Tag Archives: trans men

Trans Lives Matter in San Francisco in the 1960s

“The Central City Anti-Poverty Program Office opened that fall as a result of the Tenderloin neighborhood organizing campaign. This multiservice agency included an office for the police community-relations officer to the homophile community, a police sergeant by the name of Elliott Blackstone. One afternoon shortly after the agency opened, a transgender neighborhood resident named Louise Ergestrasse came into Blackstone’s office, threw a copy of Benjamin’s The Transsexual Phenomenon on his desk, and demanded that Blackstone do something for ‘her people.’ Blackstone was willing to be educated on the matter, and he soon took a leading role in changing police treatment of transgender people.”

From Transgender History by Susan Stryker, page 75.

A 25-Year-Old Affirmed Male with Multiple Comorbid Conditions – Review of Case Study

This is a case study of a trans man (born female) with many serious mental health problems, including an eating disorder. He was a survivor of childhood sexual abuse and the trauma seems to have been at the root of his problems.

He had “an eating disorder with restriction and purging, substance dependence, gender dysphoria, panic disorder without agoraphobia, PTSD, dissociative disorder, learning disorder, sleep disorder, mood disorder, borderline personality disorder, and pain disorder.”

This case study does not make any connections between his eating disorder and his gender dypshoria. Given the abuse and the multiple comorbidities, it is unlikely that the gender dysphoria caused the eating disorders.

The authors suggest that both the eating disorder and the gender dysphoria were caused by the early trauma.

“the underlying foundation of these multiple diagnoses is the presence of early developmental trauma to the emotion regulation system — which manifests as physical and emotional pain with impulsive and maladaptive attempts to engage in behaviors to meet personal needs, including safety. Zanarini and colleagues performed a study examining Axis I comorbidity in patients with BPD [borderline personality disorder] and identified high rates of comorbid PTSD. They also observed that meeting criteria for multiple Axis I disorders predicted meeting criteria for BPD.”

Treatment focused on the most severe issues first; suicidal thoughts and behaviors, then purging behaviors, urges towards substance abuse, self-harm, self-care, and interpersonal behavior. The patient was treated with dialectical behavior therapy.

Medical transition came later and was not part of the recovery from the eating disorder. However, at the time the patient entered therapy, he had already taken a male name and was dressing and living as a male.

This case study has some similarities to the case of a teenage girl* who developed gender dysphoria while being treated for an eating disorder. The teenage girl was also a survivor of childhood sexual abuse with multiple mental health problems: anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). In addition, she had a past history of PTSD, OCD, self-harm, and suicidal thoughts.

These two cases suggest that in some cases, gender dysphoria is not the main cause of an eating disorder. Rather, trauma causes multiple mental health issues.

There are two more case studies of transgender people with eating disorders who were survivors of child abuse. They suggest different possible conclusions, however.

A trans woman whose eating disorder began when she started to live as a woman. Her goal was to have a more feminine shape. Transition and hormones did not cure the eating disorder, however. She had been physically and sexually abused as a child.

A trans woman whose identical twin also had an eating disorder. Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both survived an abusive father who threatened them with assault and death. However, one was a trans woman and one was a gay man.

In the first case, the eating disorder seems to be closely connected to the gender dysphoria since it started when she began to live as a woman. She clearly describes wanting to look more female. The abuse may have affected her, but gender dysphoria was also a factor.

In the second case, the eating disorder seems to have been caused by a combination of genes and environment, since both twins had anorexia but only one had gender dysphoria.

We’re left with the possibility that the answer is different in different cases. Sometimes severe childhood trauma may cause multiple mental health problems that include an eating disorder. Sometimes a combination of gender dysphoria and early childhood trauma may contribute to an eating disorder. And sometimes the same genes and environment will produce two people with similar eating disorders but different gender identities.

Of course, these are only four case studies. We can’t draw conclusions from them about all transgender people with eating disorders. Most of the case histories I have found don’t mention child abuse. Many of them suggest connections between gender dysphoria and eating disorders.

What we can see from these cases, however, is that for some transgender people with eating disorders, gender dysphoria is not the main or only cause of their eating disorder. Therapists should keep this in mind when treating transgender patients for eating disorders.

And, as always, we need more research.

Original Source (full text):

A 25-Year-Old Affirmed Male with Multiple Comorbid Conditions by Katharine J. Nelson, MD; S. Charles Schulz, MD in Psychiatric Annals, February 2012 – Volume 42 – Issue 2: 48-51.

UPSETTING MATERIAL ABOUT ABUSE BELOW

A few additional details of the case history:

The article provides an interesting discussion of diagnosing and treating a patient. The full text is available online without cost, but here are a few details of the case:

The trauma the trans man survived involved “repeated episodes of sexual violence perpetrated from age 4 to 9 years old by a childhood friend’s father in the neighborhood.”

