Eating Disorders in Transgender People

Transgender man with arms folded

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Eating disorders have historically been believed to primarily afflict heterosexual, affluent, cisgender, thin, white females. This inaccurate stereotype decreases the likelihood that people with eating disorders who are homosexual, queer, poor, people of color, larger-bodied, or transgender will be diagnosed and receive adequate treatment.

In particular, transgender people represent an understudied and under-recognized group that experience 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 can include people who identify as a different binary gender from that which they were assigned at birth: female-to-male (FTM) transgender men and male-to-female (MTF) transgender women.

The term also includes people who do not identify with a binary gender (male or female) and instead identify as nonbinary, agender, genderqueer, or gender-expansive. There is tremendous diversity within the transgender community.

One problem in mental health research on transgender individuals is that the few studies that exist tend to collapse all this diversity into a single category. Studies also lump transgender people together with gay, lesbian, bisexual, and queer individuals, all people who have a non-dominant systemic sexual orientation.

This causes confusion because gender identity and sexual orientation are different. Transgender people can have any sexual orientation, including heterosexual. 

Eating Disorder Prevalence

Most research on eating disorders and disordered eating has focused on cisgender female individuals, 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.

Transgender students self-reported higher rates of an eating disorder diagnosis as well as higher rates of using compensatory behaviors such as diet pills, vomiting, and laxatives.

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 percent.

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 a feeling of distress emanating from the disparity between one’s physical appearance and one’s gender identity. Individuals suffering from gender dysphoria do not see their bodies as they want them to be. Or, they experience that society does not see their bodies as they themselves see their bodies—in either case, the disparity stems solely from their gender.

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 cisgender males and females, they are 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 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 sex. 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, trans male individuals may attempt to stunt breast growth, reduce hips, or eliminate menstruation by restricting caloric intake. Trans female individuals may engage in disordered eating to accentuate their femininity and to increase their ability to be perceived as cisgender women.

Non-binary 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.

Among both transgender and cisgender people with eating disorders, not all of them report a connection between body image and their eating disorder.

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 female. 

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.

Trans individuals face high rates of homelessness and poverty, and they are even more likely to be homeless or to live in poverty if they are transfeminine, a person of color, or a member of multiple non-dominant systemic identities.

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 be a sign of strength.

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.

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 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 they 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 females or offering a separate track for males—those who are gender non-conforming are left out or lumped in with the group that is their sex assigned at birth (which is not affirming).

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 estrogens 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, which accentuates a more feminine appearance.

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 trans feminine individuals and chest removal, body contouring, hysterectomy, and phalloplasty for trans masculine 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. 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.

Research shows that both hormone therapy and gender affirmation surgeries can decrease the level of overall body dissatisfaction and/or increase body satisfaction.

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 and is offensive to others. Research shows that hormone therapy and gender-affirming treatments result in lower levels of depression and anxiety as well as eating disorders.

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 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.

  • Trans Folx Fighting EDs 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. 
  • Nutrition Therapy For All on Instagram focuses on nutrition therapy centered around trans and other marginalized communities.
  • 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. 
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Article Sources

  • Diemer, Elizabeth W., Jaclyn M. White Hughto, Allegra R. Gordon, Carly Guss, S. Bryn Austin, and Sari L. Reisner. 2018. Beyond the Binary: Differences in Eating Disorder Prevalence by Gender Identity in a Transgender Sample. Transgender Health 3 (1): 17–23. DOI:10.1089/trgh.2017.0043.

  • Diemer, Elizabeth W., Julia D. Grant, Melissa A. Munn-Chernoff, David A. Patterson, and Alexis E. Duncan. 2015. Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine 57 (2): 144–49. DOI: 10.1016/j.jadohealth.2015.03.003.

  • Duffy, Mary E., Kristin E. Henkel, and Valerie A. Earnshaw. 2016. Transgender Clients’ Experiences of Eating Disorder Treatment. Journal of LGBT Issues in Counseling 10 (3): 136–49. DOI: 10.1080/15538605.2016.1177806.

  • Jones, Bethany Alice, Emma Haycraft, Sarah Murjan, and Jon Arcelus. 2016. Body Dissatisfaction and Disordered Eating in Trans People: A Systematic Review of the Literature. International Review of Psychiatry (Abingdon, England) 28 (1): 81–94. DOI: 10.3109/09540261.2015.1089217.

  • Jones, Bethany Alice, Emma Haycraft, Walter Pierre Bouman, Nicola Brewin, Laurence Claes, and Jon Arcelus. 2018. Risk Factors for Eating Disorder Psychopathology within the Treatment Seeking Transgender Population: The Role of Cross-Sex Hormone Treatment. European Eating Disorders Review: The Journal of the Eating Disorders Association 26 (2): 120–28. DOI: 10.1002/erv.2576.

  • Testa, Rylan J., G. Nicole Rider, Nancy A. Haug, and Kimberly F. Balsam. 2017. Gender Confirming Medical Interventions and Eating Disorder Symptoms among Transgender Individuals. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association 36 (10): 927–36. DOI: 10.1037/hea0000497.

  • Wagner, Rebecca, and Jonathan R. Stevens. 2017. Clinical Barriers to Effective Treatment of Eating Disorders and Co-Occurring Psychiatric Disorders in Transgendered Individuals. Journal of Psychiatric Practice 23 (4): 284–89. DOI: 10.1097/PRA.0000000000000248.