Monthly Archives: October 2015

Gender Identity Disorder and Anorexia Nervosa in Male Monozygotic Twins – Review

This is a fascinating study of identical twins; one had gender dysphoria and one did not. Both twins developed anorexia.

Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both had a difficult childhood with an abusive father.

Both twins were underweight at birth and needed intensive care. Both had developmental delays.

However, one twin considered himself to be a gay man while one identified as a straight woman.

In this case study, gender dysphoria did not cause the eating disorder.

This case highlights the importance of other factors in eating disorders, including genes, hormones, and trauma.

It raises the question; how important is gender identity as a cause of eating disorders?

This case is different from other case studies where gender dysphoria seems to be intimately linked to the eating disorder.

We can’t look at these two patients and conclude that gender dysphoria never contributes to eating disorders. However, this case is a good reminder to be cautious about drawing conclusions from other case studies. Perhaps there are just some people with eating disorders who also have gender dysphoria. Or perhaps there is some other factor which causes both eating disorders and gender dysphoria.

As always, we need more studies.

More about the Patients:

Eating Disorders

Twin A was diagnosed with AN-purging subtype and Twin B was diagnosed with AN-restricting subtype.

Twin B developed an eating disorder at an earlier age, but Twin A was more underweight and had a more disturbed perception of his body. Furthermore, Twin A was hospitalized for his eating disorder and Twin B was not.

Neither twin seems to have been able to maintain a healthy weight.

At age 16 Twin A “was admitted to a children’s hospital because of AN. Later, he was hospitalized in the psychiatric inpatient unit for adolescents. At first, his eating behavior was restrictive. Then he reported intermittent vomiting (AN binge-purge). His weight decreased to 46 kg/1.79 m (body mass index [BMI] ¼ 14.3 kg/m²). His ideal weight was 44 kg according to a BMI of 13.7 kg/m² , which shows his severe disturbance in body perception. During hospitalization, his behavior was sometimes aggressive. He was emotionally unstable, depressed, and was rarely able to engage in stable relationships. Despite strict dietary rules, he achieved a maximal weight of 55 kg (BMI ¼ 17.2 kg/m²). Soon after being discharged, his weight decreased again.”

Twin B’s eating disorder began at a younger age. “In puberty, he developed severe underweight. At the age of 13, he was 42 kg/1.58 m (BMI ¼ 16.8 kg/m² ). When he was referred to our outpatient unit at the age of 18½ years [for gender dysphoria], his weight was 48 kg and his height was 1.76 m (BMI ¼ 15.5 kg/m² ). He denied deliberate dieting, binging, or purging. Although he regarded himself as too slim, he did not manage to gain weight. Further medical checkups revealed no somatic cause for his underweight. An osteodensitometry yielded an osteopenia of the spine.”

Gender Identity

Twin A was a gender non-conforming gay male:

In childhood, he preferred girls’ games and toys (Barbie dolls) and was very close to his twin brother. His sexual feelings were always for males. Although he started cross-dressing at the age of about 16 years, his gender identification was always male. He considered himself to be a homosexual.”

Twin B was a trans woman:

“As far as he could remember, he had felt he was a girl, preferring girls as playmates and had started cross-dressing at nursery school. In gymnastic lessons, he refused to change with the other boys because he was ashamed of his body. Eventually, he refused to attend sports lessons at all. When he was 9 years old, he started to grow his hair. His class mates seemed to accept him as a girl. When he started to work as a hairdresser, he tried to correspond to the male gender role and did not cross-dress. However, at his professional school and in his free time, he continued to cross-dress. His employer, who realized he was transsexual, permitted and encouraged him to cross-dress at work, which consequently allowed him to live as a young woman. Sexually, he was always attracted to men. However, in contrast to his brother, he never considered himself to be homosexual and viewed this attraction as ‘‘heterosexual.’’ Until this point, he had not engaged in sexual relationships either with men or with women.”

Twin B requested hormonal and surgical sex reassignment.

Childhood

The twins grew up together in a small Swiss city without any other siblings. Their childhood was not easy:

“[Their father] was very authoritarian. He could not accept the sexual orientation and the cross-dressing of his sons and threatened them with assault and even with death.

…In family conflicts, [their mother] took a position between her husband and her sons. At a family consultation, she appeared emotionally unstable.”

Birth 

The birth was a difficult one. Both twins were underweight and spent time in intensive care.

“the mother had been admitted to a hospital with hypertension, edema, and proteinuria at 38 weeks of gestation. The vaginal delivery was induced because of maternal preeclampsia. Twin A weighed 2.17 kg at delivery and his Apgar score was 9/9/9. Because of perinatal acidosis and hypotonia, he was kept in the incubator for 3 days. He was diagnosed with a subependymal hemorrhage with ventricular invasion. Twin B’s birth weight at delivery was 1.95 kg and his Apgar score was 7/9/9. Both twins were admitted immediately to the neonatal intensive care unit.”

Developmental Delays

They both had developmental delays:

“In early childhood, Twin A showed a developmental delay in language and motor skills and had deficits in cognitive and verbal skills. He was socially isolated and his behavior was often aggressive.”

“…Twin B had delays in language and motor development during early childhood. He showed the typical symptoms of attention deficit and hyperactivity disorder. The parents refused further assessment and treatment.”