“The patient believed he had suffered multiple head injuries related to physical violence and asphyxiation in the context of sexual trauma, but was unclear if he had lost consciousness because of head injury or because of psychological dissociation during these events.”

He had “a history of heavy chemical use, starting with first use of alcohol at age 7, which continued through age 23. He also used diet pills starting at age 14, followed by heavy use of cannabis at age 15, and cocaine and other narcotics, including pills and heroin, at age 18 years.”

The patient had severe pelvic floor dysfunction which caused him a great deal of pain. It took him a while to get this diagnosed correctly.

“The patient was born and raised as a female, but in retrospect realized he did not fully identify with either the male or female gender. In the previous 2 years, he had decided to openly adopt a male gender, name, and manner of dress. He had the intention of pursuing hormone therapy and, eventually, chest reconstruction.”

Treatment and afterwards:

“Suicidal thoughts and behaviors were identified as the highest-priority target; after 6 months, these thoughts and behaviors had resolved. The patient was engaged in therapy and did not require significant emphasis on therapy interfering behaviors; therefore, quality-of-life interfering behaviors could be targeted, including purging behaviors, urges to use substances, self-injury, self-care, and interpersonally effective behaviors with friends, family, and other medical professionals. He graduated phase 1 of DBT therapy and proceeded to phase 2 to continue working on healthy emotional experiencing and management of trauma sequelae.

The patient graduated college with a high grade point average and went on to pursue master’s level education. He underwent sex hormone treatment and chest reconstruction.

He developed additional medical comorbidities, including insulin resistance and adrenal insufficiency. These medical conditions necessitated moving back in with his parents, resulting in significant familial conflict. The patient’s therapist made a referral for family therapy through our department, which was coordinated among treatment providers. The patient is enthusiastic about the progress made in treatment and states he often wonders if he would be still be alive without the intervention he received. Over the course of 3 years, his medications were all tapered to discontinuation, with the exception of prazocin 10 mg at bedtime for nightmares, ramelteon 8 mg for sleep, and clonazepam 1 mg three times a day, which was continued to assist with pelvic musculature functioning.”

Review of Disordered Eating and Gender Identity Disorder: A Qualitative Study

This is a qualitative study of eating disorders and gender dysphoria. Its strength is that the authors asked transgender people themselves what they thought. Its weakness is that we can’t draw many conclusions from it, although we can use it to find questions for future research.

Limits of the Study

We can’t use it to estimate the prevalence of eating disorders among trans people. The participants were recruited for a study of body image and eating behaviors. Transgender people with eating disorders may be more likely to volunteer for such a study.

We can’t use it to collect statistics on trans people with eating disorders because the data is not uniform. Participants were asked open-ended questions, so we can’t be sure what it means when they give different answers. For example, one person talked about wanting to control his body. Did other participants agree with him and not think to mention it or did they just not care about controlling their bodies?

We can’t look at how individual eating disorders and gender dysphoria developed over time because we don’t have case histories of the participants.

The participants in the study were not formally diagnosed with eating disorders; the data on their eating is self-reported, although convincing. It is not clear from the study how many of the participants currently had symptoms of disordered eating.

On the other hand, we do have some data we can use from this study.

Data from the Study

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise.*

About half of the transgender people with an eating disorder talked about gender dysphoria causing their eating disorder and about half did not.**

Other explanations given for the eating disorder included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

Explanations related to gender could be classified as efforts to suppress gender or efforts to accentuate gender.

A few participants talked about the relationship between disordered eating and transition. Some saw hormones as positive and some saw them as negative:

Two trans men (born female) said that hormone therapy had helped them to stop caring about their weight.

Two trans women (born male) said that hormone therapy had made them gain weight. (One of the women who said this was waiting for diagnosis and hormone treatment; presumably she was self-medicating.)

One woman who was considering gender reassignment said that breast reduction surgery had helped her stop caring about her weight.***

There was no clear relationship between medical transition and current scores on subscales of the Eating Disorder Inventory-3.**** The three people with the highest total scores included:

Two trans women who had had genital surgery and were on estrogen – the surgery means that their bodies were no longer producing much testosterone; and

One trans men who was taking testosterone and waiting for a mastectomy.

You can read further details of the study below the footnotes.

Future Research

The data we can get from this study isn’t much, but it does point to some important questions for future research. Many of these are questions raised by case studies as well.

What do transgender people see as the main cause of their disordered eating? Do they see it as being about issues like control, autonomy, and stress or do they see it as being related to gender dysphoria? Or both?

Is affirming the desired gender or suppressing biological sex a more important factor in disordered eating? Do trans men and trans women give different answers to this question?

