Tag Archives: eating disorder after sex reassignment surgery

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.

Advertisements

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.