Gender Nonconformity, Transsexuality and Eating Disorders

Too many people still mistakenly believe that eating disorders are for the Mary-Kates, Nicole Richies and Lara-Flynn Boyles, or vain adolescent and teenage girls aspiring to be just like them. Actually, as I’ve blogged earlier, even male veterans in late middle age are not immune to struggling with anorexia and bulimia nervosa. All in all, males make up ~ 5-10% of all eating disorder sufferers.

But what about those that dread having to check off “male” or “female” on a data form? What about individuals who feel their gender identity is not the same as their assigned birth sex. Perhaps they were born in a female body, with two XX chromosomes, but they feel and prefer to think of themselves as males, or the reverse? There’s some research (albeit limited, due to the rarity of both gender dysphoria and eating disorders) that suggests these individuals face an increased risk of developing eating disorders.

The most relevant and recent study on the intersection of gender identity and eating disorders that I found was published by Vocks et al. in 2009. The goal of their study was to look at how individuals with what they call “Gender Identity Disorder/GID” but I will use a neutral term like gender nonconformity (GN) or transgender compare to control groups of both sexes and to people with eating disorders in “the degree of eating and body image disturbances, self-esteem and depression.”

The strength of this study was the number of trans women and trans men that they were able to enroll (88 and 43, respectively). Their control groups included 62 females with eating disorders (16 AN, 21 BN, and 25 EDNOS patients), and 56 cis male and 116 cis female control groups without EDs. Then, they gave them a whole lot of questionnaires to fill out: six in total.


Trans Women

  • Scored higher in restrained eating, concerns about weight, eating and shape, drive for thinness, binge eating/purging behaviours, body dissatisfaction and body checking than cis male controls
  • Scored higher in weight and shape concerns, body dissatisfaction and body checking than cis female controls

Trans Men

  • Scored higher in restrained eating patterns, weight and shape concerns, body dissatisfaction and checking than cis male controls
  • Did not differ from cis female controls in risk for eating and body image disturbances

The only difference identified between trans women and trans men groups was in body checking (trans women did more than trans men). No other differences were found. But, both groups scored lower than the eating disorder group in body image and eating disorder disturbances.

The authors make many assumptions and post hoc explanations,  but I don’t think they are anything more than, at the present time, unsupported justifications on the part of the author to explain the findings . Ultimately, we don’t know anything beyond what was reported in the questionnaires, so the “why’s” will be left unanswered.

Snippets of their proposed explanations for trans women:

.. higher degree of disturbed eating behavior and body image among [trans women] compared to [cis] controls of both sexes, might be explained by the fact that, on average, these persons have a higher BMI than [cis] females… to attain a more feminine and thus a thinner body, [trans women] might experience pressure to lose body weight, and thus display a higher cognitive control of food intake, resulting in an over concern with eating, weight, and shape….. the higher scores in bulimia in the [trans women] compared to [cis] male controls might be due to a more pronounced food deprivation status. The finding of the enhanced degree of body dissatisfaction among [trans women] might be explained by the discrepancy between their own larger biological male shape and the ideal thinner feminine figure.

For trans men:

It can be speculated that this result is due to the observation that [trans men] try to reduce body weight in order to suppress the secondary sexual characteristics… one could also assume that some [trans men]  might try to avoid losing weight or even to put on weight in order to avert sexual attraction for being a woman from men or to gain weight so as to reduce the prominence of breast and hip girth compared to abdominal girth.

Limitations and Weaknesses of the Study

  • self-identified trans* (perhaps not all of them fit the full “GID” criteria in DSM-IV)
  • low sample size
  • questionnaires were developed for ED patients – the trans men and trans women groups might interpret some of the questions very differently (quite obviously, body dissatisfaction could be unrelated to EDs in gender nonconforming individuals).
  • no assessment of sexual orientation (previously implicated in predisposing toward EDs), which would have been interesting to consider

I also came across a couple of papers discussing interesting case studies of eating disorders in individuals with gender nonconformity. I’ll briefly discuss one by Hepp & Milos from 2002.

