EATING DISORDERS AND GENDER DYSPHORIA IN …



EATING YOURSELF AWAY:

Reflections on the ‘comorbidity’ of eating disorders and gender dysphoria

Introduction[i]

Conversation with L and his mother

Mother: At 15 he became really controlling about what he ate; he became obsessive about exercise and eventually was diagnosed with anorexia.

L: the whole reason I became controlling was because I was going through a puberty that I wasn’t meant to go through. It was never about being thin or losing weight. It was about having this male physique.

Mother: The child psychologist concentrated on the fact that he was a gifted child, and had been through a separation. Apparently that was a text-book diagnosis for anorexia. She actually used the term ‘text-book’. I mentioned that when he was younger he wanted to be a boy, and to dress like a boy, and it became an obsession with him. She discounted that as she had already made her diagnosis and she was happy with that.

L: I felt that was such a missed opportunity. If I could have come to terms with the fact that I was trangender, I could have started hormone-blockers and testosterone at a younger age, I would be so much more confident about my body – less insecure. I wouldn’t have had to go through so much.

Mother: Professionals should look at the bigger picture – find out more. Things that may seem insignificant turn out to be very significant.

This is a story of a transgender adolescent,[ii] L., assigned female at birth and with a clear male gender identity since early childhood. Primarily in order to avoid pubertal development, L., once puberty hit him, started to diet and to adopt disordered eating patterns. Brought at that point to the attention of the clinical psychologist, L. was diagnosed with anorexia nervosa.

Various studies have highlighted a high prevalence of eating disorders among people with gender dysphoria, particularly adolescents, and particularly transgender boys.[iii] [iv] [v] [vi] [vii] [viii] [ix] [x] [xi]

A large study published in 2015, conducted across 289,024 students in over 200 American Universities, shows that gender nonconforming[xii] students report more use of vomiting, laxatives and diet pills than do cisgender students, regardless of sexual orientation.[xiii]

It has also been noted that more than half of the adolescents diagnosed with gender dysphoria hold one additional psychiatric diagnosis.[xiv] A correlation between gender dysphoria and disorders on the autism/Asperger spectrum has also been noted[xv] and it has been pointed out that “the relationship between certain forms of psychopathology and [gender dysphoria] is still not entirely clear”.[xvi]

These findings are worrying: disordered eating patterns can cause a wide number of health problems,[xvii] and eating disorders have the highest mortality of all psychiatric disorders.[xviii] [xix] If the data reported just above are accurate, it means that a number of gender nonconforming adolescents are exposed to those risks, in addition to the hardship of gender dysphoria[xx].

This in itself provides a moral reason to think about where the clinical community, or perhaps society as a whole, is still failing to support gender nonconforming people. But other issues, both theoretical and practical, emerge while reflecting on the recent data on comorbidity.

Stressing “comorbidity” seems to mean that transgender people, particularly adolescents, are also afflicted by a psychological disorder (eating disorders) in addition to gender dysphoria (which is still listed in the DSM-V and in the ICD-10 – see also later in this paper, but that many do not see as psychopathology).[xxi] [xxii] Interpreting the data in this way can have a number of consequences: it can blind us, or healthcare professionals, to the reasons for which gender nonconforming people, particularly adolescents, adopt disordered eating patterns. It may, in other words, lead us or healthcare professionals to inadvertently construe the transgender person as a fragile individual, prone to psychological disorders and maybe afflicted by profound body dissatisfaction that appears to erupt in different ways (through the gender dysphoria, or through the eating disorder). Taking the comorbidity as a given, without reflecting carefully on its meaning, may thus in turn lead healthcare professionals to be wary of providing medical treatment to gender nonconforming adolescents: for example, they may decide not to provide pubertal suppressant medications or other hormonal treatment, at least until eating disorders are also adequately dealt with, or at least until it is clear what the deepest, underlying problem of the adolescent is.

Unless such comorbidity is properly understood, what is helpful data provided by latest research may, it will be argued, lead to serious mismanagement of gender dysphoria. This paper will suggest that the adoption of disordered eating patterns in gender nonconforming adolescents should not be regarded necessarily as evidence that the adolescent suffers from eating disorders. The salient features of eating disorders, as shall be discussed in more detail later, are typically absent in gender nonconforming youth: simply put, gender nonconforming youth may diet for reasons that are different from those found typically in eating disorder sufferers.

I will thus differentiate between eating disorders and disordered eating patterns, and suggest that not all those who adopt disordered eating patterns should be regarded as suffering from eating disorders. Healthcare professionals should be wary of easily posed correlations between syndromes, and be careful at interpreting the modality of behaviour adopted by gender nonconforming adolescents.

