Gender Identity and Eating Disorders: Anorexia Nervosa in the Transgender Community

Gender dysphoria is described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as the “distress” someone experiences when they do not feel like they should be the gender with which they were born. Previously called gender identity disorder, gender dysphoria is no longer listed as a sexual disorder and should not be considered a psychiatric disorder unless depression, anxiety, suicidal ideation, an eating disorder like anorexia nervosa or substance addiction impacts the person’s quality of life.

Like individuals with gender dysphoria, transgender individuals strongly feel like they should be a different gender. Being transgender is not a psychiatric disorder but dealing with authentic and persistent thoughts regarding sexual identity can cause mental health issues in many transgender people. In addition to worrying if something is “wrong” with them, transgender individuals must cope with societal stigma and even being ostracized by family members. They may lose jobs or face discrimination when searching for a job, which further exacerbates feelings of low self-esteem, guilt, and depression.

The Human Rights Campaign describes what it means to be transgender as “identifying as female, male, agender, gender-fluid, nonbinary, androgynous, genderqueer or somewhere else outside or on the spectrum of what society understands the term ‘gender’ to be.” HRC also says that some transgender individuals take hormones or elect to have gender reassignment surgery to transition from one gender to another. Some do not use hormones or choose surgery. Instead, they elect to simply identify openly as a transgender individual or as a man or woman.

A survey conducted by the HRC found that 10 percent of LGBTQ people identify themselves as “another gender” or “transgender, which suggests that many people under the age of 35 strongly identify themselves as being somewhere on a transgender spectrum broader than the LGBTQ spectrum. The HRC further states that “in many ways, transgender individuals are no different from non-transgender (cisgender) individuals. However, because social stigma and negative attitudes towards the transgender community persist, the community continues to face unique and troubling challenges that contribute to problems involving the physical and mental well-being of community members.

Eating Disorders Among Transgender Individuals

To manipulate the shape of their bodies to conform more closely with the gender they identify with, transgender individuals often develop anorexia nervosa symptoms as adolescents. Losing weight as a teenager may delay the emergence of female or male secondary sex characteristics, such as breast development in girls and genital growth in boys. Body dissatisfaction among transgender individuals is a primary source of anxiety just before and during adolescence because the development of specific body areas remind the person they are physically a sex they do not want to be. Body dissatisfaction is typically greater in overweight transgender individuals who want to adopt a shape that resembles their preferred gender. Consequently, eating disorders such as anorexia nervosa and bulimia nervosa are commonly diagnosed in adolescent or young adult transgender individuals who consider weight as problematic towards achieving a preferred gender appearance. 

Why Transgender Teens are Vulnerable to Depression and Anorexia Nervosa

In addition to dealing with hormonal changes that are rapidly transforming a previously asexual body into a body that “looks” like a certain gender, transgender teenagers may experience a wide variety of stressful events, ranging from their parents divorcing or separating, death of family member to which they were close, peer pressure, being bullied because they are transgender low self-esteem. Further aggravating these stressors are neurotransmitter imbalances in the brain that heighten feelings of sadness, anxiety, hopelessness, and fear. Additionally, a transgender individual may have medical conditions or learning disabilities that remain undiagnosed throughout middle and high school. This can contribute to the development of anorexia nervosa and serious psychological disorders.

Major depression differs from atypical depression, a type of depression frequently seen in teens. Transgender adolescents with atypical depression experience bouts of extreme sadness that temporarily improves when something happens to make them feel better. For example, transgender adolescents who are severely depressed and refuse to get out of bed for several days may suddenly feel happy upon hearing a certain friend is coming to visit. This is considered atypical because teenagers with major depression would fail to react this way.

Anorexia Nervosa Symptoms

Eating disorders such as anorexia nervosa and bulimia nervosa involve obsessive-compulsive eating behaviors influenced by a distorted perception of the body. People with eating disorders share common characteristics such as low self-esteem, extreme fear of being overweight, depression, guilt, and obsessive-compulsive issues. Although technically classified by the Diagnostic and Statistics Manual as a mental illness, eating disorders are primarily treated as subtypes of OCD and addiction. Transgender individuals with anorexia nervosa, bulimia nervosa or binge-eating disorder receive cognitive-behavioral therapy, family psychotherapy, nutritional counseling, medical care and other treatment methods that are tailored to meet their specific physical and psychological needs.

A clinical diagnosis of anorexia nervosa involves the following criteria:

  • Emaciation (body mass index below 16)
  • Refusal to eat adequate amounts of food calories specified for the patient’s age, height and weight
  • An abnormal fear of weight gain or “losing control” (feeling in control is a primary goal of those with eating disorders)
  • Obsession with apportioning and weighing food the person plans to eat
  • Misusing diuretics, enemas or laxatives in an attempt to facilitate weight loss
  • Excessive exercise to expedite weight loss

Transgender individuals who have presented anorexia nervosa symptoms for more than six months may be suffering from serious health issues that require immediate attention. Anemia, premature osteoporosis, sallow skin, lanugo (abnormal hair growth on the body) and even serious cognitive problems may occur if nutrients and calories essential to general health are withheld for an extended time. 

