What's Driving Eating Disorders in Trans Patients?
Eating disorders are best understood as bio-psycho-social illnesses, meaning there are genetics, psychological factors, and social influences all at play in the development of an eating disorder. An eating disorder diagnosis is also frequently associated with other psychiatric comorbidities such as anxiety, depression, and substance use disorder. Being transgender or gender nonconforming is not, of course, a mental illness; however, transgender people and gender nonconforming people seem to be at an elevated risk for eating disorders and psychiatric conditions. This is due, at least in part, to experiences of societal stigma and minority stress and made worse by health disparities and barriers to accessing expert, gender-affirming healthcare. Eating disorders often peak at the onset of adolescence. This is also usually a period of blossoming gender identity and expression. It's a time when young people are discovering and developing who they are and what role their body plays in their identity. They begin to recognize body image as a construct, which, for some transgender people, can become complicated by gender dysphoria. Gender dysphoria is discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). In order to improve care for transgender patients with eating disorders, providers need to understand the complex and interrelated factors driving the problem. Conforming Contributes to Eating Disorders  Gender dysphoria and eating disorders are both characterized by an extreme discomfort with one's body, and in both conditions, the body suffers. Gender dysphoria or gender identity concerns do not cause eating disorders; however, they are a risk factor. If someone is experiencing body dissatisfaction, minority stress such as harassment and discrimination, and/or non-affirmation of their gender identity, eating disorder behaviors might offer a sense of control. Also, eating disorder behaviors can be utilized to either suppress or support gender affirmation characteristics, with various goals. Individuals might use weight or body manipulation to conform their body to the standards of the community they identify with or, conversely, to be seen as androgynous. In some cases, the desire to change may be to protect against unwanted sexual objectification. Similar to a sense of control, eating disorder behaviors might also be an expression of autonomy. As one patient told me, "My eating disorder is powerfully validating. My world outside of my eating disorder is mostly invalidating." Consider, for example, anorexia nervosa: this eating disorder is usually characterized by a drive for thinness, but the objective around weight loss and thinness can be different for transgender patients compared to cis gender patients. And it can be different between groups of transgender patients too. For transmasculine individuals, the goal of eating disorder behaviors may be to lose curves, lose breasts, or stop the menstrual cycle. These physical changes can help to decrease distress and relieve suffering. For transfeminine people, they may believe that the drive for thinness is the norm for their gender and engaging in eating disorder behaviors can be socially reinforcing. Treatment Starts With Affirmation  No matter the specific situation or goals of a patient, gender affirming eating disorder care is imperative for positive outcomes for transgender patients. Clinicians should always investigate issues related to sexuality and gender identity in patients with eating disorders to develop more effective prevention measures and better strategies for therapeutic intervention. When both are present, body dysmorphia and eating disorders should be treated simultaneously; appropriate care for one problem should not be delayed for the other. Gender confirming medical interventions are shown to increase body image satisfaction and decrease eating disorder behaviors, even if treatment did not reduce non-affirming societal experiences. Treating underlying body dysphoria has also been shown to relieve some eating disorder behaviors and improve body image satisfaction. Gender affirming care can always begin by screening for gender. Simply asking, "What is your gender?" can be effective, as are adding standardized gender and pronoun questions to a pre-visit questionnaire. If so, are your eating disorder behaviors helping you achieve your goals?" We can also take the time to create affirming spaces for patients by posting representative flags and LGBTQ+ symbols, offering unisex bathrooms, saying or posting non-discrimination statements, and making sure images and marketing materials show racially and ethnically diverse same-sex couples and transgender people. I have also found it helpful to talk to my transgender patients about body neutrality rather than body positivity. Body positivity, actively loving your body, can be out of reach for many people, especially those with gender dysmorphia. Body neutrality focuses on the function of one's body -- recognizing what your body does for you, fueling it so it can continue to do so, and respecting your body enough to not harm it. Bigger picture, as professionals, we have to address structural and institutional policies that discriminate against the transgender population, including housing and community support concerns. We all need to show up, educate ourselves and those around us, and be advocates for our most vulnerable patients. Anne Marie O'Melia, MD, MS, is chief medical and clinical officer at Eating Recovery Center.