In the case history reported above, the diagnosis of gender dysphoria was missed altogether, but that case illustrates the importance of interpreting disordered eating patterns carefully, in order to make accurate diagnoses, and also to frame adequate and timely strategies of intervention.

2. Gender dysphoria in young persons

Gender identity refers to the sense of being a “boy”, a “girl”, a “man”, a “woman”, or being part of a non-binary group (for example “genderqueer”). For many people, gender identity is congruent with the “sex” [xxiii] assigned at birth. Those in this group are usually referred to as “cisgender”. People whose gender identity is not congruent with the “sex” assigned at birth are in this paper referred to as “gender nonconforming”. The spectrum of gender identities is wide and includes various understandings of the self: for example, for some people gender is stable across life, for some it is not, some people identify as a woman in some contexts and as a man in others, and some people do not identify in any gender.

Gender dysphoria refers to the psychological aversion towards the physical features that represent the “sex” assigned at birth, and which is experienced as being in contradiction with the inner sense of gender identity. In addition to this, there can be the discomfort arising from being “misread” - for example, being addressed by the wrong name or pronoun. And of course more serious harm derives from bullying, discrimination, and violence, still highly prevalent in several countries. [xxiv] [xxv]

Whereas the level of gender dysphoria may vary in different people, for many gender nonconforming people it includes disgust towards the physical features that are incongruent with the sense of self. Such disgust may be absent or less sharp in children, as they can live in the role that accords with their gender identity (at least if they are in a supportive environment). However, as puberty approaches, the dysphoria is likely to accentuate; as the secondary sex characteristics develop, it is more difficult to hide the “sex” of assignment, and to live in the role that accords with the gender identity.

The WPATH Standards of Care recommend that adolescents with strong and persistent gender dysphoria be treated with pubertal suppressant medications (usually gonadotrophin hormone-releasing analogue - GnRHa) soon after the beginning of pubertal development.[xxvi] Intervention with the analogue gives the young person a breathing space, during which they can consider their options for their future lives. Such intervention is entirely reversible (phenotypic puberty resumes if treatment is suspended) and it is regarded both as therapeutic and diagnostic: it helps both professionals and youth to elaborate the person’s “genuine” gender identity without the distress of the changing body.[xxvii] [xxviii] [xxix]

However, in light of the high apparent correlation between eating disorders and gender dysphoria, healthcare professionals may become wary of commencing medical treatment, particularly with pubertal suppressant medications, as these ought to be provided usually to minors, soon after the onset of puberty, and thus at a particularly delicate time of development (one additional concern may of course be that the patient may have not have attained full legal capacity to consent to medical treatment). This could be because they may want to understand what the “real” problem of their patient is; they may not want to initiate gender treatment in doubt that the underlying problem may be of a different nature. Moreover, the WPATH Standards of Care state that a criterion for initiating hormone treatment is that other medical conditions should be “reasonably well controlled”[xxx]. Even if the Standards of Care refer in this paragraph to medical conditions such as cardiovascular problems, this paragraph may in principle also apply to mental conditions, such as eating disorders. Moreover, even though the Standards of Care are not law and are not legally binding, they reflect a consensus of experts and thus it is expected that, unless there are strong reasons for doing otherwise, they will be followed.

However, for those who adopt disordered eating patterns to control pubertal development (like L. in the case history above), disordered eating patterns are unlikely to be effectively controlled until hormone treatment (at least puberty suppressant medications) is provided. The risk is thus that treatment may not be commenced because there is (so it may be believed) a concomitant eating disorder, but the disordered eating patterns are likely to continue unless medical treatment is provided.

Not providing or delaying medical treatment to adolescents needs to be considered carefully and should not be regarded necessarily as “a cautious approach”: as Kreukel and Cohen-Kettenis report, “[f]or many adolescents, being refused treatment during this difficult period is a form of psychological torture. Providing such adolescents with early interventions might be viewed as harm reduction. […] [N]ot giving these youngsters treatment might lead to risky behaviors (for example, prostitution, self-mutilation, self-medication or suicide)”.[xxxi] In the long term, untreated adolescents who will transition will have to undertake invasive surgery that would have been prevented with the analogues; mastectomy, for example, chondrolaryngoplasty (reduction of the Adam’s apple), voice-pitch altering surgery, among others. Some of the effects of pubertal development cannot be reversed even with surgery, once they have taken place (for example, body size and conformation). Therefore long-term body satisfaction is also compromised unless analogues are provided on time.[xxxii] Untreated adolescents are also more exposed to bullying and other forms of psychological, verbal and physical abuse because of their appearance. [xxxiii]

As the WPATH recognise:

[R]efusing timely interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatisation. As the level of gender-related abuse is strongly associated with the degree of psychiatric stress during adolescence, withholding puberty suspension and subsequent feminising and masculinising hormone therapy is not a neutral option for adolescents.[xxxiv]

Given how much is at stake for the adolescents concerned, it is imperative that the correlation between gender dysphoria and disordered eating patterns is understood properly. It is crucial to understand whether or not the adolescent is engaging in disordered eating patterns, but also to understand why they do so.

