Category Archives: Eating disorders

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.

Review – Eating Disorder in a Transgendered Patient: A Case Report

In this case study, the eating disorder was closely connected to gender dysphoria, although transition did not cure it. The patient’s life history may also have contributed to her eating disorder.

The patient was a 25 year old trans woman (born male) in New Zealand. Her eating disorder began when she started living as a woman at age 15. The goal of her restricted eating and purging was to have a more feminine shape and attract men. When she tried to live as a man for six months, her symptoms decreased.

The patient was a survivor of physical and sexual child abuse. She ran away from home and school before she was 15* and at 16 she was hospitalized for self-harm.  She had had short and often violent relationships with men. She was currently unemployed, but had worked in the hospitality industry and as a self-employed escort.

Transition did not cure her eating disorder. She was taking hormones and living as a woman when she came to the clinic for eating disorders. According to the clinicians, she had a “convincing female appearance.”

Treatment is hard to evaluate in this case, however, because the patient did not want to stop her restricted eating and vomiting. Instead, she asked about more efficient ways to change her shape.

It is important to remember that this is just a case study of one individual; the relationship between eating disorders and gender dysphoria is complicated. The main conclusion I have reached in looking at case studies is that each person’s story is different.

However, like the patients in this study and this one, her restricted eating and purging began when she decided to live as a woman. For some trans women, eating disorders are clearly linked to gender dysphoria.

The patient also had a history of trauma like one of the patients in this case study. Trauma may also be a factor in eating disorders for some trans people.

The authors conclude that gender dysphoria may be a risk factor for eating disorders in trans women.

By virtue of its emphasis on estrangement from body, transgendered individuals may experience heightened body dissatisfaction and excessive concern with appearance. Accordingly, in certain men, transgenderism may constitute a risk factor for developing an eating disorder. In particular, the presence of a history of otherwise known predisposing risk factors including dieting, a family history of obesity, and significant adverse life events may alert clinicians to more closely screen for an eating disorder among the transgendered population seeking psychiatric consultation.

More details about her eating disorder:

“Although of normal weight (body mass index = 23), she was significantly dissatisfied with her shape, and closer analysis revealed a wish for larger breasts, smaller hips, and a more ‘feminine shape’ overall. She frequently checked her profile in mirrors and took delight in discovering when clothes had become baggy to wear, although adamantly denied attachment to the goal of weight loss per se. Rather, she reported significant anxiety around the sensation of food in her stomach, believing that men might perceive her as a less desirable partner if she had a protruding stomach or midriff. Currently she cited this as the main cue to purge. In further pursuit of a more feminine shape, her ambition was to attain improved muscle tone by walking up to 33 km per day.”

More details about her gender dysphoria and life history:

The patient had experimented with cross-dressing in early childhood. She felt like an outcast at school, especially after she was singled out for being too feminine.

She had not had surgery because she could not afford it.

Her family had a history of obesity, but not eating disorders. According to the authors, they did not have psychiatric problems.**

Original Source:

Eating Disorder in a Transgendered Patient: A Case Report by Surgenor LJ, Fear JL in Int J Eat Disord. 1998 Dec;24(4):449-52.

*It’s not clear to me if she returned home after running away or not.

** Except for the bit about the child abuse.

Review – Anorexia Nervosa in a Young Boy with Gender Identity Disorder of Childhood : a Case Report

This is the earliest (1997) case study of someone with both gender dysphoria and an eating disorder.

Eating disorders are rare in children and in males, so an eating disorder in a boy is very unusual.

The boy’s mother had “abnormal eating habits and attitudes” and had been diagnosed with anorexia while she was pregnant with him. The boy had always been small for his age and did not get enough calories due to “extreme faddiness [picky eating] and the failure of the family to eat regular meals.” He was diagnosed with gender identity disorder when he was ten.

The boy developed a severe eating disorder at age 12 after a doctor suggested that he be given hormones to induce puberty.

In his case it looks like his gender dypshoria triggered his eating disorder, but he probably had a predisposition to problems with eating.

Treatment focused on three things: building up his weight, therapy with his family, and therapy with the patient around gender issues. In addition, a teacher was involved to prevent bullying at school. The boy refused the hormone treatments to induce puberty.

The patient’s weight improved steadily until his size was normal for his age and height, but the therapists thought he might relapse in the future due to family conflict and social prejudice.

In this case what worked was a combination of therapy for both the eating disorder and the gender dysphoria, along with family issues.

