The Role of Gender Dysphoria in the Development of an Eating Disorder

Gender dysphoria is a disorder characterized by distress associated with identifying as a gender that differs from one’s sex assigned at birth (1). This distress leads to a higher risk of body image dissatisfaction, which in turn can lead to an increased risk of disordered eating behaviors (2). According to one study, transgender college students were over four times as likely as cisgender heterosexual female college students to be diagnosed as having an eating disorder (2). Some factors commonly seen in the development of eating disorders are a fear of gaining weight, a disturbed perception of one’s own body image, and cultural value placed on thinness as the body ideal (1). These factors tend to affect woman more than men, as reflected in the 10-to-1 female-to-male ratio of disease prevalence across both anorexia nervosa and bulimia nervosa (1). Less is known about how these factors affect the development of disordered eating behaviors (DEB) among gender minorities—that is, individuals whose gender identities are discordant with their sex assigned at birth.

This case report describes a transgender male patient with an extensive psychiatric history, who was admitted to the inpatient psychiatric unit for a suicide attempt and was found during this admission to have atypical anorexia nervosa. The purpose of this case report is to explore the ways in which the psychopathology underlying DEB and eating disorders can differ between transgender and cisgender individuals.

Case Presentation

A 19-year-old female-to-male (FtM) transgender patient with a psychiatric history of attention-deficit hyperactivity disorder (ADHD), bipolar I disorder, and borderline personality disorder presented to the emergency department because of a suicide attempt. The patient reported increasing depressive symptoms, including poor appetite, in the weeks leading up to this admission. On arriving in the inpatient psychiatric unit, the patient disclosed that he had not eaten food since the day prior to admission. The patient stated that he did “not have a good relationship with food” and restricted his caloric intake in an attempt to alter his body shape. His food restriction behaviors included limiting his daily intake to 500 to 1,000 kilocalories. His purging behaviors included self-induced vomiting after meals, ranging from twice a day to once every 2 weeks. The patient endorsed a history of excessive exercise and denied current binging behaviors. His body mass index was 26 at the time of admission.

At age 8, the patient first received psychiatric care for ADHD. At age 11, he was diagnosed as having depression, with nonsuicidal, self-injurious behaviors (e.g., cutting and burning). At age 12, the patient began to identify as male. Family members were not supportive of the patient’s gender identity and continued to misgender the patient, which the patient felt contributed to the worsening of his depression. Subsequently, the patient began to engage in the restriction of his caloric intake, self-induced emesis, and excessive exercise to halt the development of secondary female characteristics during puberty. Throughout his adolescence, the patient continued to engage in DEB to “feel a sense of control” and “lose weight.” Worsening depressive symptoms led to two suicide attempts and a psychotic break at age 18.

Discussion

Eating disorders more commonly affect cisgender women than cisgender men; however, less is known about how gender minorities are affected. One literature review identified 20 publications between 2014 and 2019 on eating disorder diagnoses and symptoms among transgender youths, 10 of which were case studies (3). The existing case studies depicted a theme of gender dysphoria leading to DEB, especially food restriction as a means of delaying the progression of puberty (3). The patient described in this case study began to identify as male and displayed DEB around the onset of puberty at age 12.

Puberty contributes to the development of eating disorders in cisgender females because of associated weight gain and redistribution of body fat (4). The changes in body shape can increase body image dissatisfaction and lead to DEB (4). These same changes in body shape and weight likely contribute to the development of DEB among patients who identify as transgender and nonbinary (TGNB). Additionally, the development of secondary sexual characteristics during puberty is particularly distressing to those who do not identify with their sex assigned at birth and can lead to attempts to delay or halt the progression of puberty (5). Diet restriction and excessive exercise are far more accessible than is gender-affirming care, especially for adolescents. Consequently, DEB can delay the onset of puberty, slow breast development, and cause amenorrhea; this may be particularly desirable for FtM transgender patients (5). Of note, the prevalence of eating disorders is higher among FtM patients than male-to-female (MtF) patients, which suggests that female sex may be an independent risk factor for DEB (6).

When discussing the psychopathology of eating disorders and gender dysphoria, puberty needs to be considered a social factor as well as a biological factor. In Western cultures, societal expectations for thinness are prominent for female adolescents and contribute to the development of eating disorders (5). Such societal expectations of body weight and shape can be exacerbated for transgender patients (5, 6) because the development of secondary sexual characteristics makes it more difficult to conform to the expected appearance of their gender (7). The rate of suicidality is higher among transgender adolescents, and a contributing factor is the development of secondary sexual characteristics that are discordant with their gender identities (8). MtF transgender patients tend toward concerns of body weight and shape, concurrent with the eating disorder psychopathology associated with cisgender females (5, 7). On the other hand, DEB among FtM transgender patients may reflect a desire to change their bodies to better represent their gender identities. Examples of this include methods to halt the progression of puberty, as previously mentioned, as well as excessive exercise for muscle building in order to gain a more masculine appearance (5–7).

Both eating disorders and gender dysphoria are characterized by high rates of body dissatisfaction; however, the reasons behind the dissatisfaction differ (9). In eating disorders, body dissatisfaction is rooted in the fear of weight gain and perceived body fat (1). In gender dysphoria, body dissatisfaction is often focused on secondary sex characteristics that are discordant with the individual’s gender identity. It is important to note that transgender individuals also have higher rates of dissatisfaction with body parts that are not sex specific, such as facial features and body shape (9). The increased risk of body dissatisfaction observed among transgender individuals can become a risk factor for DEB and eating disorders (9).

Although biological, psychological, and social factors associated with puberty may increase the risk of gender dysphoria and DEB among transgender individuals, this may not be apparent to patients (9). An additional sociocultural factor that could contribute to the development of an eating disorder in TGNB patients is minority stress. Minority stress theory claims that TGNB individuals experience a higher prevalence of mental health issues because of social stigma, violence, and rejection related to their gender identity (10). Thus “DEB can serve as a coping mechanism in response to a greater burden of stress rather than strictly as a response driven by gender dysphoria alone” (11). The family of the patient described in this report did not accept his gender identity, which was distressing to him. Gender-related nonaffirmation is a contributing factor to minority stress and poor mental health outcomes (12). Additionally, transgender individuals who use DEB as a coping mechanism could change their appearance, albeit unintentionally. Changes in appearance could result in the individual being perceived and treated differently by society, which could lessen the person’s minority stress burden and serve to reinforce DEB.

Among cisgender female patients, the social pressure of body image ideals and physiologic changes associated with puberty are often seen as factors contributing to the development of eating disorders. This case report brings attention to some of the ways in which these factors can contribute to the development of DEB and eating disorders among TGNB patients. Body dissatisfaction among TGNB patients can be exacerbated by the development of secondary sex characteristics during puberty. For youths wanting their appearance to reflect their gender identity, disordered eating serves as an easily accessible method to alter one’s body shape. Further studies are needed to validate diagnostic tools for eating disorders among TGNB patients and investigate ways that the complexities of gender identity can be integrated into the treatment of such patients.

Key Points/Clinical Pearls