3. Understanding the co-morbidity of disordered eating patterns and gender dysphoria

As discussed in the Introduction, several studies have registered a high co-morbidity of eating disorders and gender dysphoria. The problem with so called “co-morbidity”, or “correlation” between gender dysphoria and eating disorders is that it is based largely on observation of people’s behaviour. But obviously someone who diets to excess is not necessarily anorexic, and does not necessarily “suffer from eating disorders”: hunger strikers are not anorexic; models, dancers and climbers or runners are not necessarily anorexic; hunger artists or “detox practisers” are not necessarily anorexic. We may debate what the notions of anorexia and eating disorders should encompass, but the salient features of eating disorders may not necessarily be present in gender nonconforming people who adopt disordered eating patterns.

In order to understand this point better, it is important to provide a brief account of eating disorders. This account will only focus on the most salient features of eating disorders, as they would usually be understood in clinical psychology and psychiatry.

3.1 Eating disorders: a brief account

Eating disorders are generally understood as including anorexia nervosa, bulimia nervosa and, according to the latest edition of the DSM, binge eating disorder [xxxv] [xxxvi] (one of the pioneers of studies of eating disorders, Hilde Bruch, also included obesity among them).[xxxvii] Very briefly, anorexia is characterised mainly by restriction of food intake, combined with an extreme fear of putting on fat and body weight. Bulimia is characterised by loss of control over food, resulting in eating large quantities of food in a very short period of time. These episodes of “loss of control”, sometimes called in the literature “food orgies” are followed by compensatory practices (these include but are not limited to self-induced vomiting, use and abuse of laxatives or diuretics, and excessive exercise). Binge eating is also described as loss of control over food and consumption of large quantities of food over a very short period of time, but the episodes are not followed by compensatory practices, such as self-induced vomiting.

Although the three syndromes are distinguished in the DSM-V, there is significant overlap: for example, many anorexics use exercise, self-induced vomiting and other compensatory practices in order to control body weight. Many of them also suffer from bulimic episodes. Likewise, bulimics are typically driven by the lure for thinness: they usually attempt to exercise strict control over food intake and they break through their regime. In fact, bulimia often appears after a period of anorexia and some argue that it is just the other side of the same coin.17 Binge eating also has features that overlap with anorexia and bulimia: in this case too eating is associated with self-disgust, shame and guilt. This indicates that the psychological dynamics that characterise bulimia may have affinity with those characterising anorexia and bulimia: there is something disgusting and shameful about eating, and control of food intake, and thus thinness, are also valuable for the binge eaters. Control of food intake, revulsion of eating, fat and body weight, and longing for thinness, are thus likely to be in the psychological background of all three groups.

Some sufferers would rather die than put on the weight sufficient for survival. Such importance attached to thinness is often qualified as “irrational”, as it has no apparent logical explanation. Eating disorders have been interpreted in various ways; for example, as originating from family dynamics in which overly controlling parents impede the expression of the autonomy of their children, and such autonomy is then claimed back by the child through control of food intake. According to another interpretation the value of thinness can be explained by reference to certain shared moral ideals relating to the value self-control and will power. According to yet another interpretation, eating disorders derive from social factors, such as the changes and confusion in expectations of women in modern Western societies; in some psychoanalytic/psychodynamic interpretations the sufferer, most usually a young woman, refuses to grow up because she is unconsciously frightened of the conflicting demands that she will be unable to fulfil. Neuro-physiological and genetic factors also seem to be associated with eating disorders. These are only a few hypotheses on eating disorders, and there are many others. 17 Eating disorders appear to have complex and multifactorial aetiology, and it is possible that many of the interpretations and hypotheses found in the literature may capture a part of the truth around such complex and clinically resilient syndromes.