As always, it is important to remember that this is a case study of just one person. So far, the main conclusion I can draw from cases studies is that each person’s story is different.

More details on the case:

The boy had been gender non-conforming since he was three and had stated that he wished to be a girl. At age 10 his weight dropped and he was referred to a psychiatrist who diagnosed him with gender identity disorder. He was being bullied at school for being gender non-conforming and developed depression, abdominal pain, and headaches.* He was also dealing with severe conflicts between his parents and an older brother with behavior problems.

At that time, therapists helped him develop coping strategies to deal with the bullying and counseled his parents. His eating, weight, and mood improved quickly.

At age 12, his weight dropped rapidly and he had cold extremities and no signs of puberty. He was living on water biscuits and low calorie orange squash (sweet fruit juice) while exercising up to five hours a day.

He was diagnosed with anorexia “in a context of long-standing eating problems and marital disharmony,” with the doctor’s recommendation of hormones to induce puberty as a “significant precipitant.”

“… he admitted feeling uncertain about hormone treatment. He wanted the comfort of acceptance by his social peer group, but felt happiest and most at ease in a feminine role. After the issue of hormone treatment was raised, B. briefly attempted to control and even deny cross-gender behaviors as if forcing himself to conform to male sex stereotypes. His behaviour soon returned to being highly effeminate. He dressed in female clothing and jewellery whenever he could, wore make-up and stylized his hair into a long pony-tail. His interests were hairdressing, fashion magazines, and knitting. At school he associated only with girls and was physically nauseated at the idea of having to play contact sports like rugby with other boys.”

Treatment included individual therapy related to his gender dysphoria:

“Individual work with B. was difficult because of his high level of denial. Over a period of time he began to focus on his dilemma between social conformity which would allow acceptance by others and his acknowledgement of his own revulsion at the idea of his developing male sexuality. In therapy he recognized that he had attempted to delay puberty by restricting his calorie intake. His anxiety about puberty related to his fear of the development of male secondary sex characteristics, the acquisition of a male sex drive, and potential loss of slimness. He was troubled and confused by homosexual and heterosexual fantasies. Exploration of these themes allowed some gradual resolution. Over a period of several months, he began to see some positive benefits from the eventual development of secondary male sex characteristics and to recognize that these changes did not necessarily preclude the continuance of cross-gender behaviour which was an undeniable part of his identity.”

A teacher at his school was also involved to “provide a contact in school who could help B. with teasing and tactfully educate other staff members about his special needs.”

His weight improved steadily and stabilized at 95 percent expected weight for his age and height.

Original Source:

Anorexia Nervosa in a Young Boy with Gender Identity Disorder of Childhood : a Case Report by E. Waters and L. Whitehead in Clin Child Psychol Psychiatry July 1997 vol. 2 no. 3 463-467.

 

*The narrative is a little confusing, but this seems to have happened before the resurgence of his eating problems at age 12.

Review – Diverging Eating Psychopathology in Transgendered Eating Disorder Patients: A Report of Two Cases

These are two somewhat unusual case studies from Singapore. Once again, there is a connection between eating disorders and gender identity. Once again, the connection is different from other case studies.

Case 1 – A Fluid Gender Identity and an Eating Disorder

In the first case, the patient had a fluid gender identity; sometimes he identified as a man and sometimes as a woman.

When he identified as a woman, he restricted his food and exercised excessively. He wanted to be thin and felt a kinship with emaciated women because they were infertile like him.

When he identified as a man, he tried to gain weight and muscles, but his exercise and eating habits were still pathological.

The patient was always distressed and dissatisfied with his body.

In other words, his gender identity affected the form his eating disorder took, but it was probably not the cause of it.

Case 2 – Changing Gender Identity, Changing Eating Patterns

In the second case, the patient identified as a woman when he first sought treatment for his eating disorder. However, after a year of treatment, the patient came out to his friends as gay. They were accepting of his sexual orientation and he became more comfortable with a male gender identity.

Similarly to the first case, when the patient wanted to be a woman, he tried to become thin, using restricted eating, excessive exercise, and purging. However, when he began to identify as a male, he tried to build up his muscles and he ate more.

The authors do not comment on whether or not this patient still disliked his body.

The authors suggest that gender identity influences the form of body psychopathology; constructing your gender identity is linked to constructing your body. However, they do not suggest that gender dysphoria caused the eating disorders or that treating the gender dysphoria will cure them.