Are there differences between the group of people who see their eating disorder as being related to gender issues and those who do not? Do they have different patterns in terms of when their symptoms of disordered eating developed, what their symptoms looked like, or what happened when they transitioned?

Do people’s perceptions of what causes their disordered eating match reality? Do they have relatives with eating disorders, for example? Were there other factors in their life that might have contributed to the eating disorder? When did the eating disorder develop?

How does the relationship between the eating disorder and gender dysphoria affect recovery from the eating disorder?

When did the disordered eating begin in relation to the gender dysphoria? How did the two conditions develop over time?

Does transition increase or decrease symptoms of disordered eating? Does it have no effect?

Are the effects of transition on eating disorders different for trans men and trans women? In this study, two trans men with eating disorders felt hormone therapy helped their recovery, while two trans women said it made them gain weight.

Trans women and trans men are not getting the same treatment for gender dysphoria; how does that affect eating disorders? In this study, trans men had mastectomies while trans women had genital surgery. Mastectomies might be more important in issues related to body shape. In addition, hormone therapy would have involved completely different medications for trans men and trans women.

Do the hormones themselves play a role in eating disorders, either reducing or increasing symptoms?

Comparison to Case Studies

Prevalence of eating disorders in trans men versus trans women

In this study, slightly over half of the participants were trans men. Trans women were not more likely to have eating disorders than trans men. In contrast, the case studies are overwhelmingly of trans women with eating disorders. What is the real prevalence of eating disorders among transgender people? Is there a difference in the rates among trans men and trans women or not?

It might be that selection bias means that case studies of trans women with eating disorders are written up more frequently. Eating disorders are relatively rare among biological males and potential authors of case studies might notice them more. Conversely, it might be that trans men were more willing to volunteer for the study than trans women or that a group of trans men encouraged each other to participate.

The link between eating disorders and gender dysphoria

Some case studies suggest that factors other than gender dysphoria are central in the development of disordered eating. We have the case of the identical twins who both had anorexia, although only one was transgender. Similarly, the trans man with an eating disorder in this case study had two cousins with eating disorders and this boy’s mother had had anorexia. Then we have the case of the teenage survivor of sexual abuse with PTSD, generalized anxiety disorder, OCD, an eating disorder, and a history of self-harm. The teenager developed gender dysphoria while being treated for her eating disorder; it may be that the trauma was the most important factor in all of her problems.

On the other hand, we have five cases of trans women whose eating disorder began when they decided to live as women, reported in this case study, this one, this one, and this one. In addition, in this case study, one trans woman’s eating disorder seems to have begun at the same time as depression related to her gender.

We also have a couple of case studies where trans men say that their disordered eating was a desire to get rid of feminine features; in this case his curves, breasts, hips, and feminine face and in this case his period and feminine shape. However, in the first case, the trans man also had two cousins with eating disorders.

There is also this somewhat unusual case of an underweight boy with poor eating habits who developed severe anorexia after a doctor suggested that he take testosterone to induce puberty. Again, in this case, his mother had also had anorexia.

Intriguingly in these two cases, gender identity seemed to affect the patient’s symptoms, but not the underlying dissatisfaction with their bodies. In the first case, the patient had a fluid gender identity; when he lived as a man he tried to gain weight and muscle, when he lived as a woman he tried to lose weight. His habits were always pathological and he always hated his body. In the second case, the patient initially identified as a woman. After coming out as gay to supportive friends, he identified as a gay man; as a woman he dieted and as a man he tried to gain muscles.

Of course, since they are case studies, there could be some selection bias. People might be more likely to report cases where gender identity seemed to have affected the eating disorder – or they might be more likely to report cases that are unusual like identical twins and fluid gender identity.

This is where this study is helpful; we see that a number of transgender patients did not bring up gender issues when asked what they thought caused their eating disorders. We also see that some patients thought gender issues were important causes. And now we need another study to find out what that means.

The effect of transition on gender dysphoria

This study found one person considering transition who said that breast reduction surgery had helped her with her disordered eating,

In contrast, there are three individual case studies where sex reassignment surgery contributed to an eating disorder. 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 the qualitative study two trans men said that hormone therapy had helped them with their eating disorders, while two trans women said hormones had made them gain weight.

On the other hand, two trans women and a trans man who were taking hormones had relatively high scores on three subscales of the Eating Disorder Inventory-3. The two trans women had already had genital surgery (which would have included removing their gonads) while the trans man was waiting for a mastectomy.

Looking at the case studies, there were two trans women with eating disorders who were already on hormones (here and here), although one of them does not seem to have been interested in recovering from her disordered eating. There was one trans woman who believed that transition had cured her, but she was severely underweight, even more so than she had been before transition.  In addition, the patients listed above who had problems with their eating after sex reassignment surgery were also on hormones, although it could still be that hormone therapy initially helped them.

