Gender nonconformity is the second most popular search term that leads people to Science of Eating Disorders. (After “science of eds” and beating “science of eating disorders”.) Not far behind are variants of “FtM/MtF/transsexual/transgender” combined with “eating disorder/anorexia/bulimia”. That’s telling. It means there is little information on this topic. And it is not just that there’s too little information available to the public – there are only a handful of published studies in the peer-reviewed literature.
One study (which I discussed in my previous post: Gender Nonconformity, Transsexuality and Eating Disorders) published by Vocks et al (2009), compared disordered eating patterns, body image disturbances and self-image scores among trans women and men (131 participants in both groups) and cis female and male controls as well as to females with eating disorders.
Overall, they found disordered eating patterns reported by trans women and trans men were in the middle of those diagnosed with eating disorders and non-ED, cis controls. More specifically, trans women individuals had more severe disordered eating pathology than both female and male control groups, whereas trans men individuals reported higher levels of disordered eating than male controls but were similar to the female control group.
Several hypotheses have been raised to explain these (and similar) findings. I discussed them in my previous post, but I’ll briefly mention what I think are the two main explanations: firstly, disordered eating patterns might be used to suppress secondary sex characteristics for both trans men and women, and secondly, disordered eating might be a way to deal with the stigma, poor self-esteem, negative self-image, perhaps abuse and/or isolation that many gender nonconforming and transgender individuals face.
But those are just hypotheses, based on the authors’ own ideas and through interviews reported in case studies. Monica Algars and colleagues wanted to evaluate trans men’s and women’s’ “own understanding of [the] underlying causes.” What explanations and reasons did trans men and women participants provide for their eating behaviours and, if applicable, how did it change after gender reassignment treatment.
Algars interviewed 11 trans men and 9 trans women adults (age range: 21-62). The table below, taken directly from the paper, summarizes several characteristics of the sample. Please note that the names of the participants have been changed to protect their identity.
I removed the BMI values (self-reported) from the table below because I don’t think it is too important. (The average BMI of all participants is in the overweight category.) There were no differences between the groups in BMI or the Eating Disorder Inventory-3 (EDI-3) scores. Fourteen out of the 20 participants reported a history of disordered eating (70%).
The table below, again copied directly from the paper, summarizes broad eating disturbances experienced by the participants along with their EDI-3 scores. I am not sure what the EDI-3 scores would be of a non-eating disordered female, for example, so it is difficult for me to compare, except within a group. What are the EDI-3 scores for a non-ED, cis female, non-ED, cis male, and cis ED female and male (for bulimia and anorexia)?
Although Algars, in the discussion, mentions that the “current mean EDI-3 scores on the subscales Drive for Thinness & Body Dissatisfaction were comparable to that of adult women not suffering eating disorders. Nonetheless, a within-study control group would be really helpful.
Algars and colleagues identified nine themes (organized into three “higher -order constructs”) that came up through-out the interviews. (Algars et al used grounded theory coding to analyze the interviews.)
The three higher-order constructs were: the nature of disordered eating, the perceived cause of disordered eating and the impact of gender reassignment on disordered eating.
In terms of disordered eating, the majority of participants reported dieting (65%), 25% said they’ve experienced bingeing, 25% engaged in purging behaviours and 40% reported excessive exercise. Note, the percentages don’t add up because one participant could have experienced all four disordered eating behaviours (or three or two or none).
The descriptions of the disordered eating behaviours are indistinguishable from diagnosable eating disorders – at least in the Algars et al paper:
dieting: ... keeping track of and restricting calorie intake, only eating certain foods, avoiding situations in which people eat, purposefully maintaining an abnormally low body weight, and weighing themselves several times a day …
bingeing: … eating large amounts of food in a short time, being unable to stop eating although they felt sick, and feeling that they could not control their eating …
purging: … purging after binge-eating, while others also had purged after eating only small amounts of food. One trans male participant reported chewing and spitting …
excessive exercise: ... bike at least xx km every day … amenorrhea due to excessive amounts of exercise
PERCEIVED CAUSE OF DISORDERED EATING
Participants that reported instances of disordered eating explained their thoughts about the underlying causes. Five participants (four trans males and one trans female) reported engaging in disordered eating patterns to suppress their biological sex (reduce femininity or compensate for masculine features, such as height). I think this is really important information, so I’m going to be quite liberal in lifting up quotes from the paper:
Andy: The background of that crazy weight loss was that my curves would disappear. They have always felt disgusting, for example my hips and my breasts.