These two cases support their theory, but it is important to remember that this is a case study of two people. So far, the main conclusion I can draw from various cases studies is that each person’s story is different.

From the Discussion:

“The present case series describes two transgendered biological males seeking treatment for eating disorders, whose intermittent periods of endorsing both masculine and feminine gender identities impacted significantly upon their experience of eating disorder psychopathology. The two patients indicated that during periods of endorsing a feminine gender identity, they experienced an elevated definite drive for thinness, such that their body image psychopathology was oriented towards weight loss, reporting dietary restriction and cardiovascular exercise to lose weight. Furthermore, both patients reported that during periods of masculine gender identity endorsement, their body image psychopathology was oriented towards weight gain with an emphasis on “buff muscularity,” reporting increased food intake and muscle building exercise regimens.

This case series draws attention to the potential role of masculinity and femininity in body image psychopathology amongst males. Both patients depicted reported that the variation in their eating disorder psychopathology was concordant with their preferred gender identity, suggesting that the construction of one’s gender identity and the construction of one’s body may be interrelated.”

More details on the gender shift in the second case study:

At the beginning of treatment,

“…he reported homosexual sexual orientation and described privately wondering whether he was born into the wrong gender from approximately age 6. He reported periodically ‘trying to like girls’ due to the cultural and legal ramifications of homosexuality in his country of origin [probably China], and further stated that on many occasions his sexual orientation resulted in him feeling victimized and bullied. Patient Z reported significant discomfort with his sexual orientation, although he did report a female gender identity, which allowed him to experience his secretive same sex relationships as heterosexual given his assumed female identity.”

Before treatment, when he was restricting his food and purging,

“Patient Z reported immense discomfort surrounding his emerging sexual orientation, and reported strongly endorsing a female identity which enabled Patient Z to experience his same-sex attraction as heterosexual, alleviating the subjective distress and internal conflict he experienced in his homosexual urges. Patient Z described his role models to be female supermodels, stating that he aspired to their thin and feminine frames, adding that his gaunt appearance brought about by dietary restriction ‘accentuated his cheekbones’ and helped him identify with his female role models. Patient Z reported egosynotonicity of eating disorder symptomatology, allowing him to feel ‘small and more like a woman’ which he demonstrated in a collection of drawings depicting emaciated women, which he described as his ideal body.”

But then,

“Approximately 12 months into treatment Patent Z revealed his sexuality to his friends, whose acceptance and support reportedly alleviated the internal conflict he experienced around his same-sex attraction. As a result Patient Z reported reduced ambiguity surrounding his gender identity, describing more comfort in identifying with a male gender identity. During this same period, Patient Z developed a desire for muscular development as opposed to emaciation, and started a muscle building training regimen. Furthermore, this period was also characterized by Patient Z consuming greater quantities of food in support of his desire for greater muscularity.”

Original Source:

Diverging Eating Psychopathology in Transgendered Eating Disorder Patients: A Report of Two Cases by Murray SB, Boon E, Touyz SW in Eat Disord. 2013;21(1):70-4.

Anorexia nervosa and gender dysphoria in two adolescents – Review of a case study

This is a case history of two Canadian teenagers with severe eating disorders. Both teens had had other psychiatric problems, and in one case the problems were quite severe.

Both teens developed gender dysphoria as time went on. In both cases, they were treated successfully for their disordered eating without being treated for gender dysphoria.

It is not clear exactly what the relationship is between the eating disorders and the gender dysphoria in these two cases.

It is important to remember that this is a case study of two people. So far, the main conclusion I can draw from cases studies is that each person’s story is different.

Case 1

The first patient identified as a very feminine gay male when he entered therapy. He was out to his friends and family and they were accepting of his sexual orientation. He was in a monogamous gay relationship.

The patient was 16 and for the past three years he had had “vomiting, food restriction, and body image distortion, perceiving his body to be overweight.” These problems became so severe that he was admitted to a hospital program.

He had insomnia, depression, problems concentrating, and a low energy level. In the past he had been diagnosed with anxiety. He had cut himself in middle school. His family’s history included substance abuse, depression, and bipolar disorder.

The patient had had body image issues since he was six. He “wanted to stay small, feminine, petite, lean, and thin. He reported that he also disliked his ‘wide torso and broad shoulders’ and wished his face shape was more round to be more in keeping with a feminine ideal.”

