Diverging eating psychopathology in transgendered eating disorder patients: a report of two cases

Gender-Affirming Nutrition: An Overview of Eating Disorders in the Transgender Population

PURPOSE OF REVIEW

Transgender individuals are vulnerable to many nutrition-related conditions, especially eating disorders due to gender dysphoria. This review aims to summarize the current literature on eating disorders in transgender individuals. The issues that should be considered in nutrition care for the transgender population are discussed regarding public health.

RECENT FINDINGS

Transgender individuals can exhibit disordered eating behaviors to overcome the stress they experience due to stigma, discrimination, social exclusion, and abuse. Recent studies showed that disordered eating and clinical eating disorders are more prevalent among transgender than cisgender people. It is very important for a multidisciplinary team working in the clinic to understand the epidemiology, etiology, diagnostic criteria, and treatment of eating disorders in the transgender population. However, multidisciplinary nutritional care is limited due to the lack of transgender-specific nutrition guidelines. It is safe to say that adhering to a generally healthy nutritional pattern and using standardized nutrition guidelines. We recommend that health professionals working with patients/clients with eating disorders receive continuing education in transgender health, be empowering and inclusive, address patients/clients with their gender identity nouns and pronouns, and develop nutritional treatment plans that are not gender-specific. Eating disorders are a significant public health problem in the transgender population. Therefore, clinical screening and early intervention are necessary to identify and treat eating disorders in transgender people. Eating disorders in the transgender population should be monitored routinely, and gender-affirming care should be provided as well as treatment of eating disorders.

A scoping review of research literature on eating and body image for transgender and nonbinary youth

BACKGROUND

Transgender and nonbinary (TGNB) adolescents and young adults are underrepresented in the literature on eating disorders and body image-related problems, despite increased mental health disparities and emerging research showing high associations between gender dysphoria, body image, and eating disorders among TGNB youth.

AIMS

The scoping review was designed to critically examine the research on TGNB adolescents and young adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this scoping review. The electronic databases of MEDLINE and PsychInfo were used for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for transgender minor children, adolescents, or young adult samples (18 to 25 years old) and address differences in eating/body-related problems by age. The relevant data was extracted and narratively summarized.

RESULTS

49 studies were identified, data extracted, and analyzed. Increased prevalence of eating disorders and body image problems were identified for TGNB youth. Body-gender congruence through gender affirming social and medical interventions (e.g., hormone therapy) were noted as significant for alleviating body image problems and facilitating eating disorder treatment. Family and social factors were not well understood in the literature and a need for increased study of TGNB youth from varied racial/ethnic, neurodiverse, and within specific identities (e.g., nonbinary) and families and cultural contexts is still needed.

CONCLUSIONS

Future research should consider the use of developmental and family theories for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups, neurodiversity, and varied gender identities (e.g., nonbinary and gender queer) for identifying important differences.

Eating disorder symptomatology among transgender individuals: a systematic review and meta-analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis was to synthesize the literature on eating disorders and eating disorder symptomatology among transgender individuals and to summarize the existing literature on gender-affirming treatment and the prevalence of eating disorder symptomatology.

METHOD

The literature search for this systematic review and meta-analysis was performed in PubMed, Embase.com, and Ovid APA PsycInfo. We searched for "eating disorders" and "transgender" using both controlled vocabularies and natural language terms for their synonyms. The PRISMA statement guidelines were followed. Quantitative data from studies on transgender individuals and eating disorders assessed with relevant assessment tools was included.

RESULTS

Twenty-four studies were included for the qualitative synthesis, and 14 studies were included in the meta-analysis. The results revealed higher levels of eating disorder symptomatology among transgender individuals compared with cisgender individuals, especially cisgender men. Transgender men tend to display higher levels of eating disorder symptomatology than transgender women; however, transgender women seem to have higher levels of eating disorder symptomatology than cisgender men and, interestingly, this study also noted a trend toward transgender men having higher levels of eating disorders than cisgender women. Gender-affirming treatment seems to alleviate the presence of eating disorder symptomatology in transgender individuals.

DISCUSSION

The body of research on this subject is extremely limited, and transgender individuals are underrepresented in the eating disorder literature. More research investigating eating disorders and eating disorder symptomatology in transgender individuals and the relationship between gender-affirming treatment and eating disorder symptomatology is needed.

Appearance and performance-enhancing drugs and supplements, eating disorders, and muscle dysmorphia among gender minority people

OBJECTIVE

Appearance and performance-enhancing drugs and supplements (APEDS) can be used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among gender minority people.