Aaron: I felt like I wanted to diet my gender away completely, or, like, dispel it altogether. I still feel like that sometimes, that I have to diet, because otherwise I’ll start looking like a woman again.
Robert: Weight gain would have brought forth my feminine ﬁgure, which was disgusting to me. (. . .) I was so skinny that people asked me if I was sick or something, because I wanted to keep my body’s femininity at a minimum, so the fat wouldn’t distribute to feminine places.
Others – three trans female and one trans male participant – reported using weight loss to accentuate their gender.
Martha: I thought that because I was a woman I had to look good, to look more like a model. I just felt a lot of pressure to be thin all the time. I wanted to be smaller, more delicate. In my opinion it is connected to being a woman.
Heather: In general, women are more slender than men. It is easier to make a man’s body look feminine if you’re a bit thinner. ( . . . ) When I was thinner it was nice to see that I had a waist.
Mike: [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. And also, I felt strong, which I perceived as masculine.
And yet for others, disordered eating served other emotional and psychological purposes, including self-control, managing feels of inadequacy and isolation, desire for autonomy and freedom, feeling that they did not deserve to eat, that it made “sexual situations easier,” and helped them manage stress.
IMPACT OF GENDER REASSIGNMENT ON DISORDERED EATING
Out of the participants, 16 had undergone some kind of gender reassignment or treatment to facilitate transitioning into their desired gender. Algars and colleagues explored the effects of this transition on disordered eating behaviours. Four participant felt that the changes were for the positive whereas two experienced negative changes due to unwanted weight gain (the result of hormonal therapy):
Robert: Until I received hormone therapy, I controlled what I ate. (. . .) Now it doesn’t matter if I gain weight, I suppose it accumulates in different places now. The fear of weight gain, or fear of femininity, is not an issue at all anymore, that’s all gone.
Megan [trans man]: After my breast reduction surgery I gained some weight, but I was only happy about it. I could imagine being a fat man, but I could never be a fat woman. There is a huge difference.
Interestingly, Julie felt almost the converse to Megan:
Julie: Immediately [after the operation] I wanted to join the other women in the sauna, even completely undressed. Somehow I tolerate it much better now, even if someone would say something about my ﬂab, it wouldn’t feel as bad as when I was a man. I feel like I am myself now, even with my fat. Maybe I’ve gained some kind of self-conﬁdence.
Case studies and qualitative approaches are insightful and often fascinating, but a sample size of 20, of course, is limiting. Moreover, the sample was not random (participants could have been attracted to take part in a study due to their previous experiences with disordered eating) and all reports were from memory. Thus, the extent to which this is representative of the larger trans community remains to be seen.
Despite this, Algars’ study highlights the need for more awareness (and understanding) of pertaining to the trans community, as well as a need for specialized treatment approaches “to develop prevention and intervention measures” for disordered eating in this population.
There is a need. As one tumblr blogger put it, when linking to my previous post on eating disorders in trans/gender nonconforming individuals:
“If there were a treatment center that specialized in transgender issues, I’d be there in a second.”
(Note: I noticed that my last post on this topic was shared on a particular tumblr blog along with the comment that the terms I had used in my post were not always correct. I inquired about the mistakes, but unfortunately did not get a response. So, if I misused or conflated terms, please let me know! I am going based on information on-line, like this. But let me know if I am messing things up and I’ll correct it.)
Algars, M., Alanko, K., Santtila, P., & Sandnabba, N.K. (2012). Disordered Eating and Gender Identity Disorder: A Qualitative Study. Eating Disorders, 20 (4), 300-11 PMID: 22703571