None of these interpretations, however, is likely to apply easily to the situation of gender nonconforming adolescents. Diet, in other words, is likely to serve markedly different purposes in gender nonconforming adolescents. But there is more: diet is also likely to serve purposes that are intelligible and that it is rational for the adolescent to pursue. Dieting may be a way to suppress secondary sex characteristics, to avoid menstrual cycles, or visible breasts, or more generally to attempt to delay puberty for as long as possible. Once these goals are achieved, there may not be further drive towards thinness. These goals are different from the drive for thinness that motivates eating disorder sufferers. Of course eating disorder sufferers, like transgender adolescents, do not just “want to be thin” – as mentioned earlier, there may be complex reasons, historical, social, familial, perhaps genetic and neurological, which may explain why people get entangled in the grip of an eating disorder. But eating disorder sufferers do not usually have clear, intelligible purposes in mind that explain why they are attempting to lose weight. So unclear are these purposes, and so powerful the drive to thinness, that eating disorder sufferers usually experience the whole eating disorder as out of control. They do not decide to be revolted by fat, and they do not decide to overeat and vomit. They attempt to exercise strict control over their diet but many would not be able to explain why they feel compelled to do so. It is precisely this difficulty in grasping the reasons that precipitate people in the vortex of eating disorders that make eating disorders – somehow paradoxically - relatively easy to identify17 but at the same time extremely hard to treat.

Instead, in the case of gender nonconforming adolescents the disordered eating pattern appears rational, if not reasonable, and understandable, especially if the person is not receiving medical help adequate to his or her needs. As Swaab notices,[xxxviii] the results of “anorexic” behaviours are perfect for gender nonconforming people, especially boys. The weight loss ensures the diminution or absence of breast tissue; the periods cease. These may be seen as advantages to be gained, rather than the accidental sequelae of not eating.

Indeed, whereas many psychiatric diagnoses are of questionable reliability and validity,[xxxix] eating disorders are a well-defined syndrome, and difficult to be mistaken for a different mental health problem. So it should be relatively easy to assess whether the adolescent’s disordered eating stems from the value of thinness and disgust for fat, or instead from the wish to arrest pubertal development. But in order to make such an assessment, it is necessary to move beyond the mere observation of behaviour.

It is of course possible that some gender nonconforming persons may also develop an eating disorder, in the same way in which it is possible that they may develop, say, gastritis. But the fact that a high number of gender nonconforming people adopt disordered eating patterns is no indication that these people also have an eating disorder as it would usually be understood in clinical psychology and psychiatry. Thus it may not be true, strictly speaking, that eating disorders are more prevalent in the transgender population than in the general population. Disordered eating patterns may be more prevalent, but this does not mean that eating disorders are more prevalent too. Gender nonconforming adolescents may adopt those patterns, as L. in the case history above, in order to deal with the gender dysphoria. The disordered eating pattern in these cases could be conceptualised as an additional sign of gender dysphoria and not as an additional psychiatric syndrome. It could also be seen as an indication that something is not right in the clinical management of the dysphoria, rather than as a sign that something is not right within the individual patient. In other words, if the adolescent sees him or herself forced to take drastic steps to conceal the secondary sex characteristics, this may indicate that the clinical management of the gender dysphoria is dissatisfactory.

Given that growing up in a body that carries visible signs of the “sex” of assignment is simply not an option for many gender nonconforming adolescents, the attempt to keep the body as undeveloped as possible may be the only solution open to the adolescent, unless satisfactory medical treatment is provided in a timely fashion.

Thus, it would be simplistic to read the correlation found in the literature as an indication that many gender nonconforming adolescents are afflicted by psychopathology, in addition to gender dysphoria. At worst, seeking alternative psychopathological reasons for the disordered eating may blind professionals to the fact that the medical care provided may be inadequate, and that this delay or failure to treat the gender dysphoria may be the direct cause of the disordered eating.

Gender nonconforming people may also adopt compensatory methods. This should likewise not deceive healthcare professionals into thinking that the adolescents have “comorbid bulimia”. Clearly two people who make themselves sick will face similar health risks. For example, both of them may suffer electrolyte imbalance, which could in turn cause arrhythmias; both may suffer tooth decay or abrasion of the oesophagus. But how these people can be helped and should be helped will vary depending on why they vomit. The psychological dynamics triggering behaviour that may appear similar to a superficial observation may be different, and different should be the understanding and the management of the distress exhibited. Understanding the possibility that dieting and compensatory behaviours may be a rational and successful strategy to avoid pubertal changes should be central to clinical responses.

It is of course possible that a transgender person on a strict diet with the clear purpose in mind to defer puberty or to conceal the secondary sex characteristics, will at some point also have a breakthrough and a food orgy followed by compensatory practices (a strictly speaking “bulimic” episode). Still that does not make the gender dysphoric adolescent “a bulimic patient” or a person affected by bulimia. The psychological dynamics and the predicaments suffered by the different sufferers may be different, and should be regarded as such.

