Body image, gender dysphoria, and gender identity
The idea of gender dysphoria as an official medical condition is still relatively new, with the term only recently being added to the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, research is increasingly uncovering new gender dysphoria facts about the ways this condition presents and the implications it may have on a person's mental health, physical health, and emotional well-being.
What is known is that gender dysphoria is intrinsically linked to body image or how people experience their bodies on a psychological level.5 A wide variety of signals, both internal and external, biological and environmental, work to create body image.5 And a mismatch between these signals and someone's assigned gender at birth can work to create gender dysphoria.
Gender dysphoria can also be connected to gender identity. Gender identity refers to someone's sense of their gender, whether male, female, somewhere in between, or neither. A combination of biological, environmental, and psychological influences also work to create someone's gender identity. When this is different from the gender assigned at birth, it can also contribute to feelings of gender dysphoria.
In either case, the result is often:
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- The strong desire to have the secondary sex characteristics of the other gender
- The strong desire to be treated as the other gender
- The strong conviction that one experiences the typical feelings and reactions of the other gender
Body image, gender dysphoria, and eating disorders
Unfortunately, transgender and non-binary people have also been found to be at high risk for developing eating disorders or disordered eating behavior.1 There may be several reasons for this related to gender dysphoria and body image.
The adoption of disordered eating behaviors, such as limited food intake, excessive exercise, and other compensatory behaviors, may be used to emphasize or deemphasize anticipated secondary sex characteristics—such as breasts and big hips for transgender women or broad shoulders and a muscular chest for transgender men.
More broadly, people experiencing gender incongruence may use disordered eating behaviors for the same reasons as most other people who struggle with an eating disorder—as maladaptive coping mechanisms. Studies have found that this population faces higher levels of stress than their cisgender peers, and fixations on food, exercising, or changing the way they look may manifest as a consequence of that stress.1
Almost 16% of transgender college students reported a past eating disorder, compared to 2% of cis hetero women.1
All told, 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
Anorexia and gender dysphoria
Research on transgender health in general is still relatively new, and few studies have parceled out the specifics of how this population experiences disordered eating. But what work has been done has found some connections between gender dysphoria and anorexia nervosa (AN).
One study that looked at the eating habits of 933 transgender people found that as many as 48% of them reported fasting within the last 12 months, specifically as an attempt to lose weight.6
Bulimia and gender dysphoria
Again, the specifics of how many transgender people struggle with bulimia nervosa (BN) have yet to be studied in detail. However, the same survey found that many in this population struggle with the same maladaptive compensatory behaviors commonly used in BN.
The group surveyed reported using these behaviors within the last 12 months to control weight:6
- 7% using diet pills
- 5% taking laxatives
- 18% vomiting after eating
Binge eating and gender dysphoria
Binge eating in the transgender community is another underreported issue, but studies have also shown a tentative connection.
The same survey found up to 42% of gender-diverse youth or transgender patients between ages 14-18 reported binge eating within the last 12 months. For survey takers between ages 19-25, the number was 29%.6
Body dysmorphia vs. gender dysphoria
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 doesn’t have to be—and usually, it's something small or even imperceivable to others. Regardless of what the fixation is, it causes significant distress and impaired functioning in a person’s life.7
Gender dysphoria is specifically related to a person’s gender identity. They don't see themselves as being "flawed" as much as they feel out of touch between their gender expression and the physical body they were born into.
Still, while gender dysphoria and body dysmorphia are not the same thing, many trans and non-binary people experience both. A common way this manifests with someone with gender dysphoria is a fixation on a sexual characteristic of their body they feel doesn't belong to their gender identity. Sometimes, these cases can also bring on disordered eating patterns as an attempt to "correct" these "flaws."1
Body image, gender dysphoria, and gender-affirming care
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.
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 the 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 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 trans or non-binary people begin to see the desired changes that align with their gender, they tend to experience more gender congruence and validation, which can result in more body satisfaction. As someone becomes more satisfied with their body and appearance, they become less likely to engage in disordered eating behaviors to change their appearance, weight, or shape.
Gender dysphoria and eating disorder treatment
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 engages in disordered eating to reduce the size of their chest, a treatment provider may gently lead a conversation about other methods for reducing chest size, including binding and the possibility of top surgery. If the client is interested, this can 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.
Still, it's important to remember 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.
Finding gender-affirming care for gender dysphoria
Gender-affirming care is still an emerging field in the medical world, with many doctors and clinics still catching up on the best methods for treating transgender and nonbinary patients in ways that affirm their experience and minimize or eliminate further trauma or damaging experiences.
When working with trans and non-binary people experiencing eating disorders, treatment providers need to understand how the safety and efficacy of gender-affirming medical care interact 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 during eating disorder recovery.
The best way to ensure your care team will understand the nuances of gender-affirming care is to do your research. Look into the history or training of the doctors or clinic you're interested in working with. You can also call to ask more about these concerns.
At Within, we take pride in ensuring our team is well-informed on gender-affirming care and how the unique experiences of transgender or nonbinary patients may impact the type of care they require. Call us today to see how we can help you create an individual treatment plan that accounts for all the facets of your experience and works to help you heal on a mental, physical, and emotional level.
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