Other

Twin A was diagnosed with borderline personality disorder and subnormal verbal intelligence.

Twin B was diagnosed with gender dysphoria.

There is no obvious pattern to any of this. Twin A was larger at birth, but had more problems right after birth. Both had developmental delays, and Twin B may have had ADHD as well. Both were feminine in their behavior, but only Twin B developed gender dysphoria. Both were sexually attracted to men. Twin B developed an eating disorder earlier, but Twin A’s eating disorder seems more severe. Twin A has borderline personality disorder and Twin B does not.

Discussion

The authors offer two possible hypotheses about the twins’ gender identity.

Perhaps the twins are on a continuum of gender non-conformity where gender dysphoria is at the extreme end.

Alternatively, perhaps gender dysphoria* in childhood is inherited, but the later development of gender identity is determined by environmental factors and psychiatric comorbidity.

“In childhood, both Twin A and Twin B showed gender atypical behavior and stereotypical feminine traits and interests. In adolescence, their sexual orientation was revealed to be homosexual. Twin A developed effeminate homosexuality with male gender identity, whereas Twin B stabilized his cross-gender identity. Although Twins A and B are concordant for GID in childhood and sexual orientation on a categorical level, they are now discordant for TS. On a more dimensional level, one could argue that Twins A and B show an opposite sex-dimorphic behavior and that they arrived at different points of a continuum. The fact that GID in childhood is a predictor for later homosexuality and TS could support the dimensional view. It could be hypothesized that GID in childhood is mainly hereditary, whereas the development of the later phenotype of the gender identification is determined by environmental factors and psychiatric comorbidity, as any difference between MZ twins provides strong evidence for the role of environmental influences.”

The authors also discuss the relationship between gender and eating disorders. However, they don’t address the fact that the two twins had different gender identities, but both had eating disorders.

Perhaps both gay men and trans women are vulnerable to eating disorders for different reasons, but perhaps genes, hormones, and environment matter more than gender identity.

“Homosexual men seem to have an increased vulnerability to eating disturbance and body dissatisfaction (Williamson & Hartley, 1998), are more dissatisfied with their weight (French, Story, Remafedi, Resnick, & Blum, 1996), and are more concerned about their attractiveness (Siever, 1994). Male AN is associated with disturbed psychosexual and gender identity development, which supports the hypothesis that males with atypical gender role behavior have an increased risk of developing an ED (Fichter & Daser, 1987). Furthermore, feminine gender traits are discussed as a specific risk factor for ED in men and women (Meyer, Blissett, & Oldfield, 2001). Although the role of sexual orientation as a risk factor for ED is well documented, there is hardly any literature about GID and ED. For men with disturbance of gender identity in addition to the aforementioned factors concerning sexual orientation, underweight could be a way to suppress their libido and the expression of their secondary sexual characteristics and, at the same time, correspond to a female ideal of attractiveness (Hepp & Milos, 2002).”

We need more research!

“Further research in eating behavior and body dissatisfaction in patients with GID could provide more insight into the role of gender identity in the development of ED and lead to a better understanding of ED as well as GID.”

 

* In this case, gender non-conformity might be a more fitting phrase. Twin A does not seem to have ever wanted to be a girl.

 

Original Source:

Gender Identity Disorder and Anorexia Nervosa in Male Monozygotic Twins by Urs Hepp, Gabriella Milos, and Hellmuth Braun-Scharm in Int J Eat Disord. 2004 Mar;35(2):239-43.

 

Quote of the Day

“Humiliation is a whip of the defenders of gender. Humiliation is sanctioned at virtually every level of the culture: people can laugh at a transgendered person; but when there’s no fear of being humiliated for one’s portrayal of gender, there’s less opportunity of the culture to exert control.”

from Gender Outlaw by Kate Bornstein, page 88.

Review of: Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned

Another case where gender identity is linked to an eating disorder, this time in a trans man (born female).

And, another case where transition did not cure the eating disorder.

In this case a teenager who was being treated for his eating disorder requested therapy for gender dysphoria. His weight had already been restored, although he was still getting therapy for the eating disorder.

After counseling for gender dysphoria, the patient took testosterone and openly identified as a man. His anxiety improved, he had more friends, and he had his first girlfriend. Five months later, he had a bilateral mastectomy.

Ten months after surgery, the patient returned to the eating clinic for help. He said that his relapse began after his surgery and got worse when he returned to normal activity.

It is important to note that six months after surgery, the patient’s weight was normal and he felt better about his appearance. However, his eating patterns do not seem to have been discussed.

The patient had not continued counseling after surgery.

There are not many details on the patient’s gender dysphoria in this case study, but there does seem to be a connection between his eating disorder and his gender dysphoria. The patient “disclosed to his family that he felt like ‘a boy in a girl’s body’ and later acknowledged that his eating disorder was related to a desire to get rid of feminine features—’I dislike my curves, my breasts, my hips, my face. I wish I had more defined muscles in my arms and a more angular face.'”

It is worth noting, however, that the patient had two cousins with eating disorders. Genetics and environment were probably also factors in his eating disorder.

The authors make a number of important points about this case in their discussion.