4. Primary and secondary gender dysphoria: the issue of body dissatisfaction

The correlation of eating disorders and gender dysphoria, unless properly understood, may be interpreted as suggesting that the primary or underlying problem in those transgender youth who adopt disordered eating patterns may be body dissatisfaction. Body dissatisfaction may, at a superficial observation, be seen as the common denominator of gender dysphoria and eating disorders.

Whereas both gender nonconforming people and people with eating disorders are likely to suffer body dissatisfaction, as with dieting the nature of such dissatisfaction needs to be understood properly in order to intervene effectively. If the “primary problem” in gender nonconforming people who adopt disordered eating patters was thought to be body dissatisfaction, this would nearly automatically rule out provision of medical treatment for the gender dysphoria.

Transgender medical care treats body dissatisfaction in a way that is at odds with the way in which other forms of body dissatisfaction are usually managed.[xl] It would be a strange way of helping, say, an anorexic, to give dieting pills to reach the desired level of thinness.[xli] But medical care of gender dysphoria does exactly that: it helps individuals to obtain the absent, or reduce the present, sex characteristics that cause body dissatisfaction. Thus transgender care is at cross-purposes and irreconcilable with the usual treatment of body dissatisfaction.

The binomial “gender dysphoria/eating disorders” could thus in principle lead us to consider “converting” the individual to accept the “sex” assigned at birth as a legitimate goal of the medical intervention: it could in fact be the only legitimate goal under this perspective. But as is now well known, “conversion” or “reparative” therapies are useless at best, are more likely to be harmful, and are currently regarded as unethical. [xlii]

In most cases the body dissatisfaction that afflicts gender nonconforming people radically decreases once medical care (for example, hormonal treatment or reassignment surgery) is provided.[xliii] [xliv] [xlv] Also in adolescents with strong and persistent gender dysphoria, dissatisfaction is usually reduced once pubertal suppressant medications are provided.28 This suggests that in all likelihood body dissatisfaction is typically not the cause of gender dysphoria, but its consequence.

Moreover, although both eating disorder sufferers and gender nonconforming people may suffer body dissatisfaction, the dissatisfaction experienced by these groups cannot be easily compared. Such comparison is beyond the remit of this paper, but, as noted earlier with regard to dieting, stressing that two groups or two individuals suffer body dissatisfaction does not mean that they suffer the same thing. As indicated in the opening case history, for L. dieting was never about being thin (it was not about being revolted at the idea of maintaining a healthy body weight, it was not about not wanting to face the challenges of adulthood, or about feeling guilty about eating, or wanting to gain control over the family): it was about growing up in the wrong body. This is illustrated further by the fact that the type of body dissatisfaction that is or may be a part of gender dysphoria may lead to the adoption of disordered eating patterns but the reverse is not true: eating disorder sufferers typically do not develop gender dysphoria along the way. Gender dysphoria and eating disorders should thus continue to be considered as two different conditions, and not two possibly related syndromes caused by underlying “body dissatisfaction”. Gender nonconforming behaviours are unlikely to serve purposes important to eating disorder sufferers; disordered eating patterns are instead likely to serve purposes important to gender nonconforming individuals (possibly when these purposes are not served by medical services).

This of course does not mean that those who apply for treatment for gender dysphoria should receive it without careful assessment. What is suggested here is that the alleged “co-morbidity” of gender dysphoria and eating disorders should be interpreted cautiously as possible co-occurrence of gender dysphoria and disordered eating patterns, rather than of gender dysphoria and eating disorders psychopathology. As a consequence, the findings reported in the literature should not lead doctors to worry that gender dysphoria may be a symptom of some other underlying psychological issue (such as body dissatisfaction) and assume that therefore the patient may not benefit from treatment for gender dysphoria at least until such dissatisfaction is properly dealt with. Even where their patients exhibit disordered eating behaviours, healthcare professionals should not automatically regard them as afflicted by two syndromes, but should investigate the meaning and purposes of the behaviours adopted. Moreover, given the high association of disordered eating patterns and gender dysphoria, healthcare professionals should also regard disordered eating patterns as a possible sign of gender dysphoria, in cases in which the adolescent (like L.) is brought to the medical attention without a diagnosis of gender dysphoria.

5. Psychopathology and stigma

Stressing the high correlation of gender dysphoria and eating disorders may, as an unintended consequence, reinforce the idea that gender dysphoria is psychopathology or often associated with psychopathology. As mentioned earlier, there is increasing recognition that gender diversity is not mental illness. The term “disorder” has been removed in the latest DSM-V and what is now still called “Gender Identity Disorder” in the ICD-10 will be renamed and removed from the list of mental illnesses in the ICD-11.21 20 The published literature on comorbidity of gender dysphoria and eating disorders and other psychopathologies may make the psychopathologisation of gender dysphoria return through the window, just after it has been ejected via the front door.

