How gender dysphoria affects body image

Gender dysphoria and eating disorders

Gender dysphoria refers to a profound anxiety and psychological distress caused by an incongruence between an individual’s assigned gender at birth and their actual gender. Gender dysphoria is common among the transgender community, though it’s important to acknowledge that not all transgender and gender expansive people experience it. 

Gender dysphoria can be extremely stressful and taxing on a person’s mental health and body image, leading to severe body dissatisfaction, depression, and anxiety. Because of the disconnect between an individual’s affirmed gender and their assigned gender at birth, they may engage in disordered eating behaviors, such as food restriction, self-induced vomiting, binge eating, compulsive exercise, and diet pills and laxative misuse. They may do this in an effort to emphasize certain body parts or features or to modify parts of their body that cause distress.

As such, the rate of eating disorders is particularly high among transgender and non-binary folks. Much more research is needed to establish prevalence; however, existing studies have revealed that just under 16% of transgender college students reported a past-year eating disorder diagnosis, compared to under 2% of cisgender heterosexual women, 3.5% of cisgender queer women, 2% of cisgender queer men, and under 1% of cisgender heterosexual men. (1)

How gender dysphoria may lead to disordered eating behaviors

Everyone experiences gender dysphoria differently, but some common examples of disordered eating behaviors being connected to gender dysphoria in trans folks include:

• Trans women may restrict food in an attempt to lose weight or muscle so they can achieve the “ideal” feminine body that is associated with thinness.
• Trans men may engage in excessive weight-lifting and exercise in an attempt to obtain an “ideal” male body, which is typically associated with muscularity and leanness.
• Trans men may restrict food or cut out an entire food group in an attempt to lose fat in traditionally feminine locations, such as around the hips, or to lose weight in the chest.
• Trans men, trans women, and non-binary people may use diet pills, misuse laxatives, skip meals, or engage in self-induced vomiting to suppress secondary sex characteristics that contribute to gender dysphoria.
• Trans men and non-binary people who menstruate may engage in disordered eating behaviors to suppress menstruation.
• Non-binary people may restrict food calories or cut out an entire food group in an attempt to obtain a more androgynous appearance however being non-binary is not synonymous with looking androgynous.

People often mistake gender dysphoria for body dysmorphia but they are different phenomena and require different treatment and care. People with body dysmorphia are extremely fixated on a perceived flaw in their appearance. This “flaw” can be weight-based but it also doesn’t have to be—some people fixate on their noses, moles, acne, or hair. Regardless of what the fixation is, it causes significant distress and impaired functioning in a person’s life. However, even if a person receives cosmetic treatment to address this “flaw,” the psychological distress will likely not dissipate. The person may find a new feature to fixate on, thus starting the cycle all over again. As such, body dysmorphic disorder (BDD) requires therapy and treatment for a person to begin to heal and recover from this condition.

Meanwhile, gender dysphoria is specifically related to a person’s gender presentation, and once trans and non-binary people begin to receive gender-affirming care, such as hormone blockers, hormone replacement therapy (HRT), or medical procedures, their gender dysphoria tends to decrease, especially as they begin to see their desired changes.

It is important to note that, although gender dysphoria and body dysmorphia are not the same thing, many trans and non-binary people experience them as inextricably linked. Some trans and non-binary people may become obsessively fixated on parts of their body which do not align with their affirmed gender presentation, and these obsessions may be tied to experiences of misgendering and transphobia. Effective treatment for trans and non-binary people should therefore simultaneously explore and address body dysmorphia and gender dysphoria. 

How gender-affirming care can positively affect body image and self-esteem

Because gender dysphoria, body dissatisfaction, and disordered eating are interconnected, receiving gender-affirming care can help improve body image and self-esteem as well as improve mental health outcomes.

In fact, transitioning isn’t just gender-affirming—it’s life-affirming. Trans people are significantly more likely to experience suicidal ideation, attempt suicide, and die by suicide than the general population. However, research on trans youth confirmed that those who received gender-affirming care were 60% less likely to experience moderate to severe depression and 73% less likely to experience suicidal ideation. (2) 

Additional research has also shown that access to gender-affirming care and severity of disordered eating behaviors are directly related. The rate of eating disorder symptoms among trans people who received HRT and surgery was lower than those who’d received no gender-affirming care or only hormones. Additionally, the individuals who were on hormones and had received surgery were also less likely to report weight and shape concerns, both of which are risk factors for disordered eating behaviors. (3)

As a trans or non-binary person begins to see the desired changes that align with their gender, they tend to experience more gender congruence and validation, which in turn, can result in more body satisfaction. And as someone grows more satisfied with their body and appearance, the less likely they are to engage in disordered eating behaviors to change their appearance, weight, or shape. 

Integrated treatment plan: Eating disorder treatment and gender-affirming care

Because gender-affirming care has such a significant impact on disordered eating behaviors, eating disorder treatment must be inclusive, trans-informed, and integrate gender-affirming care and therapy into the treatment plan as is desired and appropriate for the individual.

For instance, if a trans man or transmasculine patient engaged in disordered eating to reduce the size of their chest, then a treatment provider may gently lead a conversation about methods for reducing chest dysphoria, including binding and possibility of top surgery. If the client is interested, then that could be integrated into their treatment plan.

Likewise, if a trans woman or transfeminine individual has not previously had access to HRT, the eating disorder treatment professional may inquire as to whether they are interested in hormones and hormone blockers. Starting this conversation can help a trans person gain access to life-saving gender-affirming care, improve their body satisfaction and self-esteem, and enhance their disorder recovery.

When working with trans and non-binary people experiencing eating disorders, it is essential for treatment providers to understand how the safety and efficacy of gender affirming medical care interacts with eating disorder behaviors. Provider competency in these areas is essential for ensuring physical safety and emotional support while developing appropriate strategies for treating eating disorder behaviors, supporting medical transition, and minimizing health risks. 

Not all transgender and non-binary people wish to pursue medical transition, and some are unable to due to underlying medical conditions, lack of access, or other prohibitive factors. Even for individuals who do engage in medical transition, accessing hormones and/or surgeries does not replace other aspects of eating disorder treatment. Although these types of care are life saving and can substantially improve mental health for transgender and non-binary people, there are many other aspects of eating disorders that still must be separately addressed. 

Finally, not every transgender and non-binary person who has an eating disorder has developed it for reasons related to their gender identity. As with other populations, there are a variety of factors that can lead to the development of an eating disorder, including food insecurity, pressures from family about weight and shape, participation in athletics, co-occurring mental health diagnoses, experiences of anti-fat bias, chronic illness, and more. When working with transgender and non-binary individuals experiencing eating disorders, providers should ask about the relationship between gender identity or gender dysphoria and eating disorder behaviors, but they should not assume that this is the cause or the only cause of the disorder.