METHOD

Participants were 1653 gender minority individuals (1120 gender-expansive [defined as a broad range of gender identities that are generally situated outside of the woman-man gender binary, e.g., genderqueer, nonbinary] people, 352 transgender men, and 181 transgender women) recruited from The Population Research in Identity and Disparities for Equality Study in 2018. Regression analyses stratified by gender identity examined associations of any APEDS use with eating disorder and muscle dysmorphia symptom scores.

RESULTS

Lifetime APEDS use was common across groups (30.7% of gender-expansive people, 45.2% of transgender men, and 14.9% of transgender women). Protein supplements and creatine supplements were the most commonly used APEDS. Among gender-expansive people and transgender men, lifetime use of any APEDS was significantly associated with higher eating disorder scores, dietary restraint, binge eating, compelled/driven exercise, and muscle dysmorphia symptoms. Any APEDS use was additionally associated with laxative use among gender-expansive people. Among transgender women, use of any APEDS was not significantly associated with eating disorder or muscle dysmorphia symptoms.

DISCUSSION

APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in gender-expansive people and transgender men, thus highlighting the importance of assessing for these behaviors and symptoms among these populations, particularly in clinical settings.

PUBLIC SIGNIFICANCE

This study aimed to examine APEDS use among gender minority people. We found that 30.7% of gender-expansive (e.g., nonbinary) people, 45.2% of transgender men, and 14.9% of transgender women reported lifetime APEDS use, which was associated with eating disorder and muscle dysmorphia symptoms in transgender men and gender-expansive people. Clinicians should assess for these behaviors in gender minority populations.

Variability in Eating Disorder Risk and Diagnosis in Transgender and Gender Diverse College Students

PURPOSE

To examine differences in elevated eating disorder risk and self-reported eating disorder diagnosis across subgroups of transgender and gender diverse (TGD) college students.

METHODS

Data from 5057 TGD college students participating in the national Healthy Minds Study between 2014-2019 were analyzed. Chi-square tests and logistic regression analyses examined heterogeneity in prevalence and odds of elevated eating disorder risk, as measured by the SCOFF, and self-reported eating disorder diagnosis by gender, as well as by intersecting gender and sexual orientation identities.

RESULTS

Genderqueer/non-conforming college students reported the highest prevalence of elevated eating disorder risk (38.8%) relative to gender expansive students. Genderqueer/non-conforming (11.1%), gender expansive (12.3%), and trans men/transmasculine students (10.5%) reported higher prevalence of a self-reported eating disorder diagnosis relative to trans women/transfeminine students (6.3%). Heterosexual or straight trans men had lower odds of eating disorder risk and self-reported diagnosis relative to trans men with a minoritized sexual orientation.

CONCLUSIONS

Genderqueer/non-conforming college students may be at heightened eating disorder risk. Moreover, a heterosexual/straight sexual orientation was associated with lower odds of elevated eating disorder risk and self-reported eating disorder diagnoses among trans men and genderqueer/non-conforming college students, but this finding did not hold for other groups. College campuses should aim to reduce eating disorder risk among TGD students.

Disordered Eating, Body Image Dissatisfaction, and Associated Healthcare Utilization Patterns for Sexual Minority Youth

PURPOSE

To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status.

METHODS

Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility.

RESULTS

BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9-2.2] and adjusted odds ratio 3.8 [3.4-4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services.

CONCLUSIONS

SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.

Eating disorder symptomatology in transgender patients: Differences across gender identity and gender affirmation

OBJECTIVE

Past studies have reported high rates of eating disorder (ED) symptomatology among transgender people, yet without consideration of gender affirmation. The primary objective of this study was to evaluate the relationship between gender identity, gender affirming interventions such as gender affirming hormones (GAH) and gender affirming surgeries (GAS), and ED symptomatology.

METHOD

Transgender patients at a primary care outpatient gender health program in the United States completed a survey consisting of demographics, medical history, and clinical variables, including the Eating Disorder Examination Questionnaire (EDE-Q). Multivariate analyses of covariance were conducted to compare EDE-Q scores across gender identity and gender affirmation.

RESULTS

Compared to transgender men (n = 79), transgender women (n = 87) reported higher EDE-Q scores and significantly higher Eating Concern. Compared to hormone/surgery-naïve and hormone-experienced/surgery-naïve patients, hormone/surgery-experienced patients had lower EDE-Q scores. Hormone/surgery-experienced patients reported significantly lower Shape Concern and marginally lower Global Score and Weight Concern than hormone-experienced/surgery-naïve patients. There were no differences in EDE-Q scores between hormone/surgery-naïve and hormone-experienced/surgery-naïve patients.