However, he did not wish to transition to be a woman. He did not want to physically be a female and was not upset about being a male. Rather he wanted to appear feminine and “assume the female role in a relationship.”*

After his hospital stay, the patient entered an out-patient therapy program that “focused on body and self-acceptance, along with enhancing self-efficacy. The family was involved in order to support his eating, and to accept his sexuality and gender identity.”

With this support “he was able to maintain his weight and left his relationship with his male partner who was emotionally abusive.”

Then, after about a year of treatment, the patient said he wanted to transition to living as a female. He did not want surgery, just blockers and hormones. At that point he had already regained a healthy weight and was not restricting his food. He was referred to a gender transition clinic at his request.

Because he was turning 18, his treatment at the pediatric eating disorder clinic ended.**

Case 2

The second patient was a 13 year old girl with a past history of obsessive-compulsive disorder (OCD), generalized anxiety disorder, and post-traumatic stress disorder from sexual abuse by her father. She had also self-harmed and considered suicide. Her family’s history included depression.

At the time she came to the clinic she had anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). She was taking fluoxetine and olanzapine.

She had been hospitalized twice before for her eating disorder and had a “two year history of food restriction, a rigid eating schedule, and body image preoccupation…She described becoming distressed after eating foods she considered were unhealthy, which prompted her to forgo these foods entirely. She also reported excessive exercise due to a desire to be muscular.”

The patient refused therapy, but came in for medical visits and to see the psychiatrist. She had trouble eating more, so they asked her mother to help, but after six months the mother suggested residential treatment and the daughter agreed. The patient’s fluoxetine dose was increased.

The patient began to talk about wanting to be a boy. She also thought that sex was gross. She wanted to stay at a low weight in order to prevent breast growth and menstruation. Therapists raised the question of her trauma and how it might affect her feelings, but she did not want to discuss it.

“Mother was not accepting of the patient’s desire to be a boy and therapy with the psychiatrist was focused on mother taking a more neutral stance.”

After a year, and after she had been fully weight-restored for several months, she began to dress as a boy and use a boy’s name. She hated her breasts and sometimes hit them or thought about cutting out the fat, but she did not want to have surgery. She said that she no longer had eating problems, her only problem was wanting to be a boy. She wanted to take puberty blockers. Her mother was not in agreement and the girl dropped out of treatment.

Gender dysphoria and eating disorders in these case studies

It is difficult to figure out what these case studies mean. Rather than gender dysphoria causing an eating disorder, these patients seem to have developed gender dysphoria over time while recovering from eating disorders.

The authors suggest that as the patients regained weight, their bodies changed and this made the gender dysphoria intensify. I find this unconvincing.

In the first case, the patient was concerned about his wide shoulders and angular face; gaining weight would not have changed his shoulders or made his face more angular.

More importantly, the patient was clear at the beginning of treatment that he was a man and was not distressed by being male. Saying that he wanted to transition to a female but not have surgery was not a question of symptoms intensifying or becoming more prominent. It was a dramatic change – he went from not having gender dysphoria to having it.

In the second case, it seems likely that surviving childhood sexual abuse caused the patient’s disgust with sex and hatred of her breasts, as well as her depression, anxiety, and habit of spraying her body with Lysol.*** Both the eating disorder and the gender dysphoria could be interpreted as ways of dealing with these feelings.

Why or how exactly the patients developed gender dysphoria during this time is unclear. This question is an important area for future research.

The relationship between gender dysphoria and eating disorders is unclear in these two cases, but it looks like the eating disorders were not caused by the gender dysphoria. In the first case, the patient had the distorted perception that he was overweight; this is a symptom of anorexia rather than gender dysphoria. In the second case, the patient had been sexually abused as a child and had many psychiatric disorders, including OCD. Her eating disorder could be explained by a combination of trauma and genetic factors.

What is clear is that in these two cases, the patients were successfully treated for eating disorders before any gender issues were addressed.

Stay tuned for more case histories related to eating disorders and gender dysphoria.

Original Source:

Anorexia nervosa and gender dysphoria in two adolescents by Couturier J, Pindiprolu B, Findlay S, Johnson N in Int J Eat Disord. 2015 Jan;48(1):151-5.

 

* No, I don’t know what that means either.

** I can’t figure out the math here. He was 16, but after 11 months he said he wanted to be a girl. Then they say he left their program because he was turning 18 and had been having therapy continuously for 18 months.

