Tag Archives: eating disorder

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.

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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 Clinical Management of Youth with Gender Dysphoria in Vancouver – Part I – Demographics

This article is a report on health care provided to youth with gender dysphoria at a clinic in British Colombia, Canada. I’m going to focus on just the demographics in this post and do another post later.

QUICK OVERVIEW

The clinic saw a dramatic increase in the number of their teenage patients from 2006-2011. This is similar to other clinics serving teenagers with gender dysphoria.

Most of their patients were trans men (born female). This is similar to the current situation at other clinics for teenagers, but different from the past at other clinics. It is also different from most European clinics for adults.

Their patients had other psychiatric diagnoses including mood disorders, anxiety disorders, and eating disorders. The patients in this study had more psychiatric problems than teenagers studied at a clinic in the Netherlands.

7% of their patients had an autism spectrum disorder. This is similar to the results of a Dutch study of children and teens with gender dsyphoria.

Suicide attempts are a serious problem among their patients. 12% of their patients had attempted suicide before coming to the clinic; 5% attempted suicide after their first visit to the clinic. The decrease is encouraging, but clearly we need to do more to help patients during and after transition.

Some of their patients had to be hospitalized for psychiatric problems. 12% of their patients had been hospitalized before coming to the clinic, but only 1% were hospitalized after the first visit.  Again, we need to be sure to provide support during and after transition.

THE INCREASE IN TEENAGE PATIENTS

The clinic has seen a fairly dramatic increase in the number of teenage patients from 2006-2011. They went from fewer than 5 cases/year before 2006 to nearly 30 cases in 2011.

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Number of new patients with gender dysphoria seen in 1998-2011. MtF, black bars; FtM, hatched rectangles.

This parallels what has happened at a similar clinic in Toronto, Canada and a clinic in the Netherlands.

Unlike the other two studies, the majority of the patients at this clinic were always trans men (born female). In fact, before 2006 almost all of the patients were trans men. After 2006, the number of trans women patients (born male) began to increase. However, trans men still made up 54% of all the patients they saw between January 1998-December 2011.

This is different from the pattern found in the clinics in Toronto and Amsterdam. In those two clinics the patients were mostly trans women before 2006, but after 2006 they were mostly trans men.

It’s hard to know what these numbers mean because we don’t know how common gender dysphoria is among teenagers.

“The prevalence of adolescent-onset gender dysphoria is not known, and there are limited accurate assessments of prevalence of transgenderism in adults in North America. However, the prevalence of adults seeking hormonal or surgical treatment for gender dysphoria is reported to be 1:11 900 to 1:30 400 in the Netherlands.”

Does this increase reflect an increase in the number of teenagers with gender dysphoria? If so, why are the numbers increasing?

Alternatively, is this increase due to people with gender dsyphoria seeking physical transition at a younger age?

Statistics on most European clinics have shown many more trans women transitioning than trans men (the pattern is reversed in Japan and Poland). Now the statistics on Canadian and Dutch teenagers show more trans men transitioning than trans women.

Are there more trans men than in the past? If so, why?

Or are trans men transitioning at a younger age than trans women? But then why did the other two clinics treat more teenage trans women than teenage trans men in the past?

BASIC DEMOGRAPHICS OF THE PATIENTS IN THIS STUDY

The clinic at British Colombia Children’s Hospital saw 84 youth with a diagnosis of gender dysphoria from January, 1998 to December, 2011.

45 of the patients were trans men, 37 were trans women, and 2 were males who weren’t sure of their gender identity.

Two of the trans women had disorders of sex development – one had Klinefelter syndrome (XXY chromosomes) and one had mild partial androgen insensitivity syndrome (i.e. her body made androgens, but they didn’t fully affect her).

The median age at the first visit was 16.8, the range in ages was from 11.4 to 22.5.

At the first clinic visit, most patients were in school grades 8-10 (32%) or grades 11-12 (48%); 12% were in grades 5-7, and the remaining 8% were in college/university or no longer attending school.*

PSYCHIATRIC COMORBIDITIES

Diagnoses made by a mental health professional:**

35% of the patients had a mood disorder (20 trans men, 7 trans women and probably the two males with uncertain gender identity)

24% had an anxiety disorder (15 trans men, 4 trans women and probably one male with an uncertain gender identity)

10% had ADHD (2 trans men, 6 trans women)

7% had an autism spectrum disorder (2 trans men, 4 trans women)

5% had an eating disorder (2 trans men, 2 trans women)

7% of their patients had a substance abuse problem (2 trans men, 4 trans women)

26% of their patients had two or more mental health diagnoses (12 trans men, 9 trans women) and probably one male with an uncertain gender identity.

Suicide attempts:

10 of the teenagers attempted suicide before coming to the clinic (12%). 6 of them were trans men and 2 were trans women. Perhaps the other two were the two males who weren’t sure of their gender identity.

4 of the patients attempted suicide after the first visit to the clinic (5%). Three of them were trans men and one was a trans woman.

Psychiatric hospitalizations:

12% of the patients had been hospitalized for a psychiatric condition before coming to the clinic – seven trans men and three trans women.

One trans man was hospitalized for a psychiatric condition after the first visit to the clinic (1%).

Conditions requiring hospitalization included posttraumatic stress disorder, depression, substance abuse, behavioral issues, psychosis, and anxiety.