DISCUSSION

Transgender patients report high levels of ED symptomatology. There are subtle, yet important, differences in ED between gender identities and gender affirmations. High ED prevalence may result from the dual pathways of sociocultural pressures as well as gender dysphoria. Both GAH and GAS may be effective interventions to support gender affirmation and thereby alleviate ED symptomatology. While the potential positive benefits of GAS on ED are more apparent, the effects of GAH are less clear.

Body checking behaviors and eating disorder pathology among nonbinary individuals with androgynous appearance ideals

BACKGROUND

Internalized sociocultural standards of attractiveness are a risk factor repeatedly linked to eating disorders; however, many nonbinary individuals do not conform to these standards.

PURPOSE

This study investigated the body checking behaviors and eating disorder pathology among nonbinary individuals with androgynous appearance ideals.

METHODS

Participants (n = 194) completed an online survey assessing body checking behaviors, body appreciation, gender congruence, and eating disorder pathology RESULTS: Body checking predicted eating disorder pathology, and body image significantly improved the model. Gender congruence did not additional variance in predicting eating pathology CONCLUSION: Though gender congruence was not a significant predictor of eating pathology, content analysis revealed unique body behaviors specific to nonbinary individuals' gender identity and gender expression. Clinical implications include expanding perceptions of eating disorder presentation when working with nonbinary individuals with androgynous appearance ideals.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Rumination & eating psychopathology among trans and nonbinary individuals: A path analysis integrating minority stress

Ruminative thought patterns, defined as repetitive negative self-focused attention, are considered an avoidant coping strategy for managing stress. As trans and nonbinary (TNB) individuals commonly experience prejudice and discrimination in response to their gender identities (i.e. minority stressors), rumination over these stressors may contribute to heightened risk of psychopathology in these groups. Although rumination is a general risk factor for eating disorder (ED) psychopathology, no studies to date have examined whether eating- or gender-related ruminative patterns relate to maintenance of ED psychopathology for TNB individuals. This cross-sectional study investigated whether levels of rumination (both gender-related and ED-specific) mediated the relationship between minority stress and ED psychopathology.

METHOD

Participants were 242 TNB adults (Mage = 24.92, SD = 6.5, Range = 18-70) recruited online, who completed measures of minority stress, gender-related rumination, ED-specific rumination, and ED psychopathology. We used Preacher-Hayes' approach to examine the parallel mediation model, with gender-related and ED-specific rumination as potential mediators.

RESULTS

Gender-related rumination did not mediate the relation between gender minority stress and ED psychopathology, Indirect B = -0.00 [95% BCa CI: -0.01, 0.00]; however, ED-specific rumination was significant, indicating partial mediation, Indirect B = 0.01 [95% BCa CI: 0.00, 0.02].

CONCLUSION

As gender minority stress and ED-specific rumination relate to ED psychopathology, it is essential that clinicians adopt an intersectional minority stress framework in understanding ED psychopathology among TNB individuals.

The Body I Live in. Perceptions and Meanings of Body Dissatisfaction in Young Transgender Adults: A Qualitative Study

Body dissatisfaction in individuals with Gender Incongruence (GI) represents a primary source of suffering. Several studies have highlighted how this suffering has psychological, physical, and biological implications. This work aims to explore experiences related to body dissatisfaction and investigate the issues associated with living in a body perceived as incongruent for individuals with GI. Thirty-six individuals, aged between 18 and 30 years old and at stage T0 of hormone treatment, participated in the study. Body dissatisfaction and experiences related to it were investigated using the Clinical Diagnostic Interview. The Consensual Qualitative Research methodology was applied to the transcripts of the interviews. Several themes emerged: experiences with GI development, experiences with puberty and bodily changes, perception of one’s body, psychological problems and complex behavioral patterns related to body dissatisfaction. Results pointed out the complexity implied in the relationship with one’s body for individuals with GI, highlighting specific aspects of body dissatisfaction among these individuals (e.g., eating disorders, sexual difficulties, social withdrawal). This study underlines the need for a deeper understanding of some aspects of GI to better define guidelines for a correct assessment of it. In this way it will be easier to avoid negative outcomes for the psychological and general health of transgender people.