On the other hand, there was one trans man whose eating disorder was cured by taking testosterone. In addition, taking puberty blockers helped this adolescent trans woman restore her weight, although, of course, puberty blockers are not the same as hormone therapy for trans women or trans men.

In many of the case studies, patients recovered from disordered eating before they were referred to a gender clinic.

It seems clear that we can not rely on transition to cure an eating disorder and at times it may exacerbate it. Therapy for eating disorders should be aimed at the eating disorder and patients with gender dyshporia and eating disorders should have follow-up care for the eating disorder after they transition.

You can read further details of the qualitative study below the footnotes.

Original Source:

Review of Disordered Eating and Gender Identity Disorder: A Qualitative Study by Ålgars M, Alanko K, Santtila P, Sandnabba NK in Eat Disord. 2012;20(4):300-11.

 

*I count 16 people with an eating disturbance or excessive exercise, according to their Table 2. I’m not sure if this is a typo or if two people reported symptoms that were not considered severe enough to be an eating disorder.

**It is difficult to tell from the study how many people identified gender dysphoria as a cause of their eating disorder. The study talks about 5 people who were suppressing their gender and 3 people who were accentuating their gender, but the two groups overlap. They quote one person twice for both suppressing and expressing their gender. There is no list of which people talked about which possible causes for their gender dysphoria, so there could be more overlap.

Based on the quotes they include, at least seven and possibly eight people mentioned something to do with gender as a possible cause of their eating disorder. This means at least six or seven did not.

It is also possible that some of the people who mentioned gender dysphoria as a possible cause of their eating disorder also mentioned other possible causes. Or that some people did not answer the question.

*** There was also one trans woman (“Julie”) who felt that genital surgery had made her less self-conscious about her body and her weight. However, she had never had any symptoms of an eating disorder or excessive exercise. Her case does not answer the question of how eating disorders may be related to gender dysphoria, especially since there is a group of people with eating disorders and gender dysphoria who did not say that gender issues affected their eating.

****The participants were tested on the Drive for Thinness, Bulimia, and Body Dissatisfaction sub-scales of the Eating Disorder Inventory-3.

 

More Details on the Study:

Eating Disorders and Gender Dysphoria

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise. Looking at their Table 2, I count 16 people with disordered eating and/or excessive exercise, but perhaps there were two cases where the symptoms were not severe enough to be considered disordered.

Of these 14 people, seven or eight mentioned gender as a cause of their eating disorder or excessive exercise (see footnote above as to why the number is unclear). This included 6 or 7 trans men and 2 trans women.

Six or seven people did not mention gender as a cause of their eating disorder or excessive exercise.

Other explanations given included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

“I have always wanted to feel that I can control my body.”

“I have felt like I was an outsider since I was little. I have felt inadequate, like I don’t belong to the group, and because of that any criticism about what was most essential to me, my body and how desirable I am, was a really serious thing to me.”

“At that age [eating] was really the only thing I could have an influence on.”

Explanations related to gender fell into three categories –

  • suppressing gender (“The background of that crazy weight loss was that my curves would disappear”),
  • accentuating gender (“It is easier to make a man’s body look feminine if you’re a bit thinner”), and
  • enhanced masculinity (“[After losing a lot of weight] I could buy pants at the men’s department, and they fit in a certain way, the right way, as I see it.”)

Four trans men mentioned suppressing gender, one trans man mentioned accentuating gender, and one trans man mentioned enhancing masculinity. It is possible that there is some overlap between the categories.*

One trans woman mentioned accentuating gender and one trans woman mentioned both accentuating and suppressing gender as possible causes of disordered eating.*

Eating Disorders and Transition

The authors identified sixteen people who had already begun hormone therapy and/or had surgery. In addition, one trans woman seems to have been self-medicating and one trans man had already had breast reduction surgery. Of these 18 people:

Two trans men said that said that taking testosterone had helped them recover from their eating disorder; they stopped caring about weight gain.

Two trans women said that taking hormones caused weight gain and in one case, problems with blood sugar. It is not clear exactly which medications they were talking about – estrogen and blockers or just estrogen. One of the trans women who said this was waiting to begin hormone treatment, so presumably she was self-medicating.

One woman who was considering gender reassignment said that breast reduction surgery had helped her recover from her eating disorder. She no longer cared about weight gain after the surgery.

One trans woman said that after genital surgery she felt comfortable in her body and didn’t care about any fat. However, she had never had any symptoms of disordered eating or excessive exercise, so this may not be relevant to people with eating disorders.

Current Scores on Subscales of the Eating Disorder Inventory-3 (EDI-3)

The study does not separate data on current symptoms of disordered eating and excessive exercise from data on past symptoms. However, the study participants completed three subscales from the Eating Disorder Inventory-E (EDI-3): Drive for Thinness, Bulimia, and Body Dissatisfaction.