We don’t know if medical transition helps with eating disorders.

“Studies show that medical interventions, including both hormone therapy and surgery, improve gender dysphoria. Their effects on disordered eating in patients with gender dysphoria, however, are less clear.”

On the one hand, in one qualitative study, a trans man who had had breast reduction surgery said it helped with his eating issues. In addition, another study found that patients who had had gender reassignment surgery had less body uneasiness than patients who had not or patients with eating disorders. It is not clear to me that this last study is relevant to patients with both gender dysphoria and eating disorders.

On the other hand,

“In our patient, although he experienced considerable improvement in body image, anxiety, and social functioning following treatment for gender dysphoria, he experienced a relapse in eating disorder behaviors postoperatively. Other case reports in adults describe similar relapses in disordered eating following medical treatment for gender dysphoria.* These cases suggest that, while GCS and other medical interventions often reduce psychological distress related to gender dysphoria, additional therapies may be required to ensure long-term resolution of disordered eating. Eating disorders have high rates of chronicity as well as relapse, particularly during periods of stress and life change. It is therefore crucial to engage all patients with gender dysphoria, regardless of their stage in treatment, in open conversations about eating patterns, body image, and thought processes.”

Urgent needs have to be taken care of first.

Treatment for patients with both eating disorders and gender dysphoria needs to be integrated and hierarchical; life threatening issues have top priority. In other words, you may have to eat before you can transition.

“Eating disorder treatment is complex given the combination of medical, psychological, and nutritional needs. Patients with gender dysphoria also have distinct needs related to gender incongruity. Using a hierarchical approach is one method to help focus therapy and ensure that all needs receive attention when appropriate. Life-threatening issues, such as vital sign instability from nutritional insufficiency or suicidality, should have first priority. These issues frequently require hospitalization to initiate nutritional rehabilitation and psychiatric care in a monitored environment. Following medical and psychiatric stabilization, weight restoration can often continue in the outpatient setting with multidisciplinary support from physicians, therapists, dietitians, and when possible, family members. Throughout treatment, the eating disorder team should strive to create a safe environment for the patient to explore the sources of his or her disordered eating, providing the opportunity to recognize or reveal any underlying issues. For patients with known gender dysphoria, the eating disorder team can assist by affirming the patient’s gender identity, allowing him or her to explore different options for expressing that identity, and providing resources for specialized care.”

Trans men’s eating disorders may look different from the norm.

Trans men may have different goals from other patients with eating disorders; patients with anorexia typically wish to be thin. Trans men may be trying to eliminate their period or reduce their curves as in this case and in this Turkish case study. The trans man in this study did not care about his weight, but was very dissatisfied with his body. It is important that these patients’ eating disorders not be missed because they are atypical. As the authors say,

“While the goals of weight loss in MtF patients often align with those of cisgender eating disorder patients, the goals of weight loss in FtM patients often diverge from those of cisgender patients, potentially limiting the utility of current eating disorder questionnaires in this population.”

We need to keep track of eating disorders after transition.

We can’t assume that a patient with an eating disorder will be fine after they are treated for their gender dysphoria. Treatment for the eating disorder needs to be ongoing.

“While improvement in gender dysphoria may lead to some improvement in eating pathology, many patients may benefit from additional support from an eating disorder team, as found for our patient. Further research should explore the success of different types of eating disorder treatment in adolescents with gender dysphoria before, during, and after gender dysphoria treatment.”

Not everyone needs the same treatment for gender dysphoria.

“Treatment for gender dysphoria varies from person to person. For some individuals, dysphoria can be alleviated through psychotherapy alone or combined with non-medical changes in gender expression. For many, gender dysphoria requires hormone therapy, surgery, or both. Adolescents who desire medical treatment later in life can use hormonal treatments to suppress or delay puberty. The Standards of Care of the World Professional Association for Transgender Health, however, recommends delaying suppression until the adolescent has reached at least Tanner Stage 2, so that he or she has some experience of his or her assigned sex. Hormone therapy to feminize or masculinize the body can also be started during adolescence, although this therapy should only be used in patients who demonstrate long-lasting or intense gender dysphoria, as the effects are only partially reversible. Surgery, on the other hand, may only be pursued once the patient reaches the age of majority for his or her country. For our patient, hormone therapy began at age 18 years, 10 months after expressing symptoms of gender dysphoria, and mastectomy was performed at age 19 years.”

Comparing eating disorders in transgender teens and adults

The authors also discuss the timeline of this case – i.e. gender dysphoria was diagnosed after the eating disorder. They contrast this with case reports of adults where an eating disorder developed during or after “assuming a transgender identity.” They add that “the only other case report available on adolescent patients describes a similar progression [to this study], with both patients initially presenting with AN and later expressing themselves as transgender.” 

Therefore, they suggest that “disordered eating may be the presenting symptom in some adolescents with gender dysphoria, highlighting the benefit of addressing gender identity in young patients with eating disorders. Gender identity may be addressed either using an intake form or during the patient interview.” (see below)

The situation is a little more complicated. In fact, in this case study a teenager developed an eating disorder when she decided to live as a woman. In addition, this study of an adult mentions that her eating disorder began at age 15 when she decided to live as a woman.

