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.

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