We can not use the scores on three subscales of the EDI-3 to diagnose an eating disorder, but they may give some indication of how the participants are doing now.

Of particular concern are “Sue,” “Martha,” and “Leo.” Sue and Martha are trans women who had had genital surgery and were on hormones. Leo is a trans man who was on hormones but was waiting for a mastectomy.

Sue scored 16 on the drive for thinness scale, 17 on the bulimia scale, and 21 on body dissatisfaction. Martha scored 9 on the drive for thinnness scale, 9 on the bulimia scale, and 22 on body dissatisfaction. Leo scored 14 on the drive for thinness scale, 11 on the bulimia scale, and 34 on body dissatisfaction.  The three of them had the highest total scores compared to any of the other study participants.

Quote of the Day

“What frightened me most about the possibility of skin grafts was not my potential appearance, but rather the symbolism—my obviously stitched-together face being interpreted by others as a metaphor for the fakeness of my entire body, my gender. Whenever I shared this thought with cissexual friends, they always responded the same way, telling me that it was nonsense, that cancer-related skin grafts have nothing to do with transsexuality. And while that may be true in a logical sort of way, it seemed to me to be particularly convenient for them to say. Unlike them, I didn’t have the privilege of having my body viewed as inherently natural and congruent. My body is always betraying me, whether it was the male body that used to feel completely alien to me, or my current female state, which others view as inherently unnatural and illegitimate.”

from Excluded by Julie Serano, page 41.

Quote of the Day

“Humiliation is a whip of the defenders of gender. Humiliation is sanctioned at virtually every level of the culture: people can laugh at a transgendered person; but when there’s no fear of being humiliated for one’s portrayal of gender, there’s less opportunity of the culture to exert control.”

from Gender Outlaw by Kate Bornstein, page 88.

Review of: Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned

Another case where gender identity is linked to an eating disorder, this time in a trans man (born female).

And, another case where transition did not cure the eating disorder.

In this case a teenager who was being treated for his eating disorder requested therapy for gender dysphoria. His weight had already been restored, although he was still getting therapy for the eating disorder.

After counseling for gender dysphoria, the patient took testosterone and openly identified as a man. His anxiety improved, he had more friends, and he had his first girlfriend. Five months later, he had a bilateral mastectomy.

Ten months after surgery, the patient returned to the eating clinic for help. He said that his relapse began after his surgery and got worse when he returned to normal activity.

It is important to note that six months after surgery, the patient’s weight was normal and he felt better about his appearance. However, his eating patterns do not seem to have been discussed.

The patient had not continued counseling after surgery.

There are not many details on the patient’s gender dysphoria in this case study, but there does seem to be a connection between his eating disorder and his gender dysphoria. The patient “disclosed to his family that he felt like ‘a boy in a girl’s body’ and later acknowledged that his eating disorder was related to a desire to get rid of feminine features—’I dislike my curves, my breasts, my hips, my face. I wish I had more defined muscles in my arms and a more angular face.'”

It is worth noting, however, that the patient had two cousins with eating disorders. Genetics and environment were probably also factors in his eating disorder.

The authors make a number of important points about this case in their discussion.

We don’t know if medical transition helps with eating disorders.

“Studies show that medical interventions, including both hormone therapy and surgery, improve gender dysphoria. Their effects on disordered eating in patients with gender dysphoria, however, are less clear.”

On the one hand, in one qualitative study, a trans man who had had breast reduction surgery said it helped with his eating issues. In addition, another study found that patients who had had gender reassignment surgery had less body uneasiness than patients who had not or patients with eating disorders. It is not clear to me that this last study is relevant to patients with both gender dysphoria and eating disorders.

On the other hand,

“In our patient, although he experienced considerable improvement in body image, anxiety, and social functioning following treatment for gender dysphoria, he experienced a relapse in eating disorder behaviors postoperatively. Other case reports in adults describe similar relapses in disordered eating following medical treatment for gender dysphoria.* These cases suggest that, while GCS and other medical interventions often reduce psychological distress related to gender dysphoria, additional therapies may be required to ensure long-term resolution of disordered eating. Eating disorders have high rates of chronicity as well as relapse, particularly during periods of stress and life change. It is therefore crucial to engage all patients with gender dysphoria, regardless of their stage in treatment, in open conversations about eating patterns, body image, and thought processes.”

Urgent needs have to be taken care of first.

Treatment for patients with both eating disorders and gender dysphoria needs to be integrated and hierarchical; life threatening issues have top priority. In other words, you may have to eat before you can transition.

