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An extensive survey[1] of nearly 300,000 U.S. students published in the Journal of Adolescent Health found that transgender students experienced eating disorders at almost four times the rate of cisgender students. Sadly, in our experience at GenderGP, we see many young transgender people restricting their food intake in an effort to make their body less ‘feminine’, to ensure that breasts and hips do not grow, or to inhibit periods and menstruation.

The following three case studies highlight just how important acceptance, belief and gender affirmation are in the context of mental health and physical wellbeing.

 

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Reuben, 23

Reuben began going through puberty around the age of 10 and the experience of his changing body came as a shock to him. “Puberty was something I had never really thought about and then all of a sudden, I was hit with this overwhelming sense of discomfort, fear and embarrassment.

“I had never thought about gender, nor had it been discussed at school or with my parents. It’s natural for people to feel awkward when they start going through puberty so I thought it was inevitable for me to hate my developing body. I did not see the early signs of gender dysphoria.”

Reuben began hiding his body by wearing layers of baggy clothing. “I would wear scarves and hoodies in the height of summer because I just hated how my body was changing and did not want anyone, even myself, to know I had breasts.”

By the time Reuben was 12, he describes being in his body as “almost unbearable”. “I hated my thighs, hips, and chest. I began to restrict my intake of food as a means to try to control/slow down the rate my body was changing. I joined online networks of people with anorexia and obsessed over media images of ‘thigh gaps’ and haunting images of extremely underweight teenagers in big baggy shirts which made them look genderless, no sign of breasts or hips, just a skeletal frame.”

Reuben began self-harming and considered taking his own life. By the age of 14 Reuben had lost so much weight he was referred to CAMHS where he had weekly sessions with a psychologist and dietician.

“I explained to them that I didn’t feel fat and that it was just these particular areas of my body I couldn’t stand. I would bring in images of emaciated androgenous looking people and tell them that I wanted to look like these people. They were aware that I really struggled with my mental health around the time of my monthly cycles but just equated it to hormones. I had expressed my utter hatred for my breasts.

“The whole time they spoke of me feeling fat or overweight – yet I knew I wasn’t fat. That was the most confusing part of my anorexia that mental health professionals didn’t care to discuss with me, because it didn’t fit their usual narrative of a person suffering from anorexia.”

Reuben had grown up in a small town and he was raised in a religious family, so he had no exposure to the queer community. When Reuben was 21, a friend was talking about trans and non-binary people and there was a lightbulb moment. “I had heard about trans women but, for some reason, I‘d never heard about trans men, and non binary identities were a complete mystery to me!

“It was the first time I had EVER heard about trans people without this weird fetishized, negative narrative the media had shown me my whole life. It instantly stopped me dead in my tracks and opened up a whole new world for me, just this one exchange of information.”

A few months later Reuben came out as transmasculine to his mum.

“She mentioned that my psychologist, who I went to see when I was 14, had mentioned to my parents that I had developed an eating disorder to stunt puberty. No one had ever mentioned this to me. I was always told by professionals that I had an eating disorder as a consequence of thinking I was fat so I just went along with it. Yet if, at the time, they had investigated my feelings further and brought up this theory about me wanting to stunt puberty, I could have come to a conclusion about my gender identity much sooner while there was still time for the intervention of puberty blocking medication.

“I honestly feel like my childhood and teenage years were robbed from me because this information was withheld.

“I am so happy now kids and teens are learning about gender identity and the LGBTQ+ community. It was something that could have saved me and my family lots of pain if I had known about it.”

Reuben says he knows a lot of trans people who suffered with eating disorders as a result of their gender dysphoria. He believes that it’s something doctors should take into consideration when treating patients with eating disorders.

“Gender identity issues need to be investigated when assessing a patient with an eating disorder, even if it is just a small set of questions so that gender dysphoria can be ruled out.”

 

Jay, 27

Jay suffered from anorexia throughout his teens and was diagnosed with anorexia aged 17. “I had a period of intensive home treatment following my diagnosis at 17, followed by a mixture of inpatient and outpatient treatment for several years.

“The possibility of me being trans never occurred to me until my treatment was nearly over. Most of my treatment focused on helping me reach a safe weight and learning to manage my thoughts and behaviours around my eating disorder; there wasn’t much time to dig into the reasons why it might have developed in the first place.”

