Eating disorders in transgender peopleUnderstanding the link between gender identity and disordered eating.
The majority of us identify as one gender or the other based on our biological sex. This isn't always the case, though. A person is considered transgender if their gender identity differs from the gender society typically associates with the sex they were assigned at birth.
People who identify as a different gender than the one they were given at birth are referred to as "transgender." People whose gender identity matches the gender they were given at birth are referred to as "cisgender." People who identify as nonbinary, agender, genderqueer, Two-Spirit, or any other non-binary gender fall within the transgender category.
The relationship between the experience of transgender people and eating disorders is not yet fully understood as research into the subject has been limited. Various studies have shown that eating disorders are more common in the LGBTQ+ community than in the general population, but few have explicitly examined how common eating disorders are in the transgender community. Often studies will group transgender people with gay, lesbian, bisexual, and queer people, but due to the distinction between gender identity and sexual orientation, this can result in a confusion of findings. Transgender people can be any sexual orientation.
In our service at Schoen Clinic Newbridge, we have experience of working with young people who have an eating disorder together with a gender identity which is different to their assigned identity from birth (or expressed difficulties with their biological gender). Through our work with a small cohort of patients, we can make some observations about issues raised and the treatment pathway.
Are eating disorders common in transgender people?
There has been minimal study on transgender communities, with the majority of studies on eating disorders and disordered eating focusing on cisgender women. However, nearly 300,000 college students in the United States (including students who identified as transgender) were involved in a comprehensive study regarding eating disorders and coping mechanisms that was published in the Journal of Adolescent Health ; in the findings, transgender college students reported having disordered eating at a rate that was around four times higher than that of their cisgender counterparts.
Additionally, compared to their cisgender peers, the transgender adolescents who took part in the survey reported considerably greater rates of compensatory behaviours (like using diet pills).
Transgender vs. cisgender eating disorder figures
Percentage of college students reported receiving an eating disorder diagnosis in the last year. 
- 0.55% cisgender heterosexual men
- 1.85% cisgender heterosexual women
- 2.06% cisgender sexual minority men
- 3.52% cisgender sexual minority women
- 15% transgender
Reported eating disorders were higher amount LGB (lesbian, gay and bisexual) people than straight (heterosexual) people, but the figures are significantly higher in transgender people.
Why are transgender people at higher risk of developing an eating disorder?
Eating disorders are difficult illnesses with several underlying factors. There are a variety of reasons why a transgender person could develop an eating issue, such as:
- Managing their stress or trauma as a result of the violence or prejudice they have endured due of their transgender identity
- Attempting to provide each or both genders certain qualities
- Attempting to follow a male or female "ideal"
The Journal of Adolescent Health claims that there is a logical explanation for why eating disorders are a greater problem for transgender people than cisgender people, namely the fact that body dissatisfaction is one of the strongest predictors of developing an eating disorder while gender embodiment or presentation is crucial for many transgender people. Although not all transgender people want to transform their bodies, some do so through hormone replacement treatment, gender confirmation surgery, or other procedures that give them more masculine or feminine traits. However, some transgender people begin with dieting and exercise as the less expensive and intrusive choice, and this can result in harmful, disordered habits as they strive to achieve their desired look.
Puberty, identity and eating diordersPuberty delay
In the UK, the current average age for the onset of puberty is age 11 for girls and age 12 for boys (with a pattern of average onset becoming progressively younger over time). Puberty is defined as delayed in girls if there is no menstruation by the age of 16 and no breast development by age 13. In boys, puberty is considered to be delayed if there are no signs of testicular development by the age of 14.
One of the many different causes for puberty to be delayed is anorexia nervosa. This is because in a state of severe undernourishment, the body chooses which functions are essential to life, shutting down less critical functions. The hypothalamus, the part of the brain which regulates functions suppresses the hormonal fluctuations which regulate sexual development and puberty. In girls, this is expressed by what is described as primary amenorrhea (periods not starting by the age of 16), or in girls who have started to menstruate, secondary amenorrhea (periods are missed for three consecutive months). In boys, the impact on puberty and sexual development may not not be as easily recognisable but is likely to manifest in delayed or slow progression of puberty, reduced sexual drive and poor height gain.
It is widely recognised that the onset of adolescence and puberty is a time of change, search for identity and often, increased anxiety and conflict. If gender identity is difficult and being explored or challenged, this may be expressed in the adolescent’s relationship with food. A young person may deliberately restrict food intake in order to delay puberty because of gender identity issues. The precise causal relationship between gender identity, food restriction and anorexia nervosa will vary for each individual and require careful assessment.
For other young people, the connection may be unclear; there is disordered eating and difficulty with food as part of other challenges the young person is experiencing, and these challenges may include gender identity.
A specialised treatment approach
It might be daunting for many transgender people to seek treatment for an eating problem because it's likely they've previously suffered some type of trauma, or prejudice for being themselves. It might be difficult to even locate a behavioural healthcare professional that upholds their fundamental rights, such as using their proper name and pronouns.
People who identify as transgender have the right to care that addresses their unique issues since eating disorders impact everyone differently, regardless of gender identity. At Schoen Clinic we treat every patient as an individual, tailoring treatment to the unique needs of each person.
It is important to note that during an ongoing eating disorder, unless a gender identity has been well established within the young person prior to development of the eating disorder, a key principle is that any new decisions about gender identity should not be taken at a low weight because cognitions are impaired. Our focus is to provide wide-ranging, personalised support for the young person as they weight restore. We have links with the Tavistock Clinic, London, who are the recognised national specialists in gender identity support and treatment. Our focus is upon safe and supported weight restoration before gender assignment treatment and decisions.
 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.
Schoen Clinic specialists are here to help
Schoen Clinic Newbridge
Schoen Clinic Newbridge offers highly specialised inpatient treatment for children and young people (8-18 years) and a specialised outpatient service for young people (12-25 years) experiencing eating disorders and their associated problems. Welcoming NHS and private patients.
Schoen Clinic Chelsea
Schoen Clinic Chelsea is a leading London outpatient clinic in the heart of Chelsea.
Offering a specialised day treatment programme for children and young people (11-17 years) with eating disorders, as well as fast one-to-one Consultant appointments for young people (6-17 years) and adults (18+).
Welcoming privately insured and self-funding patients.
Schoen Clinic York
Schoen Clinic York offers highly specialised inpatient treatment for adults (18 years +) with diagnosed eating disorders and their associated problems.
Welcoming NHS and private patients.