their community (Calzo et al., 2020). The protocol also guides providers in creating safety plans specific to these circumstances to mitigate or reduce potential harm to the patient. Additionally, for patients at risk for suicide, providers are guided to identify, in advance, safety and emergency resources that provide affirming care (Smith, 2023) or options if these services are not available. Providers must consider the safety of TGE patients when referring to emergency services or other organizations, such as child protective services (Estrada & Marksamer, 2006; McCormick et al., 2016; Winter, 2013). TGE patients can be at risk for direct harm by these organizations if their gender identity is disclosed without their permission and/or if they are multiply marginalized (Estrada & Marksamer, 2006; Winter, 2013). If a safety concern arises about the home environment and a provider is required to report to child protective services, providers should work with patients to make a plan related to the risks of disclosing pronouns and gender identity within systems of surveillance, as some systems may place youth at risk of being subjected to harmful treatment such as conversion therapy (Estrada & Marksamer, 2006). Risks may vary by location due to differing legal protections, and providers must be aware of laws in a TGE patient’s jurisdiction (Tebbe et al., 2022). Therefore, the GAC protocol includes an overview of relevant safety and legal considerations, with reminders that legal stipulations may be in flux. Living in geographic locations where the legal climate is hostile for TGE individuals is a risk factor for ED behaviors. As such, providers should be mindful of the need to help the patient cope with ongoing exposure to minority stress (Paceley et al., 2023). Providers are encouraged to seek consultation regarding any legal concerns.

The GAC protocol also provides specific directions for working with TGE patients who are at risk for suicide. As with others at risk for suicide, working with TGE patients at risk for suicide necessitates cultivating a sense of hopefulness and envisioning a life worth living (Austin & Craig, 2015). This intervention may be particularly important, though, for TGE individuals. Specific strategies for cultivating hopefulness for TGE individuals are included in the protocol, such as sharing stories of adult TGE people who are thriving, connecting the patient with TGE peers, validating trauma experienced by TGE individuals, exploring TGE survival and resilience narratives, and making a plan to alleviate suffering from dysphoria and any co-occurring mental health distress (Aitken et al., 2016; Peterson et al., 2016). Other specific circumstances reviewed in the GAC protocol include considerations around access to sharps for patients who are utilizing injectable gender-affirming hormone therapy or who need to tend to facial or body hair. Special arrangements may need to be made for the supervised use of items such as syringes and razors (Smith, 2012).

Guidance on working with families

An integral part of providing GAC may include working with a patient’s caregivers or other loved ones, as family acceptance has a favorable influence on depression, anxiety, and suicidality (Malpas et al., 2022; Matsuno & Israel, 2021). When it comes to issues of gender identity, providers are often well-positioned to educate the families of TGE patients and usher them toward a more affirming stance. However, many of our providers find that working with the families of TGE patients can be very challenging. Thus, the GAC protocol also includes a section providing education and guidance to providers on specific actions to take when working with non-affirming family members to help move them towards a more affirming stance. The protocol compiles and describes several strategies, such as the provision of psychoeducation (including an appendix of resources that providers can supply to families), responses to common myths and misconceptions around gender identity, and scripted examples of how to respond to common caregiver or family concerns, and listing the advantages of caregiver affirmation (Malpas et al., 2022; Matsuno & Israel, 2021). For example, if caregivers express concerns that their child is uncertain about their gender identity, the protocol recommends that providers respond by providing education to the caregivers about identity development and helping the caregivers reframe their child’s questioning of their gender identity as a normative part of identity development. The protocol also provides education on common caregiver emotions that arise when learning about or navigating a child’s gender identity exploration, including negative, neutral, and positive reactions such as grief, fear, loss, surprise, sadness, joy, relief, gratitude, and desire to support and advocate (Matsuno & Israel, 2021). Providers should also be versed in how to facilitate access to advocacy and educational programs on allyship, as exposure to those with shared experiences and connecting with peers may reduce feelings of isolation (Austin & Craig, 2015; Matsuno & Israel, 2021). Thus, the protocol also outlines steps providers can take to educate themselves and an appendix of resources that can be provided to families.

We acknowledge that the section above does not provide guidance based on developmental stages, as that is beyond the scope of this paper. We encourage readers to consult other articles in this special issue which focus explicitly on developmental considerations.