Like Reuben, Jay was unaware that trans men exist and he had never heard of gender dysphoria.

“If I’d known about gender dysphoria in my early teens, I think I would’ve recognised the feeling of intense discomfort in my changing body that precipitated my eating disorder. I can’t be certain, but I’m pretty sure that my dysphoria was what caused me to begin restricting my food intake and over-exercising. It wasn’t about controlling my weight: I was desperate to take back control of my body, to fight back against my developing curves and keep the androgynous child’s body I felt safe in.

“The damage my illness did to my body and mind in those years will never fully heal, but transition allowed me to finally feel comfortable in my body and let go of the patterns and behaviours that fuelled my eating disorder.”

Jay says it was the realisation that he was trans and being able to begin his transition that allowed him, “to finally escape the cycle of relapsing and begin my recovery in earnest.”

“I can’t help but feel that if I’d known I was trans sooner and had been able to access puberty blockers and hormone treatment as a teenager then I wouldn’t have become so ill in the first place.”

Unfortunately Jay’s eating disorder history delayed his referral to the NHS GID services substantially. “The Gender Identity Clinic wanted to be sure my gender dysphoria wasn’t a result of my eating disorder rather than the cause of it.

“I think that because eating disorders are so common amongst trans people it’s really important for clinicians specialising in treating trans people to have some training in eating disorders and vice versa.

“Being out as trans would have made accessing inpatient treatment for my eating disorder more difficult, both because I don’t think staff on the ED unit had any training in dealing with trans people, and because there was only one bed available for a man on the inpatient ward.”

Jay says that trans people with eating disorders are stuck in a ‘Catch-22’ situation, as gender clinics require clients to be a safe weight and have any comorbid mental health conditions under control before they will prescribe any gender-affirming treatment.

“It’s essential that clinicians take a holistic approach – they should be aware that eating problems, body dysmorphia and gender dysphoria often share roots, and they should be treated accordingly.”

 

Dan, 21

Unlike Reuben and Jay, Dan realised he was trans at a young age. However he wasn’t offered any support for his gender dysphoria and so took matters into his own hands.

“I suffered with disordered eating behaviours throughout my adolescence, which began around the same time I started to figure out and come to terms with my gender identity, which coincided with the beginning of puberty.

“I frequently skipped meals that I could get away with (breakfast and lunch), and engaged in compensatory exercising behaviours when I had to eat meals with my family for dinner. A lot of this was due to wanting to reduce the appearance of secondary sex characteristics such as breasts and hips due to the dysphoria I felt, and it seemed to be the only way to take any control, due to not being able to access any GICs.

When Dan went away to university in 2017, his eating disorder became worse.

“I began living in halls, this meant I had significantly more control over my eating and my privacy. This led to these disordered eating behaviours spiralling into purging disorder. I was able to self-induce vomiting as I was no longer afraid of doing it in my parent’s house and having them hear or find out.”

In 2018, Dan was referred to both an adult GIC in Exeter and an eating disorder clinic in Southampton.

“After attending both of these, I have (thankfully) moved past my eating disorder and am now able to eat without those cognitions and behaviours.”

Dan says he felt he had to hide his eating disorder from the GIC as he felt he didn’t want to risk giving them any grounds to delay his HRT.

“I never felt that I could tell anyone at the GIC that I was struggling with an eating disorder. This was mostly because I felt that, if I appeared anything but completely psychologically and emotionally stable, they would not allow me to begin HRT. This was the only thing I wanted at that moment after waiting almost six years to get to that point.”

Dan’s experiences lead him to conduct a study into disordered eating patterns and body-image in transgender and non-binary individuals for his dissertation.

“I found that 20.2% of individuals reported moderate-severe disordered eating patterns. I also found that transgender men reported disordered eating behaviours significantly more than non-binary individuals. However, no significant difference was found between transgender men and transgender women, or transgender women and non-binary individuals. I also found that transgender men reported significantly higher levels of restricted eating behaviours compared to both transgender women and non-binary individuals.”

Dan is currently in the process of working with his supervisor to publish his study.

 

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[1] Diemer, E. W.; Grant, J. D.; Munn-Chernoff, M. A.; Patterson, D. A.; and Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 57(2), 144–149. doi:10.1016/j.jadohealth.2015.03.003.