Mood, puberty blockers, and hormones:

One trans woman and one trans man discontinued the use of a puberty blocker after they developed emotional lability (7% of the patients who took the puberty blocker). The trans man also had mood swings.***

One trans man had significant mood swings as a side effect of testosterone treatment. (3% of the patients who took testosterone.)

Two trans men temporarily stopped testosterone treatment due to psychiatric conditions – one was depressed and one had an eating disorder. (5% of the patients who took testosterone.)

One trans man temporarily stopped testosterone treatment due to distress over hair loss. (3% of the patients who took testosterone.)

Gender differences:

Trans men were significantly more likely to have depression or anxiety disorders than trans women. 44% of trans men had mood disorders compared to 19% of trans women. 33% of trans men had anxiety disorders compared to 11% of trans women.

There were no significant gender differences in other mental health issues.

27% of trans men had two or more psychiatric diagnoses compared to 24% of trans women. This seems surprising given that trans men were more likely to have mood and anxiety disorders.

The most important issue is the number of suicide attempts.

Why were there four suicide attempts after the first visit to the clinic?

Were the suicide attempts related to the two patients who developed emotional lability on blockers? or the trans man who developed mood swings after taking testosterone?

Were they related to the trans man who stopped taking hormones due to depression? Was he the same person as the trans man who developed mood swings on testosterone?

What about the trans man who stopped his hormones due to an eating disorder?

When were the suicide attempts? Were they before the patients got blockers or hormones? Did they happen after stopping hormones for any reason? Or were the patients already on hormones or blockers?

Could they have been prevented by more therapeutic support before treatment? during treatment?

Is there a way to identify which patients are at risk for suicide attempts during or after treatment?

It is encouraging to see that there were fewer suicide attempts after the first visit to the clinic than before, but it is not enough. We need to do more.

We also need more data on the decrease in the number of suicide attempts after coming to the clinic. Was it statistically significant? Was the time period before the first visit to the clinic equal to the time period after the first visit to the clinic?

Psychiatric comorbidities comparison

Compared to a clinic in the Netherlands, these patients were more likely to have mood disorders (35% vs. 12%), but about as likely to have anxiety disorders (24% vs 21%).

5% of the Vancouver patients had an eating disorder while none of the patients in the Dutch study did.

7% of the patients in this study had a substance abuse problem while only 1% of the patients in the Dutch study did.

26% of the patients in this study had two or more psychiatric diagnoses. In comparison, only 15% of the teenagers in the Dutch study had two or more psychiatric disorders.

Finally, the Dutch study found that trans women were at higher risk for having a mood disorder or social phobia while this study found that trans men were at higher risk for mood and anxiety disorders.

Why is the psychiatric comorbidity higher in the Vancouver patients?

The authors of the report suggest that it might be because the average age of their group was higher than the average age in the Dutch study – 16.6 year vs 14.6 years. It might simply be that older teenagers have had more time to develop mental health issues.

They also suggest that there could be differences in diagnostic criteria. Both groups seem to have been using DSM-IV diagnoses, but the Vancouver data was based on clinic notes while the Dutch data was based on interviewing parents. It may be that parents underestimate their children’s problems. For example, they might not realize that their teenager has a substance abuse problem or an eating disorder.

In addition, the Vancouver study includes all 84 patients their clinic saw between 1998-2011. In contrast the Dutch group invited 166 parents to participate in their study, but only 105 parents did so. It is possible that the 61 parents who did not participate had children with more problems, although the authors suggest that the inconvenience of travelling to the center was the main issue.

Finally, the Dutch group has 17 teenagers who were referred to the clinic but dropped out after just one session, “mostly because it had become evident that gender dysphoria was not the main problem.” These patients might have had more psychological comorbidity than others.

It is hard to compare this to the Vancouver clinic, however, because the Vancouver clinic’s focus is on endocrine care. 93% of the patients they saw had already been diagnosed with gender dysphoria by a mental health professional. Were there teenagers in Canada who discovered that gender dysphoria was not the main problem and did not go on to the clinic? If so we would expect the two clinics to have similar rates or psychological comorbidity. If not, we might expect a higher rate of comorbidity in Canada.

A final possibility is that the Canadian teenagers with gender dysphoria simply have more psychological problems than Dutch teenagers with gender dysphoria. Perhaps they experience more bullying and violence. Perhaps they had less supportive parents.

As usual, we need more studies. Why are the numbers of teenagers at clinics for gender dysphoria increasing? What is the prevalence of gender dysphoria among teenagers? How common are psychological comorbidities? Are trans men or trans women more at risk for depression and anxiety? What can we do to prevent suicide attempts after treatment begins? How can we better support patients with gender dysphoria during and after transition?

Original Source:

Clinical Management of Youth with Gender Dysphoria in Vancouver by Khatchadourian K, Amed S, Metzger DL in J Pediatr. 2014 Apr;164(4):906-1.

 

*This would suggest that 48% of the students were 16-17 years old, 32% were 13-15, 12% were 11-12, and 8% were 18-22.5.

** The table indicates that these were diagnoses made by a psychiatrist or psychologist. There were other diagnoses the authors didn’t include in the table: 1 patient with trichotillomania, 2 with borderline personality disorder, 1 with psychosis not otherwise specified, 1 with adjustment disorder, 2 with tic disorders, and 1 with oppositional-defiant disorder. I am not sure why these diagnoses weren’t included; perhaps they weren’t made by mental health professionals.

***The blockers being used were gonadotropin-releasing hormone analog or GnRHa.