“Eating disorder treatment is complex given the combination of medical, psychological, and nutritional needs. Patients with gender dysphoria also have distinct needs related to gender incongruity. Using a hierarchical approach is one method to help focus therapy and ensure that all needs receive attention when appropriate. Life-threatening issues, such as vital sign instability from nutritional insufficiency or suicidality, should have first priority. These issues frequently require hospitalization to initiate nutritional rehabilitation and psychiatric care in a monitored environment. Following medical and psychiatric stabilization, weight restoration can often continue in the outpatient setting with multidisciplinary support from physicians, therapists, dietitians, and when possible, family members. Throughout treatment, the eating disorder team should strive to create a safe environment for the patient to explore the sources of his or her disordered eating, providing the opportunity to recognize or reveal any underlying issues. For patients with known gender dysphoria, the eating disorder team can assist by affirming the patient’s gender identity, allowing him or her to explore different options for expressing that identity, and providing resources for specialized care.”

Trans men’s eating disorders may look different from the norm.

Trans men may have different goals from other patients with eating disorders; patients with anorexia typically wish to be thin. Trans men may be trying to eliminate their period or reduce their curves as in this case and in this Turkish case study. The trans man in this study did not care about his weight, but was very dissatisfied with his body. It is important that these patients’ eating disorders not be missed because they are atypical. As the authors say,

“While the goals of weight loss in MtF patients often align with those of cisgender eating disorder patients, the goals of weight loss in FtM patients often diverge from those of cisgender patients, potentially limiting the utility of current eating disorder questionnaires in this population.”

We need to keep track of eating disorders after transition.

We can’t assume that a patient with an eating disorder will be fine after they are treated for their gender dysphoria. Treatment for the eating disorder needs to be ongoing.

“While improvement in gender dysphoria may lead to some improvement in eating pathology, many patients may benefit from additional support from an eating disorder team, as found for our patient. Further research should explore the success of different types of eating disorder treatment in adolescents with gender dysphoria before, during, and after gender dysphoria treatment.”

Not everyone needs the same treatment for gender dysphoria.

“Treatment for gender dysphoria varies from person to person. For some individuals, dysphoria can be alleviated through psychotherapy alone or combined with non-medical changes in gender expression. For many, gender dysphoria requires hormone therapy, surgery, or both. Adolescents who desire medical treatment later in life can use hormonal treatments to suppress or delay puberty. The Standards of Care of the World Professional Association for Transgender Health, however, recommends delaying suppression until the adolescent has reached at least Tanner Stage 2, so that he or she has some experience of his or her assigned sex. Hormone therapy to feminize or masculinize the body can also be started during adolescence, although this therapy should only be used in patients who demonstrate long-lasting or intense gender dysphoria, as the effects are only partially reversible. Surgery, on the other hand, may only be pursued once the patient reaches the age of majority for his or her country. For our patient, hormone therapy began at age 18 years, 10 months after expressing symptoms of gender dysphoria, and mastectomy was performed at age 19 years.”

Comparing eating disorders in transgender teens and adults

The authors also discuss the timeline of this case – i.e. gender dysphoria was diagnosed after the eating disorder. They contrast this with case reports of adults where an eating disorder developed during or after “assuming a transgender identity.” They add that “the only other case report available on adolescent patients describes a similar progression [to this study], with both patients initially presenting with AN and later expressing themselves as transgender.” 

Therefore, they suggest that “disordered eating may be the presenting symptom in some adolescents with gender dysphoria, highlighting the benefit of addressing gender identity in young patients with eating disorders. Gender identity may be addressed either using an intake form or during the patient interview.” (see below)

The situation is a little more complicated. In fact, in this case study a teenager developed an eating disorder when she decided to live as a woman. In addition, this study of an adult mentions that her eating disorder began at age 15 when she decided to live as a woman.

So we have two cases of teenagers who decided to live as women and then developed eating disorders and three cases of teenagers who were diagnosed with gender dysphoria during treatment for eating disorders. We don’t have enough cases to come to any real conclusions about the development of eating disorders and gender dysphoria in teenagers.

In any case, it may be that interviewing teenagers when they enter treatment for eating disorders will not lead to a diagnosis of gender dysphoria. In this case study, one of the teenagers was clear at the beginning of treatment that he was a gay man and did not want to be a woman. His gender dysphoria developed during the treatment of his eating disorder.

As always, we need more research. So far we have case studies of 17 patients. The individual cases vary widely and it’s unclear exactly how gender dysphoria and eating disorders are linked. It does not seem that treating gender dysphoria cures eating disorders, however.

This newest case study demonstrates that transition for gender dysphoria does not cure an eating disorder. It points to a connection between the eating disorder and the desire to be a man, but it also points to a possible contribution from genetic and environmental factors.

Original Source:

Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned by Strandjord SE, Ng H, Rome ES in Int J Eat Disord. 2015 Nov;48(7):942-5.