Gender Dysphoria, Eating Disorders and Body Image: An Overview

Background::

Gender dysphoria is a clinical condition in which a state of inner suffering, stress and anxiety is detected when biological sex and a person's gender identity do not coincide. People who identify themselves as transgender people are more vulnerable and may have higher rates of dissatisfaction with their bodies which are often associated with a disorderly diet in an attempt to change the bodily characteristics of the genus of birth and, conversely, to accentuate the characteristics of the desired sexual identity.

Aim::

The purpose of this work is to examine the association between dissatisfaction with one's own body and eating and weight disorders in people with gender dysphoria.

Results::

Gender dysphoria and eating disorders are characterized by a serious discomfort to the body and the body suffers in both conditions. The results of our study suggest that rates of pathological eating behaviors and symptoms related to a disordered diet are high in patients with gender dysphoria and that standard screening for these symptoms must be considered in both populations at the time of evaluation and during the course of the treatment.

Conclusions::

In light of this evidence, 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..

Body Image Concern and Gender Identities between Transgender and Cisgender Persons from Iran

The aim was to compare body image concern and gender identities between post-operative transgender and cisgender persons. Participants included 48 transgender persons (25 trans men, 23 trans women) and 48 cisgender persons (24 cismen, 24 ciswomen). The data were collected with Littleton's Body Image Concern Inventory and the Singapore Androgyny Inventory. Results showed that body image concern was significantly higher in transgender participants compared to cisgender participants, and these scores were especially higher in trans women compared to other groups. Furthermore, trans women scored higher in the femininity subscale compared to ciswomen. Body image concern was also higher in participants with feminine gender identity compared to participants with masculine gender identity (whether they were transgender or not). Moreover, transgender persons with traditional gender identity had higher scores in body image concern in comparison to those who had nontraditional identities, as well as trans men had more Androgynous or undifferentiated identities than trans women. We also found a significant correlation between feminine subscale and body image concern. Based on our results, it seems hormonal and surgical treatments in transgender persons only can eliminate body dissatisfaction to a certain extent. The higher scores of trans women, both in body image concern and femininity, indicate that it may be harder for trans women to believe they are perceived as female by others and their bodies are adequate. Changing cultural beliefs, social values, and increasing social acceptance with the help of the media may play an important role in improving body image in the future.

Prevalence of Self-Injurious Thoughts and Behaviors in Transgender Individuals With Eating Disorders: A National Study

PURPOSE

This study examined prevalence of self-injurious thoughts and behaviors (SITBs) in transgender individuals with eating disorders, as compared to cisgender individuals with eating disorders and transgender individuals without eating disorders.

METHODS

Data were analyzed from 365,749 individuals (median age 21 years, 71.8% White/Caucasian, 34.9% male, 64.9% female, and 0.2% transgender) who participated in American College Health Association-National College Health Assessment, an annual national assessment of college student health, from 2008 to 2011.

RESULTS

Rates of past-year nonsuicidal self-injury, suicidal ideation, and suicide attempts were elevated in transgender participants with eating disorders (74.8%, 75.2%, and 74.8%, respectively), as compared to cisgender participants with eating disorders and transgender participants without eating disorders. Follow-up logistic regression analyses indicated these differences were statistically significant above and beyond the effects of demographic variables and depression.

CONCLUSIONS

Results found extremely high rates of SITBs in transgender individuals with eating disorders. This combination of identities, each associated with SITBs, may have a compounding effect.

Multidisciplinary care considerations for gender nonconforming adolescents with eating disorders: A case series

Gender nonconforming youth are at risk for body dissatisfaction and disordered eating. Currently, only a small body of literature addresses this high-risk group. The five cases in this series highlight important themes for this patient population from an interdisciplinary perspective. Identified themes include increased risk for self-harm/suicide, complex psychiatric, and medical implications of delay to treatment for either gender dysphoria or disordered eating, and the importance of collaborative management to maximize care and facilitate healthy development to adulthood. The purpose of this case series is to expand the interdisciplinary discussion regarding the breadth of presentation and management considerations for gender nonconforming adolescents with disordered eating. An interdisciplinary approach to care might enhance access to comprehensive, collaborative treatment for disordered eating, and gender dysphoria in this unique population.