Of course often gender nonconforming adolescents may come to the attention of healthcare professionals with a number of mental health issues. Many gender nonconforming youth still experience rejection within their families, bullying and isolation in school, and many other forms of social ostracism and discrimination, culminating at times in open violence. These experiences are all likely to cause psychological suffering; this adds to the intra-psychic difficulties that may accompany the elaboration of a nonconforming gender identity. However, the mental health issues that often accompany gender dysphoria (such as anxiety or depression) are typically secondary to the gender dysphoria, and usually ease off or disappear once the dysphoria is treated properly.[xlvi]

It is not claimed here that gender nonconforming adolescents who adopt disordered eating patterns will immediately stop doing so once medical treatment is provided. What is claimed instead is that recognising the difficulties that may be experienced by gender nonconforming adolescents should not foster the misguided idea that gender nonconforming youth is typically a psycholabile group likely to suffer from a number of psychiatric comorbidities.

6. Conclusions

A proper understanding of the association of gender dysphoria and disordered eating patterns is essential to good clinical practice. Obtaining medical treatment for gender dysphoria is not straightforward, and the additional diagnosis, unless properly interpreted, instead of facilitating and improving care, may turn the journey towards medical care even harder than it already is.

An unqualified statement of the correlation between gender dysphoria and eating disorders may lead healthcare professionals to believe that medical treatment for gender dysphoria should not be provided, at least until the “underlying” body dissatisfaction is dealt with, or until it is clear what the relationship between body dissatisfaction, disordered eating and gender dysphoria is.

However, the body dissatisfaction of gender nonconforming adolescents often cannot be treated without medical help (medical help that often these adolescents, differently from eating disorder sufferers, are desperate to obtain). Deferring treatment may thus lead to an exacerbation of the disordered eating patterns, as this (together with self-medication) is what is left to the adolescent to cope with the development of the body.

Of course the finding of a correlation between gender dysphoria and disordered eating patterns is an important one. Any research, or investigation, be it theoretical or empirical, from any discipline, which sheds light on the complexities of gender identity development, conforming or not, is a valuable addition to the knowledge of human nature. But the findings need to be read accurately and interpreted carefully.

Although gender diversity (like sex diversity) is increasingly recognised as a natural part of being human, gender nonconforming people are still afflicted by a number of predicaments: some of them are inherent to the mismatch between the body and the self; some of them may relate to the way in which diversity is accepted, validated or ostracised in the familial and social systems in which people happen to live. There is no doubt that, even in the more accepting families and societies, gender nonconforming people may face hardship that is not known to others.

That a high number of gender nonconforming adolescents engage in self-harming eating patterns is a reason for concern. It means that a number of these adolescents are not only at risk of the well-known sequelae of psychological and physical harm associated with gender diversity (such as discrimination, verbal physical and sexual abuse, refusal of medical care, rejection, and self-medication), but also at risk of the secondary symptoms of abnormal eating, which can be severe, long-lasting and even fatal. Care and medical treatment should therefore be adjusted to consider those health risks.

Perhaps more importantly, the correlation between gender dysphoria and disordered eating should alert us to the fact that healthcare systems may still be failing to provide appropriate and prompt medical care. If the necessary medical treatment was made available, it is possible that the raised prevalence of disordered eating in gender nonconforming youth would decrease. Whether that would happen is a question of an empirical nature that cannot be answered in this paper. However, there is a good reason to believe that it may: thus the correlation between gender dysphoria and disordered eating patterns must be understood properly, should not be interpreted simplistically as comorbidity of gender dysphoria and psychopathology, and should not in principle cause the provision of medical treatment for the gender dysphoria to be delayed or withheld.

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[i] The author acknowledges the Gender Identity Research and Education Society and Surrey and Borders Partnership NHS Trust (2014) Gender Variant Children and Trans Adolescents for the case history, and for extensive comments on earlier drafts of this paper; eLearning at nlmscontent.nesc,nhs.uk/sabp/gv, funded by Health Education England. The author also wishes to thank Neil Allen and colleagues at the CSEP for their helpful comments.

[ii] In this paper, those assigned female at birth who identify as boys or who identify as non-binary but towards the masculine end of the gender spectrum are described as trans boys and vice versa.