 

*In this case study, one of the trans women had an eating disorder in adolescence that returned many years later after surgery. In this case study, one of the trans women had transitioned but was still severely underweight – although the authors did not seem to think she had an eating disorder. Finally, in this case study, a trans man developed an eating disorder after surgery. He had not had an eating disorder previously.

In addition, there are a number of case studies where patients had eating disorders, although they were on hormones and had socially transitioned.

 

More details from the case study:

The patient had been seeing doctors for a couple of years before he brought up his gender issues.

At age 16 the patient was not getting his period, but his weight was normal and he said he had no body image concerns. The doctors prescribed oral contraceptives.

“The patient returned a year later with 2.3 kg of weight loss, resulting in a body mass index (BMI) of 16.9 kg/m2 (81% expected body weight for females of the same age). CS acknowledged daily exercise and a ‘desire for a different body shape,’ with a ‘more toned and muscular’ appearance. The patient denied food restriction, purging behaviors, or body image distortion and committed to increasing caloric intake to gain weight. Gender identity was not discussed and no treatment was pursued after this visit.

Five months later, CS presented with an additional 4.5 kg weight loss, resulting in a BMI of 14.9 kg/m2 (70% expected body weight). The patient then admitted to food restriction as well as a fear of gaining weight, leading to a diagnosis of anorexia nervosa (AN). The clinician did not inquire about underlying motivations for weight loss beyond general body dissatisfaction and anxiety.

There was no significant medical, psychiatric, or surgical history at the time of diagnosis. Family history included two cousins with eating disorders (specific diagnoses unknown). Socially, the patient was a high-achieving student with few peer relationships and no high-risk behaviors.”

At this point, the patient began 9 months of outpatient family-based therapy for anorexia. Four months into this treatment, he requested therapy for gender dysphoria. “He began biweekly individual psychotherapy to explore his gender identity and cognitive behavioral therapy to address ongoing anxiety.”

Ten months later he started to take testosterone and five months after that he had surgery to remove his breasts at age 19.

Medical treatment for gender dysphoria helped the patient significantly with his anxiety. He began to live as a man, expanded his peer relationships, and had his first romantic relationship with a woman.

His weight was stable for six months after surgery and he was more satisfied with his body, but the follow-up does not seem to have included any discussion of his eating (“a detailed discussion of his eating patterns and cognitions was not documented”).

He returned to the clinic four months later to deal with restrictive eating and excessive exercise. His body weight had decreased and his BMI had dropped from 19 kg/m2  to 17.9 kg/m2. He explained that “his relapse began postoperatively due to exercise restrictions and school-related stress, with his behaviors intensifying when he returned to normal activity.”

More details on interviewing patients about gender

The authors offer these sample approaches:

Sample approach on an intake form.
Use a two-step approach to identify both assigned sex and current gender identity.
Assigned sex at birth:
What sex were you assigned at birth, on your original birth certificate? (check one)
□ Male
□ Female
Current gender identity:
How do you describe yourself? (check one)
□ Male
□ Female
□ Transgender
□ Do not identify as male, female, or transgender
Sample approach in an interview.
Frame discussion with an opening statement.
“Because many people are affected by gender issues, I ask all patients if they have any concerns in this area. As with the rest of the visit, what you say will be kept strictly confidential.”
Begin discussion with a broad question(s).
“What questions or concerns do you have about gender, sexuality, or sexual orientation (who you are attracted to)?”
“How do you define your gender?”
“Have you been exploring gender?”

Sample intake form from:

Reisner SL, Conron KJ, Tardiff LA, Jarvi S, Gordon AR, Austin SB. Monitoring the health of transgender and other gender minority populations: Validity of natal sex and gender identity survey items in a U.S. national cohort of young adults. BMC Public Health2014; 14:1224. 

Sample approach for an interview from:

Makadon HJ. Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleve Clin J Med 2011; 78:220224

Transsexualism and Anorexia Nervosa: A Case Report – Review

This is a somewhat surprising case report of a trans man (born female) who developed anorexia nervosa after sex reassignment surgery.

The 24-year-old patient had surgery to remove his breasts, ovaries, and uterus. Afterwards he began binging and purging. He had not had problems with eating behaviors or weight loss before surgery.

This case is similar to the trans woman (born male) in this study who began to diet excessively after sex reassignment surgery. It is, however, different from this trans man who stopped dieting once he was on hormones and menstruation ceased.

The authors suggest that the eating disorder is an “expression of a gender identity process, or a conflict of an acceptance of one’s own sexuality.”

It is easy to understand why someone with gender dysphoria might dislike their body and develop problems eating, but in this case, the patient had already changed his body.

Why did the eating disorder develop after physical transition was complete?

