Eating Disorders in Transgender People

Eating disorders have historically been believed to primarily afflict heterosexual, affluent, cisgender, thin, white women. This inaccurate stereotype decreases the likelihood that people with eating disorders who are same/similar gender attracted, low-income, of color, fat, and/or transgender will be diagnosed and receive quality treatment.

In particular, transgender people represent an understudied and under-recognized group that experiences eating disorders at higher rates. Eating disorder research is already underfunded, which means that there is an even greater disparity in research about transgender people with eating disorders.

Defining Transgender

The term "transgender" is used to define people who identify as a different gender than the gender they were assigned at birth. The term "cisgender" is used to describe people whose gender identity matches the gender they were assigned at birth. The transgender umbrella includes people who identify as a different binary gender or as nonbinary, agender, genderqueer, Two-Spirit, etc. There is tremendous diversity within the transgender community.

Studies also lump transgender people together with gay, lesbian, bisexual, and queer individuals. This causes confusion because gender identity and sexual orientation are different. Transgender people can have any sexual orientation. 

Eating Disorder Prevalence

Most research on eating disorders and disordered eating has focused on cisgender women, with little research available on transgender populations. The most comprehensive study to date on eating disorders among transgender people found that transgender college students reported experiencing disordered eating at approximately four times the rate of their cisgender classmates.

They experienced these symptoms at even higher rates than heterosexual cisgender women, who are often thought to be the population most affected by eating disorders. In one study, the prevalence of self-reported eating disorders among transgender individuals was 7.4%.

What Is Body Dissatisfaction?

Body dissatisfaction—the negative evaluation of one’s appearance—is considered a risk factor for mental health issues in general and is thought to be experienced by both trans people and those with an eating disorder.

Research shows that body dissatisfaction and poor body image can lead to chronic depression, social anxiety disorder, substance use, and other mental health issues.

What Is Gender Dysphoria?

Gender dysphoria is psychological distress emanating from feeling that there is a disparity between one’s internal gender identity and one's body. Gender roles about how women and men are supposed to look and act are a significant reason that transgender people experience dysphoria.

For instance, some transgender people are dysphoric over their chests because a large chest is traditionally associated with womanhood. A transfeminine person might want top surgery to increase their breast size, while a transmasculine person might want a double mastectomy.

This experience can be reinforced by daily encounters due to dominant societal gender expectations. Many, but not all, trans individuals experience gender dysphoria. Research indicates that body dissatisfaction may be experienced in relation to specific body parts.

Just as the cultural ideals of gender and beauty are unattainable for most of us in society, they may be even more unattainable for many transgender people. Transgender people may become more focused on beauty ideals because they anticipate they might be accepted as their true gender if they can meet them. 

We know that the popularized beauty and gender standards play a role in diet culture and contribute to dieting, which in turn, can lead to disordered eating and eating disorders. However, it's important to remember that eating disorders are complex; societal standards are not the full cause.

The Link Between Gender Dysphoria and Eating Disorders

Gender dysphoria and body dissatisfaction in transgender individuals is often cited as a key link to eating disorders. It is often hypothesized and reported that transgender individuals may attempt to suppress features of their assigned gender. Or they may try to accentuate features of their gender identity specifically to present gender identity in ways that are understandable to the world around them.

For example, transmasculine people may attempt to stunt breast growth, reduce their hips, or eliminate menstruation by restricting caloric intake. Transfeminine individuals may engage in disordered eating to lose muscle mass and become thinner to meet an idealized feminine standard. Nonbinary people may restrict their eating to appear thin, consistent with the common stereotype of androgynous people in popular culture.

As with any population, however, it is dangerous to generalize. We know that eating disorders are complex and stem from a combination of factors. While some transgender people with eating disorders may attempt to change their bodies to conform to their gender identity, others may feel that their eating disorder is not related to their physical body.

Interestingly, gender non-conforming individuals assigned female at birth appear to have heightened eating disorder symptoms compared to transgender individuals assigned male at birth. This alludes to the cost one must pay for being socialized as a girl or woman. 

Oppression-Based Trauma

Eating disorders among transgender individuals may be related to discrimination and bias experienced by those whose physical features are not consistent with societal expectations for people of a particular gender.

Researcher Elizabeth Diemer and colleagues emphasize the role of minority stress, which is defined as the excess stress experienced by individuals in stigmatized social categories as a result of their social position.

Marginalized individuals, including trans individuals, experience higher rates of discrimination, violence, pressure from concealing one’s true identity, alienation, and internalized social stigma. Marginalized individuals, as a result of these experiences, often have decreased economic resources as well as worsened physical and mental health.