[iii] Fisher AD, Caltellini G, Casale H et al. Body uneasiness and eating disorders symptoms in gender dysphoria individuals. J Sex Med 2015; 12 (Special Issue Supplement 3): 203-203

[iv] Couturier J, Pindiprolu B, Findlay S, Johnson N. Anorexia nervosa and gender dysphoria in two adolescents. Int J Eat Disorder 2015; 48(1): 151-155

[v] Fisher AD, Castellini G, Bandini E. et al. Cross Sex hormonal treatment and body uneasiness in individuals with gender dysphoria. J Sex Med 2014; 11(3): 709-719

[vi] Diemer EW, Grant JD, Munn-Chernoff MA , Patterson DA, Duncan AE. Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students. J Adolescent Health 2015; p://dx.10.1016/j.jadohealth.2015.03.003

[vii] Gastellini G, Fisher AD, Bandini E, Casale E, Fanni E. Gender dysphoria is associated with eating disorder psychopathology in gender dysphoria subjects. J Sex Med 2014; 11 (Special Issues SI Supplement 1) : DOI: 10.1111/jsm.12413

[viii] Algars M, Alanko K, Santtila P, Sandnabba KN. Disordered eating and gender identity disorder: a qualitative study. Eating Disorders: the Journal of Treatment and Prevention 2012 20(4): 300-311

[ix] Bandini E, Fisher AD, Castellini G, et al. Gender identity disorder and eating disorders: similarities and differences in terms of body uneasiness. J Sex Med 2013 10(4): 1012-1023

[x] Ewan LA, Middleman AB, Feldmann J. Treatment of anorexia nervosa in the context of transsexuality: a case report. Int J Eat Disorder 2014; 47(1): 112-11

[xi] Vocks S, Stahn C, Loenser K, Legenbauer T. Eating and body image disturbance in male-to-female and female-to-male transsexuals. Arch Sex Behav 2009; 38: 364-377

[xii] Terminology is often controversial in this area of study. Gender expansive and gender diverse are sometimes used and may be regarded as more inclusive notions. However, I will use “gender nonconforming” because it is more commonly used

[xiii] Diemer EW, Grant JD, Munn-Chernoff MA , Patterson DA, Duncan AE. Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students. J Adolescent Health 2015; p://dx.10.1016/j.jadohealth.2015.03.003

[xiv] Edwards-Leeper L, Spack NP. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a Major Pediatric Centre. Journal of Homosexuality 2012; 59(3): 321-336, p. 326.

[xv] Jones RM, Wheelwright S, Darrell K, Martin E, Green R, Di Ceglie D, Baron-Cohen S. Brief report, female to male transsexual people and autistic traits. J Autism Dev Disord 2012; 42(2): 301-306

[xvi] De Vries ALC, Cohen-Kettenis PT. Clinical management of gender dysphoria in children and adolescents: the Dutch approach. Journal of Homosexuality 2012; 59(3): 301-320, p. 304

[xvii] Giordano S. Understanding Eating Disorders. Oxford: Oxford University Press, 2005, chapter 1

[xviii] Griffiths R, Russell J. Compulsory treatment for anorexia nervosa patients. In: Vandereycken W, Beumont PJV, eds. Treating Eating Disorders: ethical, legal and personal issues. New York: New York University Press, 1998: 127-150, p. 127

[xix] Busko M. High suicide rate in anorexia linked to lethal methods, not fragile health. J Affect Disorders 2008; 107: 231-236

[xx] Jones BA, Haycraft E, Murjan S, Arcelus J. Body dissatisfaction and disordered eating in trans people: a systematic review of the literature. International Review of Psychiatry 2016; 1, 81-94

[xxi] A 2015 resolution by the Council of Europe is available at . Members of the WHO Working Group on the Classification of Sexual Disorders and Sexual Health have published two papers. In these papers the authors propose the removal of GID from the Mental and Behavioural Disorders and its inclusion in a non-psychiatric category. See Drescher J, Cohen-Kettenis P, Winter S. Minding the body: situating gender identity diagnoses in the ICD-11. Int Rev Psychiatr 2012; 24(6): 568-577

[xxii] Drescher J. Controversies in gender diagnoses. LGBT Health 2013: 1(1):9-13. Available at

[xxiii] In this paper I use the notion of “sex” of assignment in inverted commas. This is the terminology typically used in the scholarly literature, and in standard definitions adopted - for example, by the World Professional Association for Transgender Health. “Sex” is usually meant to refer to the set of biological data and it is differentiated from both “gender identity” and “gender role”. See for example World Professional Association for Transgender Health 2011, online p. 2. For the sake of simplicity I use here the standard terminology: however, it is important to note that talking about “sex of assignment” seems to suggest that an individual’s “sex” is something observable, a set of biological data that can be “seen” at birth or maybe later (presumably by looking initially at the genitalia, or by taking further tests). Instead, the “sex” of an individual is not a simple matter, and not purely a matter of “observation” as is sometimes claimed. As I have argued elsewhere, it is not clear what “biological sex” actually is, and what people look for when they try to determine a person’s “sex”. I have argued that “sex” is no less of a construct than gender. For this reason I use “sex” in inverted commas. It would be more precise to talk about “gender of assignment” but to align the paper to common usage I will use “sex of assignment”. For more on this point see Giordano S. The confused Stork. Sex, gender, parenting. In: Hens K, Cutas D, Horstkötter D, eds. Parental responsibility in the context of neuroscience and genetics. Dordrecht: Springer, 2016