So we have two cases of teenagers who decided to live as women and then developed eating disorders and three cases of teenagers who were diagnosed with gender dysphoria during treatment for eating disorders. We don’t have enough cases to come to any real conclusions about the development of eating disorders and gender dysphoria in teenagers.

In any case, it may be that interviewing teenagers when they enter treatment for eating disorders will not lead to a diagnosis of gender dysphoria. In this case study, one of the teenagers was clear at the beginning of treatment that he was a gay man and did not want to be a woman. His gender dysphoria developed during the treatment of his eating disorder.

As always, we need more research. So far we have case studies of 17 patients. The individual cases vary widely and it’s unclear exactly how gender dysphoria and eating disorders are linked. It does not seem that treating gender dysphoria cures eating disorders, however.

This newest case study demonstrates that transition for gender dysphoria does not cure an eating disorder. It points to a connection between the eating disorder and the desire to be a man, but it also points to a possible contribution from genetic and environmental factors.

Original Source:

Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned by Strandjord SE, Ng H, Rome ES in Int J Eat Disord. 2015 Nov;48(7):942-5.

 

*In this case study, one of the trans women had an eating disorder in adolescence that returned many years later after surgery. In this case study, one of the trans women had transitioned but was still severely underweight – although the authors did not seem to think she had an eating disorder. Finally, in this case study, a trans man developed an eating disorder after surgery. He had not had an eating disorder previously.

In addition, there are a number of case studies where patients had eating disorders, although they were on hormones and had socially transitioned.

 

More details from the case study:

The patient had been seeing doctors for a couple of years before he brought up his gender issues.

At age 16 the patient was not getting his period, but his weight was normal and he said he had no body image concerns. The doctors prescribed oral contraceptives.

“The patient returned a year later with 2.3 kg of weight loss, resulting in a body mass index (BMI) of 16.9 kg/m2 (81% expected body weight for females of the same age). CS acknowledged daily exercise and a ‘desire for a different body shape,’ with a ‘more toned and muscular’ appearance. The patient denied food restriction, purging behaviors, or body image distortion and committed to increasing caloric intake to gain weight. Gender identity was not discussed and no treatment was pursued after this visit.

Five months later, CS presented with an additional 4.5 kg weight loss, resulting in a BMI of 14.9 kg/m2 (70% expected body weight). The patient then admitted to food restriction as well as a fear of gaining weight, leading to a diagnosis of anorexia nervosa (AN). The clinician did not inquire about underlying motivations for weight loss beyond general body dissatisfaction and anxiety.

There was no significant medical, psychiatric, or surgical history at the time of diagnosis. Family history included two cousins with eating disorders (specific diagnoses unknown). Socially, the patient was a high-achieving student with few peer relationships and no high-risk behaviors.”

At this point, the patient began 9 months of outpatient family-based therapy for anorexia. Four months into this treatment, he requested therapy for gender dysphoria. “He began biweekly individual psychotherapy to explore his gender identity and cognitive behavioral therapy to address ongoing anxiety.”

Ten months later he started to take testosterone and five months after that he had surgery to remove his breasts at age 19.

Medical treatment for gender dysphoria helped the patient significantly with his anxiety. He began to live as a man, expanded his peer relationships, and had his first romantic relationship with a woman.

His weight was stable for six months after surgery and he was more satisfied with his body, but the follow-up does not seem to have included any discussion of his eating (“a detailed discussion of his eating patterns and cognitions was not documented”).

He returned to the clinic four months later to deal with restrictive eating and excessive exercise. His body weight had decreased and his BMI had dropped from 19 kg/m2  to 17.9 kg/m2. He explained that “his relapse began postoperatively due to exercise restrictions and school-related stress, with his behaviors intensifying when he returned to normal activity.”

More details on interviewing patients about gender

The authors offer these sample approaches:

Sample approach on an intake form.
Use a two-step approach to identify both assigned sex and current gender identity.
Assigned sex at birth:
What sex were you assigned at birth, on your original birth certificate? (check one)
□ Male
□ Female
Current gender identity:
How do you describe yourself? (check one)
□ Male
□ Female
□ Transgender
□ Do not identify as male, female, or transgender
Sample approach in an interview.
Frame discussion with an opening statement.
“Because many people are affected by gender issues, I ask all patients if they have any concerns in this area. As with the rest of the visit, what you say will be kept strictly confidential.”
Begin discussion with a broad question(s).
“What questions or concerns do you have about gender, sexuality, or sexual orientation (who you are attracted to)?”
“How do you define your gender?”
“Have you been exploring gender?”

Sample intake form from:

Reisner SL, Conron KJ, Tardiff LA, Jarvi S, Gordon AR, Austin SB. Monitoring the health of transgender and other gender minority populations: Validity of natal sex and gender identity survey items in a U.S. national cohort of young adults. BMC Public Health2014; 14:1224. 

Sample approach for an interview from:

Makadon HJ. Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleve Clin J Med 2011; 78:220224

Transsexualism and Anorexia Nervosa: A Case Report – Review

This is a somewhat surprising case report of a trans man (born female) who developed anorexia nervosa after sex reassignment surgery.

The 24-year-old patient had surgery to remove his breasts, ovaries, and uterus. Afterwards he began binging and purging. He had not had problems with eating behaviors or weight loss before surgery.

