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.
- 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
- 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?
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