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.”
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.
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?
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.