*** No doubt there were genetic and hormonal factors as well, but I think it’s fair to point to the abuse as a cause.

Review: Treatment of anorexia nervosa in the context of transsexuality: A case report

This is a depressing study. The main conclusion I get from it is that we need a better health care system.

The patient in this case is a 19 year-old American trans woman (born male) who developed a severe eating disorder when she decided to dress and live as a woman.

She became malnourished and ill and was hospitalized. During her treatment, she became upset as she gained weight and was afraid she would look masculine. She said she would be willing to gain a healthy amount if it would be on her hips and breasts.

When her testosterone levels returned to normal, hair began growing on her face and legs again. The patient began to exercise secretly and stopped gaining weight.

The hospital discussed gender transition with her, including the risks of treatment. She agreed to try hormone blockers and was given a three month dose of leuprolide. She was also given the androgen blocker spironolactone. After this, the patient progressed well and gained enough weight to leave the hospital.

During follow-up, the patient continued to gain weight until she began working. She lost weight while working, but was able to stabilize her weight with the help of a dietitian.

The patient was referred to an endocrinologist and a center for transgender youth for estrogen therapy and gender transition. She lost her health insurance coverage and could not afford to follow-up with transition.

Short-term hormone therapy helped this trans woman to recover from an eating disorder that made her seriously ill, but it’s unclear what will happen to her without health insurance.

It is important to remember that this is just a case study. This is only one individual; the relationship between eating disorders and gender dysphoria is complicated. We can only come to limited conclusions from any one person’s story.

I will be reviewing more case studies of eating disorders and gender dysphoria. At this point, the main conclusion I can draw is that each case is individual.

The hormone treatment in this case was not the standard cross-sex hormone treatment for people with gender dysphoria. We can not, therefore, draw conclusions about the standard hormonal treatment for trans women.

In addition, the hormone treatment the patient received in this case would not work for everyone. Leuprolide can decrease bone density which may be a problem for malnourished patients with eating disorders. In this case the doctors decided that it would be only used for a short time and the benefits outweighed the risks.

The doctors speculate about the possibility that the androgen blockers caused the patient to gain weight under the skin rather than at the belly and that this may have made her look more feminine.

It is also possible that leuprolide itself had an effect on the eating disorder. Leuprolide is a puberty blocker and eating disorders develop at puberty; perhaps when you block puberty, you block something that causes disordered eating. For example, estrogen may play a role in eating disorders and leuprolide blocks estrogen as well as testosterone.

The bottom line is that this trans woman developed a life-threatening eating disorder when she decided to live as a woman. During recovery she was distressed by the idea of looking more masculine as she regained a healthy weight. Puberty blockers and androgen blockers helped her to regain a healthy weight. Her weight was stable at follow-up, but she lost her health insurance and it is unclear what will happen to her.

More from the authors’ discussion of the case:

“Because her identity as TS [transsexual] and desire to appear more feminine were inextricable from her disordered eating, we felt that her recovery from her ED [eating disorder] would be aided by supporting her gender transition. After consulting the Endocrine Society Guidelines on Treatment of Transsexual Persons and discussing treatment possibilities with experts in transsexual youth, medical treatment options included cross-hormone (i.e., estrogen) therapy (which would also suppress testosterone release) and/or suppression of testosterone with GnRH agonists with or without the use of spironolactone as an antiandrogen agent. Treatment with cross-hormone therapy requires close follow-up with an endocrinologist familiar with this treatment; the children’s hospital to which DS was admitted is not a site experienced in cross-hormone therapy for transsexual youth. For this reason, GnRH agonist therapy with spironolactone was chosen to suppress testosterone at the level of the pituitary and delay resurgence of testosterone-related changes until the patient could access appropriate TS medical care and follow-up.

To our knowledge, there are no studies describing the patterns of weight gain in TS patients who receive antiandrogens in comparison to those who do not. However, studies of antiandrogen use for other medical conditions have shown that patients receiving antiandrogens tend to gain subcutaneous adiposity, as opposed to primarily intra-abdominal adiposity gained by patients not on antiandrogens. One could theorize that this subcutaneous pattern of weight gain would be more tolerable to MtF transsexual patients who strive for a more feminine appearance, which would support the use of GnRH agonists in these patients. This is an interesting area for future inquiry.