This case is similar to the trans woman (born male) in this study who began to diet excessively after sex reassignment surgery. It is, however, different from this trans man who stopped dieting once he was on hormones and menstruation ceased.

The authors suggest that the eating disorder is an “expression of a gender identity process, or a conflict of an acceptance of one’s own sexuality.”

It is easy to understand why someone with gender dysphoria might dislike their body and develop problems eating, but in this case, the patient had already changed his body.

Why did the eating disorder develop after physical transition was complete?

Had he been focused on changing his body with hormones and surgery and then when he was done, he focused on his shape?

Was his eating disorder a sign of persistent body dissatisfaction no matter what he did?

The authors suggest that the patient’s underlying problems may have caused the eating disorder:

“In this case, there was clearly a linkage between a lack of sense in self-efficacy and a body dissatisfaction that continued after the sex change surgery. Discomfort with her/his own body appeared to be more deeply anchored than just being rooted in the wish to change the physical appearance.”

Alternatively, might the surgery have caused an abrupt shift in hormones that led to an eating disorder? More importantly, could adjusting his hormones help him recover from the eating disorder?

We think of testosterone and estrogen as sex hormones, but they are much more than that. Like all hormones, they are part of a complex system of chemicals that affect each other. Specifically, we know that “sex” hormones also play a role in appetite.

“The sex hormones estrogen, progesterone and androgens are involved in the complex regulation of appetite, eating and energy metabolism. In most species, including man, food intake and reproductive functions are closely linked. Thus, during the different hormonal phases of the menstrual cycle daily food intake varies and, moreover, remarkable physiological adaptations of appetite and body composition occur during pregnancy and lactation. In addition, regulation of eating behaviour and metabolic functions by sex hormones is of considerable general importance for women’s health, as indicated by the disturbances in this regulation associated with a number of clinical disorders.”

From “Sex hormones, appetite and eating behaviour in women.”

In this case study, the patient’s estrogen levels would have dropped significantly after his ovaries were removed. In addition, doctors normally reduce the dose of testosterone after surgery, although to a level typical for a man.

Women eat less during the phase of the menstrual cycle when estrogen levels are high, so it is possible that a drop in estrogen levels would be connected to eating more.

Furthermore, bulimia may be connected with polycystic ovary syndrome (PCOS), a syndrome which is characterized by elevated androgen levels.

Testosterone stimulates appetite and high circulating levels of this androgen in women have been associated with impaired impulse control, irritability and depression, i.e., common features of women with bulimia. Accordingly, it has been proposed that elevated levels of androgens may promote bulimic behaviour by influencing craving for food and/or impulse control. Hypothetically, bulimia may, in some cases, have a hormonal, rather than a psychiatric etiology, a suggestion supported by the observation that antiandrogenic treatment reduces bulimic behaviour. This may turn out to be a novel and valuable approach to treating women with BN, particularly those with hyperandrogenic symptoms.

From “Sex hormones, appetite and eating behaviour in women.”

The patient in this case study had symptoms that are typical of bulimia, binging and purging. Perhaps in his case the bulimia was related to the sudden drop in estrogen after surgery coupled with male levels of testosterone.

Most people do not develop eating disorders after sex reassignment surgery. There would have to be other factors involved, possibly genetic or psychological.

We have very little data on eating disorders and gender dysphoria, just a set of case studies.

However, we now have two cases of trans people developing an eating disorder after having surgeries that would have changed their hormones.

In one case, a trans woman began restricting her eating after surgery; in her case the surgery would have decreased her testosterone levels and thus, possibly decreased her appetite.

In this case, a trans man began binging and purging after surgery which would have decreased his estrogen levels and thus, possibly increased his appetite.

We need more research into this question. Do changes in hormones trigger eating disorders in some trans people? Most of all, can we use this to find a way to help trans people with eating disorders?

 

Original Source:

Transsexualism and Anorexia Nervosa: A Case Report by Fernando FernÁndez-Aranda, Josep Maria Peri, Victor Navarro, Anna BadÍa-Casanovas, Vicente TurOacuten-Gil,& Julio Vallejo-ruiloba in Eating Disorders: The Journal of Treatment and Prevention, Volume 8, Issue 1, 2000 pages 63-66.

 

More details on the patient:

After surgery, the patient had “2-4 weekly binge episodes with daily vomiting and abuse of laxatives and diuretics.”

He was overly concerned with being fat and wished to be thinner so his body shape wouldn’t look female.

He was moderately underweight, but then “during the last six months, he lost more than 15 kg [33 pounds] of body weight through restricting food intake.”

The Eating Attitudes Test, Eating Disorders Inventory, Body Attitudes Test, and Body Shape Questionairre showed “severe eating pathology and negative body experience.”

The patient also had problems with alcohol and drug abuse, self-mutilation, and suicide attempts, but these had begun at age 17.  He was diagnosed with “gender identity disorder, alcohol dependence, anorexia nervosa (purging subtype), major depression (Axis I), and borderline personality disorder (Axis II).

The patient’s father had obsessive-compulsive disorder and one of his sisters had an affective disorder.