Towards Providing Culturally Aware Nutritional Care for Transgender People: Key Issues and Considerations

Transgender people are an important group for whom access to healthcare is often problematic. Dietitians need to be aware of key issues in transgender health to provide culturally competent clinical nutritional care. This article serves as a primer, clarifying key terms and concepts, exploring the impact of stigma and discrimination on health and nutrition for people from transgender communities, and offering practical advice for nutritional and other related issues. Education for dietitians both pre- and postqualification is an important part of improving care and building skills and awareness of cultural humility. Transgender people may be at increased nutritional risk due to increased risk of cardiovascular disease, HIV, body image issues, and food insecurity. This risk profile, along with the history of trauma both outside and related to the medical community means that there is an urgent need for dietitians to develop practice tools for assessment, care, and referral to improve the nutritional status and well-being of this client group.

Discrimination, mental health, and body image among transgender and gender-non-binary individuals: Constructing a multiple mediational path model

The purpose of the current study was to examine the relationships among discrimination, mental health, and body image in a national sample of transgender adults. Participants (N = 78) identified as transgender, genderqueer, or other gender non-binary identities and were recruited via a national online survey. Harassment/rejection, work/school, and other discrimination explained10.4% of the variance in body appreciation, while satisfaction with life, anxiety, self-esteem, and depression explained 60.7%. Within these models, harassment/rejection was inversely associated with body appreciation, while self-esteem and satisfaction with life were positively associated. A series of path models moving from a measurement model to a more parsimonious and excellent-fitting model found that the effect of harassment/rejection on body appreciation was fully mediated by self-esteem and satisfaction with life, resulting in a multiple mediation.

Longitudinal course of eating disorders after transsexual treatment: a report of two cases

Background

Several reports have been published on patients with gender dysphoria and eating disorders. However, there have been few reports on the longitudinal course of eating disorders after gender reassignment surgery (GRS)/gender confirmation surgery (GCS).

Case presentation

We report two Japanese cases of transsexual persons with eating disorders who underwent GRS/GCS, one male-to-female (MtF) and one female-to-male (FtM). Case 1 was a 35-year MtF person who had a 14-year-course of bulimia nervosa that developed after GRS. Case 2 was a 35-year FtM person with anorexia nervosa who underwent GCS 9 years before.

Conclusions

We found that the treatment of our transsexual patients influenced the course of their eating disorders for a long period, which could be attributable partly to the cultural situation in Japan, an East Asian country. It is possible that many gender identity problems and identity problems in general persist even after surgery and treatment; therefore, continual clinical support should be provided for patients with gender dysphoria and eating disorders even after hormonal therapy or GRS/GCS.

Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors

PURPOSE

Research has documented high rates of disordered eating for lesbian, gay, and bisexual youth, but prevalence and patterns of disordered eating among transgender youth remain unexplored. This is despite unique challenges faced by this group, including gender-related body image and the use of hormones. We explore the relationship between disordered eating and risk and protective factors for transgender youth.

METHODS

An online survey of 923 transgender youth (aged 14-25) across Canada was conducted, primarily using measures from existing youth health surveys. Analyses were stratified by gender identity and included logistic regressions with probability profiles to illustrate combinations of risk and protective factors for eating disordered behaviors.

RESULTS

Enacted stigma (the higher rates of harassment and discrimination sexual minority youth experience) was linked to higher odds of reported past year binge eating and fasting or vomiting to lose weight, while protective factors, including family connectedness, school connectedness, caring friends, and social support, were linked to lower odds of past year disordered eating. Youth with the highest levels of enacted stigma and no protective factors had high probabilities of past year eating disordered behaviors.

DISCUSSION

Our study found high prevalence of disorders. Risk for these behaviors was linked to stigma and violence exposure, but offset by social supports. Health professionals should assess transgender youth for disordered eating behaviors and supportive resources. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2017; 50:515-522).

Transgender and Gender Diverse Clients with Mental Disorders: Treatment Issues and Challenges

A number of transgender and gender diverse individuals face risks of mental health problems and suicidality, often as a result of transphobia and gender minority stress. There are many resilience and protective factors that transgender individuals use to cope with mental distress and thrive. In this article, a review of the literature on transgender and gender diverse individuals with mental health problems is provided, as well as a discussion of the protective factors that enhance resilience.

Perceptions of eating disorder diagnoses and body image issues in four male cases in Singapore

BACKGROUND

Despite the increasing number of patients presenting for treatment, little is still known about male eating disorders cases. The current study presents four male eating disorder cases presented to our specialized treatment facility in Singapore.

CASE PRESENTATION

Cases 1, 2 and 3 are homosexual males in their twenties and thirties who presented with anorexia nervosa and bulimia nervosa. Case 4 is a heterosexual male in his twenties diagnosed with binge eating disorder. All four cases expressed body image dissatisfaction, fat phobia and fear of weight gain. Additionally, all of them sought treatment because of comorbid psychiatric conditions or parental wishes. Premorbid obesity and homosexual orientation may be potential risk factors for males in developing eating disorders.

