By Rachel Harvey
Most people don’t remember when they first became aware of their gender.
Children typically begin to label themselves as a male or female and begin to develop their gender identity around two or three years old, and in most cases, a child’s gender identity aligns with the sex they were born with. But, according to an analysis based on federal and state data, 0.6 percent of individuals (roughly 1.4 million people in the United States) identify as transgender, meaning their gender identity or gender role differs from those typically associated with the sex they were assigned at birth — and the numbers are increasing, particularly among youth.
“The number of individuals who identify as transgender or use non-traditional gender terms to identify themselves has increased significantly within the past 10 years. With trans visibility growing in the United States, individuals are finding it increasingly safer and more accepting to come out and discuss their gender identity,” says Kyle Bonner, LCSW, LCADC, coordinator of Diversity and Inclusion Programs for Princeton Health “The shift in society’s acceptance of transgender and gender non-conforming individuals comes with a greater need to provide inclusive and compassionate care to the LGBTQ+ population.”
Research also shows that transgender children are at greater risk for developing eating disorders such as bulimia and anorexia, even more so than their cisgender peers (individuals whose gender identity and gender expression matches the sex they were assigned at birth).
For example, a 2015 study found that transgender college students were more than four times more likely than their cisgender female counterparts to report an eating disorder diagnosis such as anorexia nervosa or bulimia, and two times more likely to report eating disorder symptoms such as purging. Similar results were reported in a 2013 survey of high school youths, showing transgender students as nearly three times as likely than their cisgender peers to restrict eating, almost nine times as likely to use diet pills, and seven times as likely to use laxatives to control their weight.
The signs and symptoms of eating disorders are similar across the gender spectrum, but experts say that transgender people may face additional hurdles to diagnosis and treatment.
“Unfortunately, it’s likely that those who identify as LGBTQ+ have already faced stigmas at some point in their lives,” Bonner says. “Identity-related negative experiences like bullying, trauma, and violence can precipitate the need for care. And seeking behavioral health care when you’re wondering if you’ll be treated differently can be especially intimidating.”
Additionally, many transgender individuals experience gender dysphoria, a medical diagnosis for the serious stress associated with the conflict a person experiences between the way they feel and think of themselves and their physical or assigned gender. It is important to note that not all transgender people suffer from gender dysphoria or have a negative body image, but the American Psychiatric Association notes that those who do may experience significant emotional distress and/or problems functioning associated with this conflict.
“In treating transgender patients with eating disorders, we understand that gaining weight is especially difficult as their weight served a very real function for them. Specifically, transgender females often use symptoms such as restricting, purging, or exercising to achieve a more feminine appearance and transgender males often use the same symptoms to suppress secondary sexual characteristics and menstruation,” says Janine Averbach, MSW, LCSW, senior primary therapist at Princeton Center for Eating Disorders. “But we also know that weight restoration cannot be compromised when the goal is full recovery from an eating disorder.”
According to the National Eating Disorders Association, eating disorders such as anorexia nervosa and bulimia nervosa will affect at least 30 million individuals in the United States at some point in their lives. No matter their gender, people with eating disorders are often unusually concerned with weight loss, dieting and control of food.
And while the outward signs of an eating disorder may be obvious, malnutrition associated with an eating disorder has serious hidden health complications that can impact the immune system, digestive system, skeletal system, cardiovascular system, and reproductive system.
Childhood and adolescence can be a very vulnerable time in developing one’s identity. By shifting our understanding of what eating disorders look like, and who they affect, we can open the lines of communication for youth and help to eliminate discrimination and stigma.
“It’s becoming increasingly common to have transgender youth in our center, including those who come into treatment and open up about their gender identity for the first time,” Averbach says. “And for those patients in particular, we have this incredible opportunity to allow them to explore their gender in a safe space, which for some has included name/pronoun preferences or haircuts and wardrobe changes. With respect to family involvement, parents also have the opportunity to openly process their feelings which may include a sense of grief and loss.”
While transgender children and adolescents will undoubtedly face unique challenges and hardships, promoting the health and positive development of youth that identify as transgender can help prevent eating disorders. But experts say more work is needed to create safe spaces, facilitate access to care, educate families, and raise awareness about the fact that eating disorders impact many individuals outside of stereotypical demographics.
“It’s important to remember that the LGBT community has many of the same health concerns as other patients, but historically have had poorer access to health care and experiences of stigma and discrimination resulting in increased risk for certain health conditions and support around mental wellness,” said Rosemary Thomas, MPH, CHES, program coordinator of the Penn Medicine Program for LGBT Health.
Penn Medicine is the first academic medical center in the Northeast — one among just a handful of academic medical centers in the U.S. — to launch a program across multiple professional schools and affiliated hospitals to improve the health of LGBT individuals. Transgender patient advocates are available to assist patients in finding appropriate providers, making appointments and ensuring optimal patient care for transgender-identified individuals.
Eating disorders affect everyone differently, but their affects can be devastating and even life-threatening, but seeking professional treatment is a critical moment on the path to recovery. With the proper treatment, long-term recovery is both achievable and sustainable.