Anorexia nervosa (AN) is a serious eating disorder involving severe caloric restriction, an intense fear of gaining weight, and a preoccupation with weight and shape. Individuals with AN over evaluate themselves based upon how their bodies appear, and they tend to have a distorted view of themselves. (1) Transgender people may be at increased risk of anorexia nervosa because of gender dysphoria, which is a sense of distress over sex assigned at birth, and increased pressure to conform to stereotypical gendered body ideals. (2)
Studies show that many, though not all, transgender individuals experience distress surrounding the appearance of their bodies, which can lead to feelings of depression, despair, and worthlessness. The distress surrounding gender dysphoria can lead to physical symptoms, such as stomach aches and panic attacks. (2)
Eating disorder behaviors may become a method of coping for transgender individuals who struggle with gender dysphoria. In fact, studies have shown that disorder eating and weight manipulation behaviors are more common among trans individuals when compared to those who are cisgender. Research has also shown that the prevalence of eating disorders in transgender college students is as high as 17.6%, compared to 0.2% for cisgender men and 1.8% for cisgender women. (3)
Transgender youth with gender dysphoria may engage in restriction in order to delay puberty and to help them look more like the gender with which they identify. For instance, a person assigned female at birth who suffers from gender dysphoria and identifies as a man may restrict calories in order to maintain low body fat and prevent breast development. (3) Another recent research report indicates that trans women may engage in restrictive eating behaviors in order to appear more feminine. (4) There is evidence that nonbinary people may resort to disordered eating behaviors at higher rates than trans individuals with a binary gender identitiy, possibly in order to conform to stereotypes of genderless bodies as thin and androgynous. (5)
In summary, individuals in the transgender community are at high risk of eating disorders. They may turn to restrictive eating in order to cope with the distress of gender dysphoria, or they may restrict order to achieve an appearance that is more in line with their gender identity.
Given the overlap between gender dysphoria and eating disorders, treating anorexia nervosa in transgender individuals requires both expertise in eating disorders and knowledge of gender-affirming care.
Research at the Cleveland Clinic has demonstrated that access to gender affirming care can help reduce eating disorder symptoms for people with gender dysphoria. For instance, transmasculine individuals who undergo testosterone therapy have been found to show a reduction in anxiety and symptoms of AN after treatment. (4) Additional studies have found that transgender individuals who receive gender-affirming medical services, including hormone replacement therapy, experience an improvement in body satisfaction and psychological wellbeing, as well as a reduction in eating disorder symptoms. (3)
It is important to remember that eating disorders in transgender and nonbinary individuals are not always or only related to issues of gender identity and gender dysphoria. Not all transgender individuals experience gender dysphoria or need to medically transition, and for those who do, transition related care does not take the place of eating disorder treatment. As with cisgender individuals, it is essential to work with trans and nonbinary individuals to address all contributing factors to the eating disorder, including family history, chronic illnesses, sensory sensitivities, trauma, experiences of anti-fat bias, and other potential triggers.
Members of the transgender community require eating disorder treatment that is sensitive to their needs and addresses underlying issues of gender dysphoria when present. As noted above, gender-affirming medical interventions can improve body dissatisfaction, which can make them an integral part of, though not a replacement for, eating disorder treatment for transgender individuals.
Beyond treatment for gender dsyphoria, interventions that specifically address eating disorder symptoms must be implemented in a trans competent environment in which all physical spaces are accessible for gender nonconforming individuals and correct names and pronouns are used. In the beginning stages of treatment for anorexia nervosa, patients may require services to address any medical complications, including malnutrition. Once someone is medically stabilized, it is important for them to receive nutritional and psychological services to help normalize eating adequately, learn coping skills, and address negative body image. (4)
For individuals in the transgender community, treatment for anorexia nervosa will involve services that address body image concerns, gender dysphoria, and the medical/nutritional complications associated with AN. A team of physicians, counselors, dieticians, and social workers will likely be involved in eating disorder treatment. Physicians can determine what medical intervention is needed, and they should provide expert knowledge on gender-affirming treatments like hormone therapy. Dieticians can help patients to develop recovery focused meal plans, while professionals like counselors and social workers can address concerns related to body image disturbance, self-esteem, coping skills, emotional regulation, and mental health. It is essential that all members of the treatment team are trained in trans competency and can provide care that affirms the individual’s gender identity.