[xxiv] Steinmetz K. Why Transgender People Are Being Murdered at a Historic Rate, Time, US, 17/08/2015.

[xxv] Anonymous. Transphobic hate crimes rising in UK, police say. The Guardian, UK, 26/12/2014,

[xxvi] World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Seventh Version, WPATH, 2011. Online at

. p. 2

[xxvii] Wallien MSC, Cohen-Kettenis PT. Psychosexual Outcome of Gender Dysphoric Children. Journal of American Academy of Child and Adolescent Psychiatry 2008; 47: 1413–1423

[xxviii] Giordano S. Children with Gender Identity Disorder. An ethical and legal analysis. London and New York: Routledge, 2013

[xxix] Giordano S. Children with Gender Identity Disorders: treatment, ethical and legal issues. In: Kreukels BPC, Steensma TD, de Vries ALC, eds. Gender Dysphoria and Disorders of Sex Development, New York: Springer, 2014: 205-230

[xxx] See note 25, p. 47

[xxxi] Kreukels BPC, Cohen-Kettenis PT. Puberty suppression in gender identity disorder: the Amsterdam experience. National Review Endocrinology 2011; 7: 466-472. doi:10.1038/nrendo.20. 11.78

[xxxii] Giordano S. Lives in a chiaroscuro. Should we suspend the puberty of children with Gender Identity Disorder? J Med Ethics 2008; 34(8): 580-586

[xxxiii] NatCen. Tackling homophobic, biphobic and transphobic bullying among school-age children and young people. London: NatCen Social Research, 2014

[xxxiv] See note 25, p.21

[xxxv] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-V. US: American Psychiatric Association, 2013, Section 2.10

[xxxvi] The DSM-V is only a diagnostic instrument, and there is wide and comprehensive psychological literature on eating disorders that provides much more detailed descriptions of eating disorders. Due to its large use, I will rely here on the classification exposed in DSM.

[xxxvii] Bruch H. Eating Disorders: Obesity, Anorexia Nervosa, and The Person Within. US: Basic Books, 1973

[xxxviii] Swaab, D. 2014. We are our brains? England, New York, Ontario, Melbourne, New Delhi, Aukland: Penguin

[xxxix] Rosenhan D. On being sane in insane places. Science 1973; 179(4070): 250–258

[xl] With the exception perhaps of some isolated cases of body dysmorphia, in which healthy leg amputation has been authorised

[xli] Indeed, the so-called “paradoxical method” has been used in the past for anorexia nervosa. The idea was to ignore completely the thinness of the anorexic, and indeed subtly praise it, so that as a strategy to elicit concern that modality of behaviour would lose its efficacy. The paradoxical method has been abandoned for being highly hazardous. In any case, the ultimate aim of that approach was to get rid of the thinning strategy, and not to help the anorexic to obtain the thinnest body she could

[xlii] Pyne J. The Governance of Gender Non-Conforming Children: A Dangerous Enclosure. Annual Review of Critical Psychology 2014; 11: 79-96

[xliii] Spack N. An Endocrine Perspective on the Care of Transgender Adolescents. Presented at the 55th annual meeting of the American Academy of Child and Adolescent Psychiatry, 28 October–2 November 2008

[xliv] Imbimbo C, Verze P, Palmieri A, Longo N, Fusco F, Arcaniolo D, Mirone V. A report from a single institute's 14-year experience in treatment of male-to-female transsexuals. J Sex Med 2009; 6(10): 2736-2745. doi: 10.1111/j.1743-6109.2009.01379.x

[xlv] De Cuypere G, Elaut E, Heylens G, Van Maele G, Selvaggi G, T'Sjoen G, Rubens R, Hoebeke P, Monstrey D. Long-Term Follow-Up: Psychosocial Outcome of Belgian Transsexuals after Sex Reassignment Surgery. Sexologies 2006; 15(2): 126–133

[xlvi] Moller B, Schreier H, Li A, Romer G. Gender Identity Disorder in Children and Adolescents. Current Problems in Pediatric and Adolescent Health Care 2009; 39(5): 117–143

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