Tag 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.

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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.