As a child, the patient felt like a boy, didn’t play with girls, tried to hide any feminine parts of his silhouette, and hated feminine features of his body.

Review – Anorexia Nervosa and Gender Identity Disorder in Biologic Males: A Report of Two Cases

Two more case histories of trans women (born male) with eating disorders, this time from the United Kingdom.

There are many more case studies of trans women (born male) with eating disorders than trans men (born female). This may mean that trans women are more likely to have eating disorders than trans men.

Alternatively, it might mean that therapists are more likely to write case studies about trans women with eating disorders.* It may be that therapists are more surprised to find patients who were born male with eating disorders because eating disorders are rare in males. It might also be that therapists are interested in trans women with eating disorders because these cases support the theory that femininity and female socialization contribute to eating disorders.

We need more research on the prevalence of eating disorders among people with gender dysphoria.

Back to the case reports. As with other cases, each one is a little different from all the others.

In the first case the patient had a long-standing eating disorder that was clearly linked to her gender dysphoria. She also had had a difficult childhood and was depressed. The patient had to be hospitalized twice for her eating disorder, but was eventually able to maintain a normal weight. She was referred to a gender identity clinic.

The second patient described anorexia as “providing an escape from emotional pain, confusion, and dissatisfaction with [her] life,” although she also wanted a more feminine physique. She eventually suggested that she could not resolve her eating disorder and depression until she dealt with her gender dysphoria. She was referred to a clinic and transitioned.

This is where it gets confusing. After surgery, she felt complete and normal and her mood stabilized. In terms of the eating disorder:

Although she remains underweight (weight 52.4 kg, BMI 16.2 kg/m²), she now feels more satisfied with her body shape. Her only current concern in terms of body image is that her breasts are too small.

The authors believe that she is doing well. However, a BMI under 16 is dangerously thin and her BMI is only 16.2.  Furthermore, she weighed 20 pounds more when she started treatment for her eating disorder than she did after transition.

Her gender dysphoria has been resolved, but I am not sure about her eating disorder. A BMI below 17.5 may be a sign of anorexia. You cannot diagnose anorexia without more information, but her low weight is a red flag.

So, we have two more cases where an eating disorder was linked to gender dysphoria. In one case, the patient was treated for her eating disorder in the hospital and was eventually able to maintain a normal weight. In the other case, the patient decided she needed to deal with her gender dysphoria in order to cure her eating disorder; it is unclear if this approach worked.

There are three cases of trans women who transitioned and still had eating disorders, described in this study and this study. In one case, the trans woman had an eating disorder as a teenager and it returned years later after she had sex reassignment surgery.

In this study and this one, the young patients’ eating disorders were treated without transition. However, in this study the use of blockers helped a young trans woman recover from her eating disorder. Finally, this trans man’s eating disorder was cured by transition.

These are, of course, case studies so we can not draw broad conclusions from them. Case studies bring home the individual nature of each patient’s history.

More details about Patient 1:

The first patient had a long-standing eating disorder.

“His** symptoms included a desire to be thin, distorted body image, fear of fatness, self-induced vomiting, and laxative abuse. He attributed his desire for thinness to a wish to attain a more feminine physique. The onset of his eating disorder was associated with the development of depressive symptoms, which he attributed to the fact that he could not be a woman.”

Her eating disorder was very severe with marked dietary restriction, frequent vomiting, extreme laxative use, and exercising. Her BMI was 17.0 kg/m². She was involved in internet chat rooms related to eating disorders. She was depressed, she lacked energy, she couldn’t sleep, and she couldn’t concentrate.

Her eating disorder did not begin when she decided to live as a woman as it did for the patients in this studythis studythis study, and one of the patients in this study. However, it seems to have begun at the same time as depression related to her gender, so her eating disorder is closely linked to her gender dysphoria.

She had had a difficult childhood and could not remember much of it.

“…as a child he had felt isolated from his family and peers and was shown little affection by his mother. His mother had wanted a daughter and he felt that he might have received more affection as a girl. His father, who was described as stern and authoritarian, died when he was 15 years old.”

She had been bullied at school.

She “took the female role in play” as a child and had cross-dressed starting at age 6 or 7. “During adolescence and early adulthood, he attempted to prove his masculinity by drinking heavily and becoming involved in football-related violence. However, he never felt comfortable with a male identity. He subsequently developed strong religious beliefs, which conflicted with his wish to be female and resulted in powerful feelings of guilt. These beliefs also prevented him from contemplating gender reassignment surgery. He has had one short-term heterosexual relationship. His sexual fantasies are directed towards men but take the form of being treated like a woman rather than being clearly homosexual.”

The patient requested hospitalization for her eating disorder. She gained weight well, but she began to self-harm and think about suicide.

Her treatment involved therapy that seemed to help her.

“Within individual psychotherapy, he explored issues of masculinity and maternal neglect. He appeared to experience the hospital as providing the nurturing that he had lacked as a child. It became clear that his motivation for weight loss reflected a need for a sense of internal control and clarity in the face of a confused identity. In addition, he felt that he was attempting to starve the masculine part of himself.”

She reached a normal weight, but when she left the hospital, she relapsed and had to be readmitted.

However, at the time of the case report, she was maintaining a normal weight and had been referred to a gender clinic.