Hepp  & Milos (2002) cite the following statistics:

  • incidence of anorexia nervosa in males: 0.34/100,0000 (data from Switzerland, by Milos et al., 2001)
  • lifetime prevalence of transsexualism (in European countries) ~ 2/100,000 adults

While homosexual men are recognized to be a risk group for eating disorders, there exists hardly any literature about gender identity disorder [gender nonconformity] and eating disturbance.

They report three cases of transsexual patients with eating disorders. They were referred to their “outpatient service for sex-reassignment [and] are first accurately assessed” (unlike in the Vocks et al., study) “Hormonal treatment takes place when transgender identification has proved to be constant and the patients have succeeded in living in the new gender role for at least 12 month. The surgical sex reassignment takes place after a period of at least 6-12 month of hormonal treatment”.

Case 1: 35-year-old Trans Woman with Anorexia Nervosa:
“In adolescence [she] felt a deep body dissatisfaction, [she] engaged in restrictive eating behaviour and [her] body weight decreased to .. [a low BMI]…[ after sex-reassignment surgery], she again showed an increasing preoccupation with her body weight and shape. Her eating behaviour was again restrictive. She still avoids highly calorific foods and warm meals. She feels too fat and seeks an “ideal” body shape.”

Case 2: 22-year-old Trans Woman with Bulimia Nervosa:
Initially obese, after deciding to “come-out” and begin cross-dressing in public, [she] lost weight to a low-range of normal in 2 years. “The eating behaviour at the beginning was dietary restriction, followed by purging, binge-eating, and self-induced vomiting. [She] consumed anorexic 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. [She] is convinced that [her] acceptance as a female would depend greatly on an ideal body shape.”

Case 3: 43-year-old Trans Man Transsexual with Anorexia Nervosa (?): 
Although [he] was underweight during [his] initial visit, and [his] minimal adult BMI was really low, accompanied by amenorrhea and [he] had never reached a normal weight, “[He] denied ever having intended to diet deliberately. [He] reported no binge-eating or self-induced vomiting, but [he] was purging. [He] denied preoccupation with her weight but reported a strong body dissatisfaction.” Unfortunately, “because of severe liver disease and the psychic instability and alcohol dependence, it was impossible to start a hormonal treatment.”

Hepp & Milos hypothesize:

The hypothesis could be that for [trans women] underweight is a way to suppress their libido, and at the same time their way to correspond to a female ideal of attractiveness. Many of the [trans women] strive to be a “superfemale” and tend to accentuate female traits. Being female and attractive is put on the same level as being slim (Waters, 1998). For [trans men] underweight is a possibility to suppress the secondary sexual characteristics and the menstruation. It is probably not so much the wish to be slim rather than the rejection of the feminization that leads to a weight restriction… Changing the eating behaviour (fasting, dieting, vomiting) might be an inadequate strategy to reduce stress and modify the body and the sexuality.

Those are interesting hypotheses, but whatever the reasons may be (and I don’t feel expert enough to comment on this topic), there are clear clinical implications of these findings:

Most treatment programs are designed for adolescent girls, and while that’s remains the majority of the treatment seeking population, a different approach to treatment and prevention is needed for all of the others: adult women with eating disorders, adult men, young men, gay men, and trans people. These groups have different needs and need a different approach.

Vocks et al concludes by stating this better than I can:

Future research should develop and evaluate the effects of such prevention programs for persons with [gender nonconformity] with regard to eating and body image disorder. The aim should be to find out which treatment module is most helpful for which persons at which stage of transsexual development in order to prevent these persons from establishing dysfunctional eating patterns that might enhance the risk for a clinically relevant eating disorder.

If you are interested in reading more, there are two other papers that I read for this post but didn’t have space to include, “Anorexia Nervosa and Gender Identity Disorder in Biologic Males: A Report of Two Cases” by Winston et al., 2004 and “Gender Identity Disorder and Anorexia Nervosa in Male Monozygotic Twins” by Hepp, Milos & Braun-Scharm, published in 2003.