Possible adverse effects of GnRH agonists include decrease in bone density. This is of particular concern in malnourished patients, as malnutrition alone can adversely affect bone density. This potential drawback of GnRH therapy for DS was discussed at length as a team, and it was determined that the benefits of GnRH use outweighed the risks for two primary reasons: (1) the expected duration of GnRH therapy was brief, as it was being used as a bridge to initiation of cross-hormone therapy; and (2) suppression of DS’s testosterone level would likely facilitate her willingness to achieve weight restoration. In studies of malnourished patients with low bone density, weight restoration is the most important factor in improving bone density. Spironolactone was added to DS’s therapy regimen for additional anti-androgen effects. This medical plan enabled DS to continue to improve her nutritional status while avoiding the unwanted increase in testosterone and consequent physical changes.”

Original Source:

Treatment of anorexia nervosa in the context of transsexuality: A case report by Ewan LA, Middleman AB, Feldmann J. in Int J Eat Disord. 2014 Jan;47(1):112-5.

Review of: Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report

This is a fairly straightforward case study of a Turkish trans man (born female) with anorexia. In order to avoid menstruating, he dieted excessively and induced vomiting. He also wished to avoid looking female. This went on for 21 years, beginning when he was 19.

Once he was on hormones and menstruation stopped, the disordered eating ended. It has not returned after two years. He says he is no longer concerned with his weight since he is living as a man.

It is important to remember that this is just a case study. This is only one individual; the relationship between eating disorders and gender dysphoria is complicated. We can only come to limited conclusions from any one person’s story.

In fact, there are six other case studies where physical transition did not cure an eating disorder. Two trans women with eating disorders were already on hormones (here and here), although one of them does not seem to have been interested in recovering from her disordered eating. One trans woman believed that transition had cured her, but she was severely underweight, even more so than she had been before transition.

There are three case studies where surgery seems to have caused or triggered disordered eating. This trans man began binging and purging for the first time after having his breasts, uterus, and ovaries removed. One of the trans women in this study had an eating disorder in adolescence; her symptoms returned after sex reassignment surgery 20 years later. Finally, this adolescent trans man recovered from an eating disorder and transitioned; after his mastectomy, he began to relapse and ten months later he returned to the clinic for eating disorders.

In addition, there are a number of case studies where factors other than gender dysphoria played a role in an eating disorder. The most striking is this case of identical twins; both twins had anorexia, but only one had gender dysphoria. The twins shared genes and an abusive father, but one grew up to be a feminine gay man while the other was a trans woman.

Back to this case study. It is clearly different from typical cases of anorexia:

The rejection of femininity was the primary underlying motivation for loss of weight, and not the wish to look slim. She stated that her primary motive for purging was to stop menstruation and her second motivation was to get rid of female body shape; the latter motivation was so strong that she expressed that if she could look like a man if she put on weight she would eagerly try to put on some weight. Thus with this definite statement she was to be separated from the primary cognition of AN which is an intense fear of gaining weight. Her eating disorder symptoms were greatly alleviated after sex reassignment.”

More importantly, in this case, taking testosterone stopped the disordered eating.

The trans man in this story also had a sex reassignment surgery, although the study does not say what the surgery was (mastectomy, genital surgery, or hysterectomy with removal of the ovaries). He changed his name and is living as a man.

It is likely that transitioning cured him of anorexia. However, it is also possible that the testosterone itself played a role. Low testosterone is linked to eating disorders in both men and women. There is a study underway to see if taking testosterone can help women with eating disorders, but we will not know the results for a few more months.

A few other things of note:

The patient did not seek help for his eating disorder, even when he saw a psychiatrist for depression. His eating disorder only came out when he applied to change his sex on his identity card and was referred to a psychiatry clinic.

In order to be able to take hormones, the patient stopped vomiting. However, he continued to restrict his calories until he was actually on hormones.

Before treatment, the trans man ate more when he was depressed.

He had problems with his teeth due to vomiting eroding the enamel.

After finishing college, he had a serious suicide attempt.

The patient’s gender dysphoria began in childhood:

“In her early childhood A.T, felt strongly that she belonged to the male sex. She played boys’ toys and games, preferred boys for playmates, and she was interested in football. When she reached puberty the growth of her breasts and the onset of menstruation caused her to have severe stress, in order to hide her breasts she was wearing extra large size clothes and she was pretending a kyphosis-like posture. During the first year of her university education she had severe depressive symptoms connected with her gender dysphoria; she was spending the greater part of her time at home as she was uneager to dress and live like a woman.”

Original Source:

Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report by Şenol Turan, Cana Aksoy Poyraz, Alaattin Duran in Eat Behav. 2015 Aug;18:54-6.