Medical & nutrition-related practices and considerations

In settings with multidisciplinary teams that include medical providers and/or dietitians, a GAC protocol should detail the unique aspects of medical and nutritional care for TGE patients. The medical and nutrition sections of the GAC protocol call attention to several specific and important considerations that medical providers and dietitians must attend to in their patient care with TGE individuals. These considerations include guidance around DEXA scans, side effects of gender-affirming hormone therapy, menstruation, holistic lab interpretation, and target weight assessment. For example, the use of puberty blockers and hormones has implications for lab interpretations, and may also increase the risks of bone loss (Ferguson et al., 2019; Riddle & Safer, 2022). Information is provided to medical providers and dietitians that review specific concerns that can arise in the context of EDs and have serious implications for TGE patients, such as the effects of malnutrition on hormone production, the resumption of menses and options for treatment, or the importance of adequate nutrition to facilitate the desired effects of gender-affirming hormone therapy. The goal of this information is to improve the care provided by the medical and nutrition teams as well as better enable these providers to discuss these concerns with their patients. Finally, the protocol highly recommended that teams work closely with GAC experts and/or have both awareness of and access to a comprehensive list of resources, such as Riddle and Safer (2022) or Riddle, Silverstein, and Wassener (2023), to provide more in-depth clinical guidance.

Care coordination/continuity of care

Finally, the GAC protocol also includes guidance to providers on coordinating care with outside providers or making referrals. Providers are offered explicit recommendations around evaluating the appropriateness and expertise of outside providers or treatment programs to ensure that referrals are safe for TGE individuals. For example, how does the referral treat co-occurring gender dysphoria? Are there gender-inclusive facilities? Are there TGE providers on staff? This section of the protocol was included because best practice guidelines suggest that providers learn how to identify and offer appropriate referrals to experienced gender care specialists.

Discussion

Implications for the field of LGBTQ+ health and body image/eating disorders

This paper outlines guidelines and best practices for providing GAC for TGE individuals undergoing ED treatment in a multi-disciplinary setting via the development of a comprehensive and multi-disciplinary GAC protocol. The protocol’s guidelines draw from existing research and experts with lived experience to outline the fundamental elements of GAC specific to ED treatment. They can serve as a roadmap and centralized resource for ED professionals. The use of GAC principles has the potential to standardize practices, facilitate a higher quality of care delivery, and improve clinical outcomes for TGE individuals.

Limitations

Perhaps the most significant hindrance encountered in developing a GAC protocol for ED treatment is the dearth of existing evidence-based resources. With an ever-shifting legislative climate, previous recommendations for GAC have become outdated, with few resources that capture nuances regarding patient safety and provider liability for GAC. There are no comprehensive best practices for medical management of EDs in TGE populations that account for non-binary biological realities—that is, sex traits that differ from male-typical or female-typical. Especially for non-binary persons, the existing research largely employs methods that eclipse lived experience. While we were able to adapt recommendations to be inclusive of non-binary experiences, there were few pre-existing recommendations. Existing literature on the benefits of GAC for binary transgender individuals tends to focus on linear pathways to resolve gender dysphoria. However, careful assessment of the function of ED behaviors is a meaningful component of care while avoiding assumptions that gender dysphoria is implicated in ED etiology or function (Galupo et al., 2021; Hartman-Munick et al., 2021). Non-binary individuals may experience this same process with greater complexity, as choices surrounding transition can feel like an inadequate compromise or accentuate concerns and feel like a “no-win” situation (Galupo et al., 2021).

Additionally, as development began with a focused literature review, it is possible that some relevant literature may have been excluded. However, in order to mitigate biases, both external and internal stakeholders were included in the development process. Importantly, limited perspectives were contributed from a lived experience of trans-femininity. Lastly, the authors suggest that any GAC practices are reviewed and revised at least annually to account for emerging research and changes to legislation that impact TGE individuals.

Closing remarks

This paper offers a framework for multidisciplinary ED care providers supporting TGE individuals. By integrating comprehensive GAC practices, we aim to create a more supportive and safe environment for all individuals exploring their gender identity. Future research is needed to assess the impacts of implementing GAC practices on provider behavior, patient experience, and clinical outcomes.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.