The treatment of her eating disorder included therapy around her childhood trauma and her gender issues. Transition was not part of the treatment for her eating disorder, however, it may be that the referral helped her to maintain her normal weight. The timing of the events is unclear from the article.

More details on Patient 2:

The second patient had been restricting her eating for the past 13 years, since she was 28. She had “a marked preoccupation with shape, including a desire to have a more feminine physique.” Her BMI was 18.8 kg/m², which would be just within the range for normal weight.

She had had a happy and caring home life and was close to her parents who she still lived with.

However, “from the time he started school, Patient 2 felt that he did not fit into the male gender. At school, he was bullied for being passive and sensitive. He had no friends and felt he had more in common with girls than boys. He had difficulty with some subjects at school. As an adult, he was diagnosed as dyslexic but this was not recognized in childhood. He completed a qualification in electronic engineering and worked for many years as an engineer. He denied sexual feelings of any sort and has never had a sexual relationship.”

She had been referred for psychological problems seven years ago and had raised the issue of her gender dysphoria then. She was given anti-depressants, but felt that her gender issues had been ignored.

Her eating disorder did not begin when she decided to live as a woman as it did in some other cases. However, she may have been trying to look more feminine.

She began outpatient counseling for her eating disorder.

“He described AN as providing anorexia as a an escape from emotional pain, confusion, and dissatisfaction with his life. He eventually expressed his belief that his AN and depression would not resolve until his concerns regarding gender identity were addressed. He was subsequently referred to a gender identity clinic.”

As I said above, this is where it gets confusing. She transitioned and was happier, but she was even more underweight than when she began treatment. Has she truly recovered from her eating disorder or not?

“After living as a female for 2 years, he underwent gender reassignment surgery. Since the surgery, she describes herself as feeling complete and normal. Her self-confidence has increased and she feels more at ease with herself. Her mood has stabilized. Although she remains underweight (weight 52.4 kg, BMI 16.2 kg/m² ), she now feels more satisfied with her body shape. Her only current concern in terms of body image is that her breasts are too small. She has completed professional training in counseling and adult education in the female role. Although she feels the need to be in a relationship, she has no desire for a sexual relationship.”

Comparing the Two Cases

The authors conclude by comparing the two patients. In both cases the desire for thinness was associated with wanting to look feminine. In addition both patients had educational differences.

However, in the first case, “significant emotional deprivation” as a child may have made her problems more severe and harder to treat.

“This difference seems to have been reflected in the clinical presentation and response to treatment. Patient 2 was able to make good use of outpatient psychotherapy and subsequently showed a good response to gender reassignment surgery. Patient 1, by contrast, had a complicated clinical course and required inpatient treatment on two occasions. In his case, GID was associated with disturbed early relationships and a global disturbance of identity which was not restricted to gender.

We suggest that GID in Patient 1 may have had its origins in early psychological development. We speculate that, in his case, the issue of gender identify may have served to express more complex issues of personal identity. GID, like AN, may have provided the patient with a sense of structure in a chaotic internal world. Patient 2, however, may be thought of as having a more ‘‘biologic’’ form of GID, which accounts for the successful response to gender reassignment surgery. Furthermore, the lack of major personality disturbance in her case enabled her to be treated as an outpatient.”

The author conclude by suggesting that clinicians look at issues of gender identity whenever they have male patients with eating disorders.

 

Original Source:

Anorexia Nervosa and Gender Identity Disorder in Biologic Males: A Report of Two Cases by Winston AP, Acharya S, Chaudhuri S, Fellowes L. in Int J Eat Disord. 2004 Jul;36(1):109-13.

 

*For more on the difficulties of using case studies for research, see my review of Gender Identity Disorder in Twins: A Review of the Case Report Literature.

** The authors of the article refer to the trans women as “he” until they transition.

Gender Identity Disorder and Eating Disorders – a Review

Three more case reports, three different stories. In each case gender dysphoria is related to the eating disorder, but in each case the relationship is different.

In the first case a trans woman (born male) had an eating disorder in adolescence. After sex reassignment surgery, her eating disorder returned.

In the second case, a trans woman developed an eating disorder when she decided to come out and live as a woman. At the time of the case report, she was on hormones and awaiting surgery.

In the third case, a trans man (born female) who had been living as a man had had long periods of being underweight and not menstruating. He denied dieting or caring about his weight, but he was very dissatisfied with his body. He was purging. Unfortunately, he also had alcoholism and had developed liver disease; he was therefore unable to take hormones.

There is no clear relationship here between transition and eating disorders. In one case, transition made the eating disorder worse. In another deciding to transition was linked to the eating disorder, but taking hormones did not cure the eating disorder.

These are, of course, case studies of only three individuals, so we can not draw any conclusions from them. As with other case studies, it seems that each individual is different.

However, for one of the patients, her eating disorder seems to have started when she decided to live as a woman, like the patients in this studythis study and this one. For some trans women, at least eating disorders are linked to gender dysphoria.

In the case of the trans man, his eating disorder went untreated for many years, like the trans man in this case study.

These cases are from a Swiss hospital program for gender identity disorder.