CONCLUSIONS

These findings suggest that more exploration needs to be done for males diagnosed with eating disorders, particularly in the Asian society. A deeper understanding into factors associated with symptom presentation and treatment-seeking behaviors would greatly assist in informing the direction and focus of treatment in the region.

Disordered Weight Management Behaviors, Nonprescription Steroid Use, and Weight Perception in Transgender Youth

PURPOSE

Disordered weight management behaviors are prevalent among youth; recent case reports suggested that these behaviors might also be common in transgender youth. We studied associations of gender identity with disordered weight management behaviors, nonprescription steroid use, and weight perception among transgender and cisgender (nontransgender) high-school students in Massachusetts.

METHODS

Data were analyzed from the 2013 Massachusetts Youth Health Survey, an anonymous survey in a random sample of Massachusetts public high schools. Respondents were divided into three groups: transgender (n = 67), cisgender male (n = 1,117), and cisgender female (n = 1,289). Fisher's exact tests and multivariable logistic regression models were used to examine unhealthy weight management behaviors in the past 30 days: fasting >24 hours, vomiting, diet pill use, and laxative use; nonprescription steroid use; and self-perceived weight status. Analyses controlled for age, race/ethnicity, and body mass index.

RESULTS

Compared with cisgender males, transgender adolescents had higher odds of fasting >24 hours (adjusted odds ratio [AOR] = 2.9, confidence interval [CI] = 1.1-7.8), using diet pills (AOR = 8.9, 95% CI = 2.3-35.2) and taking laxatives (AOR = 7.2, 95% CI = 1.4-38.4). Transgender youth had higher odds of lifetime use of steroids without a prescription than male cisgender respondents (AOR = 26.6, 95% CI = 3.5-200.1). Compared with cisgender females, transgender respondents had higher odds of perceiving themselves as healthy weight/underweight when they were overweight/obese (AOR = 2.4, 95% CI = 1.5-4.1).

CONCLUSIONS

Transgender youth disproportionately self-reported unsafe weight management behaviors and nonprescription steroid use compared with cisgender youth. Clinicians should be aware of this increased risk among transgender youth. Research is needed to further understand these disparities and to inform future interventions.

Body Image and Eating Disorders Among Lesbian, Gay, Bisexual, and Transgender Youth

Adolescence is a crucial period for emerging sexual orientation and gender identity and also body image disturbance and disordered eating. Body image distortion and disordered eating are important pediatric problems affecting individuals along the sexual orientation and gender identity spectrum. Lesbian, gay, bisexual, transgender (LGBT) youth are at risk for eating disorders and body dissatisfaction. Disordered eating in LGBT and gender variant youth may be associated with poorer quality of life and mental health outcomes. Pediatricians should know that these problems occur more frequently in LGBT youth. There is evidence that newer treatment paradigms involving family support are more effective than individual models of care.

Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned

Patients with gender dysphoria and patients with eating disorders often experience discontent with their bodies. Several reports have recognized the co-occurrence of these two conditions, typically in adults who identify as transgender females and desire a more feminine physique. This case report, in contrast, describes a 16-year-old patient with a female sex assigned at birth who first presented with features consistent with anorexia nervosa and later revealed underlying gender dysphoria with a drive for a less feminine body shape. We discuss both the path to recognizing gender dysphoria in this patient as well as the impact of treatment on his eating disorder and overall well-being. This case is one of only a few reports describing a female-to-male transgender patient with an eating disorder and is the first to explore the effects of hormone and surgical intervention in an adolescent patient.

Anorexia nervosa and gender dysphoria in two adolescents

Little has been published about the co-occurrence of gender dysphoria (GD) and eating disorders (ED) in adults, with no cases described in the adolescent population. The emphasis on body shape in both conditions suggests that there may be some overlap in symptomatology. We report two adolescent cases initially diagnosed with anorexia nervosa who later met criteria for GD. The drive for thinness for the 16-year-old male was associated with a wish to achieve a feminine physique whereas there was an emphasis for stunted breast growth and a desire for muscularity in the 13-year-old female. Complexities in presentation, evolution of symptoms over time, and the treatment of the two cases are discussed. Clinicians should inquire about sexual issues in the presentation of ED and should monitor for symptoms of GD, not only at initial presentation, but throughout treatment, especially as weight gain progresses.