Bulimia nervosa and binge-eating disorder are also commonly seen in transgender individuals. People with one of these eating disorders will eat a large amount of food at one time and feel overwhelming guilt for engaging in such uncontrollable behavior. Consequently, individuals with bulimia nervosa or binge-eating disorder will force themselves to vomit after eating to avoid gaining weight. They may also use dangerous quantities of diuretics and laxatives or exercise vigorously for hours to burn calories.

The primary difference between bulimia nervosa and anorexia nervosa is that people with bulimia nervosa are generally height-weight proportionate but feel intense terror at the thought of gaining just one pound. Alternately, people with anorexia nervosa see themselves as “fat” even though they are dangerously underweight for their height and body frame.

Transgender Individuals, Anorexia Nervosa, and Anxiety

Anxiety disorders are the most common mental illnesses in the U.S. They include panic disorder, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), generalized anxiety disorders, and phobias. Anxiety disorders frequently co-occur with depressive disorders, eating disorders and gender dysphoria. In some cases, transgender individuals with anorexia nervosa are co-diagnosed with more than one type of anxiety disorder.

Anxiety is a physiological and psychological response to real or perceived danger. This danger can be in the form of a threat, pressure or a stressful situation. However, anxiety isn’t always a bad thing. In fact, anxiety can help you stay alert and focused, spur you to action, and motivate you to solve problems. But when anxiety is constant or overwhelming, when it interferes with your relationships and activities, it stops being functional—that’s when you’ve crossed the line from normal, productive anxiety into the realm of anxiety disorders.

Anorexia nervosa in transgender individuals arises out of anxiety over feeling and appearing like a gender they do not want to be. Anxiety over gender dysphoria and body dissatisfaction can interfere with school, work and family responsibilities. When confronted with situations hostile to their desires and beliefs about themselves, transgender people can begin having panic attacks that worsen anorexia nervosa symptoms and deepen their sense of alienation from others.

In many cases, eating disorders also develop because the person experiences physical and/or emotional abuse as a child. This abuse can further involve various degrees of social isolation, authoritarian or uninvolved parenting styles and extreme sensitivity to peer and cultural pressures for being thin. Subjective media perceptions regarding what is “beautiful” and what is “ugly” is a concept heavily explored and analyzed during anorexia nervosa recovery treatment. Therapeutic counseling for transgender patients with anorexia nervosa also includes teaching transgender individuals about learning to accept and love themselves for who they are and not because unrealistic and self-defeating images perpetuated by the media tell them they should “look” a certain way.

Untreated anorexia nervosa and anxiety can negatively impact the physical and mental health of transgender individuals. When stress hormones remain elevated and the body is in a constant fight-or-flight mode due to chronic anxiety and anorexia nervosa health problems may arise that include:

  • Hypertension/high blood pressure
  • Unnaturally accelerated metabolism/rapid weight loss
  • A compromised immune system incapable of resisting infections
  • Premature onset of osteoporosis
  • Sleep problems (insomnia, sleep-walking, restless leg syndrome)
  • Gastrointestinal disorders (nausea, irritable bowel syndrome, constipation, chronic diarrhea)
  • Impairment of memory, concentration, and motivation

Transgender individuals with severe anxiety feel their only option is to avoid situations that cause extreme stress. While the transgender community and online transgender support groups offer empathy and support, it should not be considered a type of “treatment” option for transgender people with anorexia nervosa or other eating disorders. 

Treatment for Transgender Individuals with Anorexia Nervosa

The goal of anorexia nervosa recovery treatment programs is to first stabilize a person’s physical health before addressing psychological issues. However, anorexia nervosa treatment does not involve trying to change a transgender individual’s core feeling that they should be a different gender. Instead, treatment involves teaching patients how to deal with anxieties by using evidence-based coping strategies. Patients learn how to re-shape negative thought patterns by replacing them with realistic, objective thoughts.

Cognitive-behavioral therapy and personalized psychotherapy are two mainstays of all eating disorder treatment programs. CBT helps people confront their fears incrementally by showing how thoughts can be gradually reframed to prevent anxiety-driven responses to stressful situations. In some cases, specific interventions may be warranted for transgender individuals who have trauma histories (childhood abuse, for example) and are appropriately developed as part of a person’s anorexia nervosa treatment program.

Because the majority of eating disorders emerge from the complex interplay of psychological, genetic, social and behavioral factors, anorexia nervosa recovery programs are carefully developed to comprehensively approach the needs of the whole person. Additional psychological tests may be recommended to determine if any personality or attentional disorders exist. Transgender individuals with anorexia nervosa who enter a treatment program will also undergo a complete physical examination to rule out neurological issues that may be influencing abnormal eating behaviors.

Eating disorder therapists and counselors at Oliver-Pyatt Centers provide empathetic, client-oriented treatment for transgender individuals with anorexia nervosa and other eating disorders. Call us today if you or a loved one needs treatment for anorexia nervosa, bulimia nervosa or binge-eating disorder.