Case 1 – Trans Woman’s Eating Disorder Returns After Surgery

In early childhood, the patient was gender non-conforming and felt that she was a girl. As a teenager, she felt a deep aversion to her genitals and the development of secondary sex characteristics. She avoided swimming because she was ashamed of her body.

In adolescence, the patient was dissatisfied with her body and dieted until she was underweight (BMI=16.9 kg/m²). She held the weight for several months.

She cross-dressed “moderately” starting at age 20. She was distressed during her compulsory military service. She lived with a woman and later married, but was not very interested in sex. Her marriage only lasted 1½ years and after the divorce she decided to transition.

At age 36 she began taking hormones. Sixteen months later she had sex reassignment surgery and her eating disorder returned:

After the operation she again showed an increasing preoccupation with her body weight and shape. Her eating behavior was again restrictive. She still avoids highly caloric food and warm meals. Although her actual BMI is 20.0 kg/m²she feels too fat and seeks an ‘ideal’ body shape. After the first operation there were some complications and she had to undergo several re-operations. She herself wanted an augmentation of her breasts and is considering further cosmetic operations, which can be interpreted as persistent body dissatisfaction. She engages in excessive sporting activity and has repeatedly had minor injuries partly provoked by taking higher risks.

It is not clear why the eating disorder would return after she had surgery. By the time she had surgery, she had been living as a woman for a few years and taking hormones for over a year.*

Did the change in hormones after surgery affect her eating disorder? After surgery, her testosterone levels would have been lower than most cis women’s and low testosterone is linked to eating disorders in both men and women. In addition, for some women, higher levels of estrogen are linked to eating disorders.

Alternatively, did the complications of her surgery trigger a desire to control her body? Or had she been focused on changing her body with hormones and surgery and then when she was done, she focused on her weight? Or was her eating disorder a sign of persistent body dissatisfaction no matter what she did?

Case 2 – Trans Woman Develops Eating Disorder When She Transitions

The second patient had identified as a girl and felt like an outcast since early childhood. Her teachers did not allow her to play with girls’ toys. She started secretly cross-dressing in elementary school. She was suicidal at age 10 and said she wanted to live as a girl.

The physical changes of puberty were very distressing to the patient. She was attracted to men, but did not have any sexual relationships because she was afraid and because she did not want people to think that she was gay.

The patient attempted suicide at age 20 because of her gender dysphoria. After the suicide attempt, she got psychiatric therapy and decided to come out as a woman. She started to dress as a woman in public.

This is when the eating disorder began:

“Before his** coming-out, his body weight was 120 kg and his height was 1.97 m (BMI30.9 kg/m²). After the suicide attempt he started dieting and lost 40 kg of weight within 2 years. The minimal weight was 80 kg (BMI: 20.6 kg/m²). The eating behavior at the beginning was dietary restriction, followed by purging, binge-eating, and self-inducevomiting. He consumed anorectic medication and engaged in excessive sporting activities. The decision to come-out went hand-in-hand with the ambition to attain a more feminine shape by losing weight. He is convinced that his acceptance as a female would depend greatly on an ideal body shape. The patient is currently under hormonal treatment and the surgical reassignment will soon take place.”

Deciding to transition caused this patient to develop an eating disorder as she tried to change her shape. Socially transitioning and taking hormones did not cure her eating disorder.

Case 3 – Trans Man with a Long-standing Eating Disorder

This is a very depressing case.

The patient preferred boys’ games growing up and felt he belonged with the boys. At age 6 he was sent to the school counselor because he refused to play with girls. His breasts caused him distress, but he did not bind them or self-mutilate. He got his period at age 14, but had secondary amenorrhea (no period for six months or more) for many years.

He was attracted to females and had had only female partners. His partners accepted him as male.

He had been living “in the male role” for over 20 years, but had never had any medical treatments for his gender dysphoria. He had refused to take estrogen for his amenorrhea, however.

The patient was underweight when he came to the gender identity clinic and he had been very underweight in the past.

Her** minimal weight at the age of 40 was 33 kg (BMI: 13.5 kg/m²).*** She reported longlasting periods of underweight accompanied by amenorrhea. She denied ever having intended to diet deliberately. She reported no binge-eating or self-induced vomiting, but she was purging. She denied preoccupation with her weight but reported a strong body dissatisfaction.

The authors could not treat her with hormones, however, because of “severe liver disease and the psychic instability and alcohol dependence.”

Although the patient denied it, it might be that he was keeping his weight down in order to avoid having periods.

Social transition did not help this patient with his eating disorder. We can’t know whether or not hormones would have helped him since he was medically unable to take them.

Gender dysphoria is clearly linked to the eating disorders of the two trans women and possibly linked to the trans man’s eating disorder. Transitioning did not cure the trans women’s eating disorders, however. In one case surgery led to the symptoms returning after many years.

Original Source (full text):

Gender Identity Disorder and Eating Disorders by U. Hepp, G. Milos in International Journal of Eating Disorders,12/2002; 32(4):473-8.

 

*In Switzerland at the time of these case studies, trans people had to live as their preferred gender for at least a year before they could get hormones. After at least 6 to 12 months on hormones, they were eligible for surgery.

** The authors of this study refer to the patients by their birth sex unless they have fully and legally transitioned.

*** A BMI under 16 is dangerous, a BMI of 13 is a serious problem.