Finally – this is not a topic I am familiar with but thought it would be interesting to discuss and read about, following a request by a reader to write about the intersection of gender dysphoria and eating disorders. So, I’d love to hear any of your thoughts, opinions and perhaps, personal experiences, with regard to this topic. Do you think ED’s in transgender individuals are the same, different or in some ways similar but in other ways different, from the  typical young adult or adult female with an eating disorder?

Follow-up post: “Understanding Disorders Eating in Trans Individuals”


Hepp, U., & Milos, G. (2002). Gender identity disorder and eating disorders. International Journal of Eating Disorders, 32 (4), 473-478 DOI: 10.1002/eat.10090

Vocks, S., Stahn, C., Loenser, K., & Legenbauer, T. (2009). Eating and body image disturbances in male-to-female and female-to-male transsexuals. Archives of Sexual Behavior, 38 (3), 364-77 PMID: 19030979

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Tetyana is the creator and manager of the blog. She has an Honours BSc in Neuroscience and an MSc in Medical Science. She can be reached at tetyana[at]scienceofeds[dot]org.


  1. I had an ED (NOS and then Bulimia) from age 18 to 23, bookended by disordered eating. I’ve had body image issues since the onset of puberty. I didn’t come out as transgender until age 26, mostly because I hadn’t known that was a possibility. In my teens and early twenties, I fought against my body, punished it for its disobedience to my will, dissociated from my body often just to get through the days.

    I always wonder how my life would be different if the idea of gender dysphoria were brought up in therapy years ago. Would it have clicked for me at age 19? Would it have saved me years of self-abuse and body hatred if someone had told me that I could make my body match my mind?

    • Thanks for the comment fourlinepoem, really appreciate it. I can’t help but wonder whether EDs in this subpopulation are related more to the physical body (what the authors hypothesize above) or to the fact that it is just a way to deal with the stress, frustration and all the other emotions that come with GN? Both?

      When you came out, did the begin to subside or end (or did it end prior to that?)

  2. I am a gender nonconforming person with a long history of eating disorders–Anorexia and NOS bouncing back and forth with occasional periods of “disordered eating.” I am not trans, but I do not gender identify with my biological sex. (I’m queer)

    Personally, the eating disorder has been related to both trying to suppress the physical body and for more typical emotional reasons (need to control, abuse, etc).

    The first time it got really bad was during puberty when I became very angry about my body. I am female bodied and I was a nationally competing athlete. For a long time I was pissed off that at puberty males tend to gain muscle and lose fat while females gain fat and lose muscle. I fought against that by starving. I refused to gain fat.

    Later, when my gender became more firmly non-female, I starved even more to try and suppress my breasts.

    As a child it was all about control, and my most recent relapse has been more about control and emotional issues than about my need to suppress my secondary sex characteristics–but it’s still about both.

    I’ve always felt that if I was not queer my eating disorder would never have developed as much as it has. That may be an unreasonable assumption, but it’s how I feel about it.

    • Kae, thank you for commenting.

      I don’t think what you said is an unreasonable assumption – what makes you say that? It seems very reasonable.

      For me, the things that lead me to restrict, binge and purge have changed drastically over the last 9 years. My eating disorder has at times been very connected to my physical body, particularly in the beginning (associated with a lot of body dysmorphia). Although I feel like those were distractions from a lot of other stressors in my life at the time (hating my body felt easier, and it was a nice “reason” to restrict, which was just so utterly calming). But now it is not at all connected to it (comparatively, I have almost no body image issues, despite my weight fluctuating rapidly, and often), it is about the anxiety-reducing effects of restricting and bingeing/purging, more than anything. But, even that isn’t always true: after 9 years, a lot of things are just a habit. It seems like just my “natural” state to mildly restrict if everything is well and I’m fine, or binge/purge or severely restrict if things aren’t, depending on the situation.