Had he been focused on changing his body with hormones and surgery and then when he was done, he focused on his shape?

Was his eating disorder a sign of persistent body dissatisfaction no matter what he did?

The authors suggest that the patient’s underlying problems may have caused the eating disorder:

“In this case, there was clearly a linkage between a lack of sense in self-efficacy and a body dissatisfaction that continued after the sex change surgery. Discomfort with her/his own body appeared to be more deeply anchored than just being rooted in the wish to change the physical appearance.”

Alternatively, might the surgery have caused an abrupt shift in hormones that led to an eating disorder? More importantly, could adjusting his hormones help him recover from the eating disorder?

We think of testosterone and estrogen as sex hormones, but they are much more than that. Like all hormones, they are part of a complex system of chemicals that affect each other. Specifically, we know that “sex” hormones also play a role in appetite.

“The sex hormones estrogen, progesterone and androgens are involved in the complex regulation of appetite, eating and energy metabolism. In most species, including man, food intake and reproductive functions are closely linked. Thus, during the different hormonal phases of the menstrual cycle daily food intake varies and, moreover, remarkable physiological adaptations of appetite and body composition occur during pregnancy and lactation. In addition, regulation of eating behaviour and metabolic functions by sex hormones is of considerable general importance for women’s health, as indicated by the disturbances in this regulation associated with a number of clinical disorders.”

From “Sex hormones, appetite and eating behaviour in women.”

In this case study, the patient’s estrogen levels would have dropped significantly after his ovaries were removed. In addition, doctors normally reduce the dose of testosterone after surgery, although to a level typical for a man.

Women eat less during the phase of the menstrual cycle when estrogen levels are high, so it is possible that a drop in estrogen levels would be connected to eating more.

Furthermore, bulimia may be connected with polycystic ovary syndrome (PCOS), a syndrome which is characterized by elevated androgen levels.

Testosterone stimulates appetite and high circulating levels of this androgen in women have been associated with impaired impulse control, irritability and depression, i.e., common features of women with bulimia. Accordingly, it has been proposed that elevated levels of androgens may promote bulimic behaviour by influencing craving for food and/or impulse control. Hypothetically, bulimia may, in some cases, have a hormonal, rather than a psychiatric etiology, a suggestion supported by the observation that antiandrogenic treatment reduces bulimic behaviour. This may turn out to be a novel and valuable approach to treating women with BN, particularly those with hyperandrogenic symptoms.

From “Sex hormones, appetite and eating behaviour in women.”

The patient in this case study had symptoms that are typical of bulimia, binging and purging. Perhaps in his case the bulimia was related to the sudden drop in estrogen after surgery coupled with male levels of testosterone.

Most people do not develop eating disorders after sex reassignment surgery. There would have to be other factors involved, possibly genetic or psychological.

We have very little data on eating disorders and gender dysphoria, just a set of case studies.

However, we now have two cases of trans people developing an eating disorder after having surgeries that would have changed their hormones.

In one case, a trans woman began restricting her eating after surgery; in her case the surgery would have decreased her testosterone levels and thus, possibly decreased her appetite.

In this case, a trans man began binging and purging after surgery which would have decreased his estrogen levels and thus, possibly increased his appetite.

We need more research into this question. Do changes in hormones trigger eating disorders in some trans people? Most of all, can we use this to find a way to help trans people with eating disorders?

 

Original Source:

Transsexualism and Anorexia Nervosa: A Case Report by Fernando FernÁndez-Aranda, Josep Maria Peri, Victor Navarro, Anna BadÍa-Casanovas, Vicente TurOacuten-Gil,& Julio Vallejo-ruiloba in Eating Disorders: The Journal of Treatment and Prevention, Volume 8, Issue 1, 2000 pages 63-66.

 

More details on the patient:

After surgery, the patient had “2-4 weekly binge episodes with daily vomiting and abuse of laxatives and diuretics.”

He was overly concerned with being fat and wished to be thinner so his body shape wouldn’t look female.

He was moderately underweight, but then “during the last six months, he lost more than 15 kg [33 pounds] of body weight through restricting food intake.”

The Eating Attitudes Test, Eating Disorders Inventory, Body Attitudes Test, and Body Shape Questionairre showed “severe eating pathology and negative body experience.”

The patient also had problems with alcohol and drug abuse, self-mutilation, and suicide attempts, but these had begun at age 17.  He was diagnosed with “gender identity disorder, alcohol dependence, anorexia nervosa (purging subtype), major depression (Axis I), and borderline personality disorder (Axis II).

The patient’s father had obsessive-compulsive disorder and one of his sisters had an affective disorder.

As a child, the patient felt like a boy, didn’t play with girls, tried to hide any feminine parts of his silhouette, and hated feminine features of his body.