It appears that a big reason for the homelessness and poverty is that many trans people lack support from their families.

One potential way in which stigma impacts health among transgender people is the use of coping such as disordered eating to manage stressors. Given the real threats they face on a daily basis, relying on disordered eating can symbolize strength or control to the individual.

Research has shown that transgender people who conform less to traditional gender appearances experience more mistreatment and worse health than transgender people who conform more to society's expectations. This reality is because of how cisnormative society physically, financially, and emotionally punished trans people who do not pass (passing means to be seen as a cisgender person of one's gender identity).

Treatment for Eating Disorders

Both transgender populations and people with eating disorders have elevated rates of suicide, which means the combination of transgender identity and disordered eating must be taken very seriously. There are currently no specific treatments for transgender people with eating disorders.

Furthermore, many eating disorder therapists lack training in working with transgender people and many therapists who treat transgender people may not be specialists in eating disorders.

Less Access

Transgender people and people with eating disorders each are subject to prejudice—the combination of the two increases the stigma. As a result, many may be reluctant to disclose their gender identity, their eating disorder, or both.

Many transgender people report receiving inadequate care from health professionals. Due to their often limited resources resulting from discrimination and lack of community and family, they may be less likely to have access to health insurance and treatment.

Stigmas

When trans people do receive treatment, they may experience disregard for their gender identity which can include being misgendered, and professionals may assume their primary objective is a surgical transition without an understanding of gender-affirming care.

The body discomfort of transgender people with eating disorders is complex and may not be successfully addressed by the same body image interventions designed with cisgender patients in mind. These interventions that focus on accepting aspects of their body may be experienced as invalidating.

Historically, many eating disorder treatment centers have organized along binary gender lines, providing treatment only to women or offering a separate track for men—those who are gender non-conforming are left out or lumped in with the group that is their sex assigned at birth.

Gender-Affirming Treatment

Many transgender people are helped by medical interventions aimed at affirming their gender identity. Measures to achieve the desired masculinization or feminization include administration of hormone therapy, hair removal, and/or surgical interventions (including surgical change of the genitalia and other sex characteristics).

Hormone Therapy

Hormone therapy may include estrogen and antiandrogens for trans women and testosterone for trans men. Transfeminine individuals who take estrogen and antiandrogens may experience decreased facial hair growth, an increase in fat deposits around the hips and buttocks, breast growth, and reduced muscle mass.

Transmasculine individuals who take testosterone can experience a redistribution of fat, increased muscle mass, and a deepened voice, which promotes a more culturally masculine appearance.

Surgical Options

Non-binary and gender-nonconforming people ideally should have access to gender-affirming care as well. Surgical interventions may include breast augmentation, tracheal shave, orchiectomy, and/or vaginoplasty for transfeminine individuals and chest removal, body contouring, hysterectomy, and phalloplasty for transmasculine individuals.

Historically, individuals seeking these interventions receive hormone treatment prior to surgery, although not all individuals follow this sequence.

Further, there are many barriers (including the cost) that prevent trans individuals from obtaining gender-affirming treatments. Individuals have to be diagnosed with gender dysphoria disorder for medical providers and insurance companies to approve their procedures, even though not all trans people identify body dysphoria.

Many trans individuals do not undergo all surgically available options—though, in the past, these options were presumed to be the endpoint of the trans experience.

Not surprisingly, having a physical body that is more closely aligned with one’s gender identity can relieve distress. It can also increase one’s confidence in “passing” or blending in with cisgender people.

This is a goal for some trans people, but it's certainly not a goal for all trans people. Research shows that hormone therapy and gender-affirming treatments result in lower levels of depression and anxiety as well as eating disorders for those who have elected to undergo these treatments.

In Summary

Treatment for transgender people with eating disorders should address the complexity of their identities without assuming the causes of the eating disorder. It should also leave room for them to pursue medical treatments aimed to alter their bodies if they are interested in these options versus focusing only on body acceptance.

Transgender individuals are best served by a comprehensive team that includes mental health professionals specialized in eating disorders as well as gender-affirming care.  

Resources

There are a number of blogs and organizations that are continuing the conversation about eating disorders in the trans community.

• FEDUP Collective is a collective of trans/gender diverse people and allies who believe eating disorders in marginalized communities are social justice issues.
• Thirdwheeled is a blog by a queer couple that explores gender identity and its relation to eating disorders 
• Resilient Fat Goddess is a queer, fat, trans body liberation project that promotes eating disorder awareness, identity affirmation, and fat liberation. 
• The Body Is Not An Apology is an online international movement committed to cultivating global radical self-love and body empowerment for all bodies.
• Let's Queer Things Up is a personal blog exploring queer/trans identity and mental health.