      The topic of sexuality and gender and how it is connected to eating disorders is so interesting to me, but I feel like I can only go from my own experiences and I don’t know how much of what I think and feel now, about that aspect of the ED etiology, are just posthoc rationalizations. It seems to make sense, but it is not necessarily so. I think my eating disorder is also quite tied into these topics, but, I haven’t thought about it enough to feel comfortable writing about it, just yet.

  3. i identify as genderqueer and i had a some disordered eating for a bit. Gender and eating are so tied together, like at the end of middle school i was super restrictive and lost weight but also was big on exercise; the sense of control i got from being able to sculpt my body into something more masculine, and then i had type II ammennorhea, which also secretly made me very happy, as i always had fantasies of some sort that i wasn’t a biological female, that i would be infertile, or my estrogen levels would be low or testosterone high. i was secretly very happy that my doctor thought that my case warranted genetic testing for some sort of chromosomal abnormality that would be make me “not entirely female.” Well that wasnt the case, but i was happy that my estrogen levels wound up low. i never really hated menstruating, sometimes i viewed it as a stark biological function, and other times when i was in “girl mode” cuz my gender even then was so fluid, it was this cool “forcedefemme” almost empowering thing, but either way i was happy to see it go because that would reinforce my identity as “neither male nor female”.

    And then theres also just the desire to have control or to make meaning of the world around you when you dont socially fit in or have any friends. it was lonely out there, i needed SOMETHING to do, so even when i didnt want to be restrictive anymore i still had disordered eating because food became my life. I wouldnt eat anything all day, work out hard, and then seriously eat all night i think simply because i felt i had nothing else better to do with my life besides engage in this starvation-feast addiction.

  4. Hello! There is indeed a burgeoning recovery resource for trans* people struggling with EDs! T-FFED: Trans* Folx Fighting Eating Disorders is the first grassroots, trans*-focused, affordable eating disorder recovery initiative to address the underserved and under-researched needs of transgender, genderqueer and non-binary people who disproportionately struggle with eating disorders and body image issues. T-FFED aims to produce multi-day and digitally accessible pop-up events (featuring workshops, support groups, nutrition, healing activities, resource-sharing and toolkit building) in cities with demonstrated need, as well as train ED healthcare professionals to better understand the unique needs of their trans* clients and patients. We are also currently conducting a survey to assess/demonstrate need and receive valuable feedback from the trans* community. Please share this valuable resource and help in this revolutionary work!!

  5. For me, starving was always about looking more masculine. I wanted a more defined jaw, a flatter chest, narrower hips, and I wanted the menstruation to stop. I didn’t particularly care about being skinny, I just wanted to not look so female. To not feel so female.

    I still struggle with allowing myself to eat, because every calorie looks like a breast-enlarging piece of fat. And I sometimes work off more than I’ve eaten. I’m slowly developing better and more healthy habits, but it’s going to take a while. I think beginning hormones will help finally get me out of this, since the fat I gain won’t go directly to my chest and hips. I wouldn’t mind being kind of fat, as long as I was a kind of fat MAN.

  6. Late to the discussion here but was thinking about this today. I am not trans but realizing I am probably non-binary, though I didn’t previously think that applied to me, but I have always been a very masculine heterosexual cisgendered female. A “tomboy” but moreso. To the point where as a child I hated the things that made me a “girl.” And still do, I would rip out my uterus and rip off my breasts in a second if I could but don’t feel that I was assigned the wrong gender, just that I don’t like the femininity in my gender. And with my ED my period stopped, my breasts shrank, I was able to almost eliminate those parts of myself. Correlation or causation? I don’t know. I wish there was more insight into this area.

    • Thanks for your comment, Jessica. I agree that it is hard to know how they relate, especially since the relationship might vary for different people. For some, the weight loss might be more purposeful and more connected to the gender dysphoria, but perhaps for others the results of the weight loss are a nice bonus for the gender dysphoria issues, if that makes sense?

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