Recently I was doing some research for an upcoming (and very exciting) endeavour that involves exploring eating disorders among LGBTQ individuals. As one does, I set about scouring the research literature in this area in the hopes of stumbling across some prior articles on which to hang my proverbial research hat.
As I sifted through the databases, however, my searches kept coming up short. After sending out a call to a list-serv enquiring about the state of the field in this area, I received many responses highlighting the gap that surrounds trans individuals in particular. While this is good news for arguing for the value in conducting research in this area, it is discouraging news when it comes to understanding and attending to the experiences of trans people with eating disorders.
All this is to say, it seems as though now is as good a time as any to dip my toes into writing in this area through blogging about it. To focus this discussion, I will explore an article I came across in my search by Murray, Boon, and Touyz (2013) presenting case studies of two trans eating disorder patients. Tetyana has also blogged about some other articles in this area, including a study by Algars et al. (2012) here and one by Vocks et al. (2009) here.
It might be helpful to explore some of the language used in such studies before beginning. I will use the word “trans” to refer to this population. Often, the academic literature uses clinical terms such as “GID” for gender identity disorder; however, there is a fair amount of controversy surrounding the clinical label of GID. I am far from an expert in this area, however, a basic debate to keep in mind relates to how trans individuals feel about being labeled as having a “disorder.”
This label can be useful in terms of obtaining coverage for gender reassignment surgery, much in the same way having a diagnosis of anorexia nervosa may allow treatment to be covered under insurance plans. However, there is also a legacy of discrimination and marginalization surrounding the terminology and labeling of trans people that may lead to a rejection of the label. If you are interested in learning more about the debates about this label, there are some interesting articles (see here).
The literature often also refers to “biologically female” and “biologically male” participants, which can also open up a whole new can of worms, particularly if participants are referred to by pronouns concordant with “biological sex” depending on whether or not they have undergone gender reassignment surgery. As I am obviously unable to ask these individuals which pronoun they prefer, I will adopt a more neutral “they” when referring to specific individuals below.
Also, “trans woman” refers to an individual who identifies as a female but was assigned male at birth, and vice versa for “trans man.” (In contrast, “cisgender”/”cis woman”/”cis man” refer to individuals whose experience of their gender match the sex they were assigned at birth.)
What I mean to say in this very unwieldy, brief, and simplistic discussion is that there are politics around language use. It is not my intention to spark debate around these labels in this post, but this is something to keep in mind when interpreting literature in this area. I’m bound to offend someone when navigating the language, so please call me out if I do so. I’m always pleased to learn.
Among the studies highlighting eating disorders among trans individuals, the case study has been most prominent. In 1998, Surgenor & Fear published a case study reporting on a 25-year-old trans patient at an eating disorder clinic. This paper is widely reported to be the first major published study looking at the experiences of a trans person with an eating disorder. Since then, other case studies have been published, revealing mixed degrees of association between participants’ eating disorders and experiences of being trans.
In the case study vein, Murray, Boon, and Touyz (2013) present two case studies of trans women, both of whom met diagnostic criteria for eating disorders. The authors discuss how these two patients endorsed feminine and masculine gender identities at different times in their lives, and how these differing orientations toward gender altered their perceptions of their bodies and, ultimately, their eating disordered behaviour.
The first case study presents a 23-year-old patient diagnosed with anorexia nervosa (AN). When this individual identified with a female gender, they expressed a preference for a thin female body. Accordingly, they scored high on measures of drive for thinness and engaged in body excessive exercise and restriction in order to lose weight. They also found that occupying an emaciated body helped them to cope with their inability to bear children.
When this patient endorsed a preference for a male gender identity, they preferred a bulky, muscular body, and oriented their eating and exercise behaviours around the pursuit of muscle gain. Most interestingly, the patient experienced an equal degree of body distress and dissatisfaction regardless of gender orientation.
In the second case study, the authors present details about a 24-year-old patient diagnosed with bulimia nervosa (BN). This individual had a history of discomfort around both sexual orientation and identity, finding that endorsing a female gender helped to alleviated discomfort they experienced related to homosexuality. They also adopted both a masculine and a feminine gender at various points in time, endorsing a muscular ideal and thin ideal, respectively.
Using both of these cases as a framework, the authors suggest that more research specifically focuses on the links between gender identity, body image and eating disorders.
It is pretty interesting that both of these patients identified with feminine and masculine gender identities at different points in their lives. This not only highlights the fluid nature of gender identity, but complicates the gender binaries we place on individuals in our society.
This article begins to scratch the surface of the complicated relationship between gender identity and eating disorders. It builds, too, on an increased interest in how eating disorders manifest in “biological males,” whether or not they are transgender. The recognition that body dissatisfaction is not always tied up with a desire for thinness is certainly of note; drive for muscularity seems to have contributed to both patients’ body dissatisfaction.
The particular relationship between gender identity and eating disorder symptoms also bears further exploration, as the authors acknowledge. While we could make the more simplistic assumption that trans men may engage in disordered eating to suppress secondary sex characteristics while trans women desire to lose weight in order conform to feminine body ideals, there seems to be more to the picture than that.
It may well be that some trans individuals desire to become the “hyper feminine” or “hyper masculine.” However, these explanations hinge heavily on the assumption that body image has the most influence on the development of eating disorders. We cannot overlook other potential contributors, such as depression, anxiety, and trauma, and other factors. Is engaging in eating disorders a way of managing depression and anxiety symptoms, or of coping with living in a gender binarized society?
Murray, S. B., Boon, E., & Touyz, S.W. (2013). Diverging eating psychopathology in transgendered eating disorder patients: a report of two cases. Eating Disorders, 21 (1), 70-4 PMID: 23241091