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.
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.**
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.
* 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.