Eating Behaviors 18 (2015) 54–56

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Eating Behaviors

Prolonged anorexia nervosa associated with female-to-male gender

dysphoria: A case report
Şenol Turan, Cana Aksoy Poyraz ⁎, Alaattin Duran
Department of Psychiatry, Cerrahpaşa School of Medicine, Istanbul University, İstanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Transsexual (TS) individuals seem to display an increased risk in having eating disorders. Several case reports
Received 16 October 2014 describe TS individuals with anorexia nervosa (AN). In order to understand better the impact of gender dysphoria
Received in revised form 9 January 2015 (GD) and hormonal/surgical treatments on the occurrence and course of eating disorders in TS patients long term
Accepted 25 March 2015
follow-up studies are needed. We present here a 41-year-old female-to-male TS patient suffering from AN.
Available online 1 April 2015
History revealed that pathological eating habits could strongly be associated with her GD. Hormonal and surgical
Keywords:
treatments resulted in substantial improvement in the given eating disorder. The impact of GD on the develop-
Transsexual ment and treatment of eating disorder is discussed in this report.
Gender dysphoria © 2015 Published by Elsevier Ltd.
Eating disorder

1. Introduction Hormonal and surgical reassignments have been reported to im-

Transsexuality is defined by a strong and persistent identification
with the opposite sex; the patient is uneasy about his or her biological
sex, and has a sense of inappropriateness in the gender role of that sex
(Hepp & Milos, 2002). Most studies confirm that people with gender
dysphoria (GD) do not show primary psychiatric pathologies (Cole,
O’Boyle, Emory, & Meyer, 1997; Hoshiai et al., 2010) but rather they
experience the outcome of the difficulties in coping with GD (Gómez-
Gil, Trilla, Salamero, Godás, & Valdés, 2009) or being isolated from
their families or friends (Factor & Rothblum, 2007). However, GD itself
may be a risk factor about eating disorders. Case reports have described
patients with GD suffering from eating disorders, particularly anorexia
nervosa (AN) (Fernández-Aranda et al., 2000; Hepp & Milos, 2002;
Hepp, Milos, & Braun-Scharm, 2004; Winston, Acharya, Chaudhuri, &
Fellowes, 2004). Studies have found higher rates of disordered eating
in transsexual (TS) subjects compared with controls (Ålgars, Santtila,
& Sandnabba, 2010; Vocks, Stahn, Loenser, & Legenbauer, 2009). It has
been noticed that there exists an interaction between transsexuality
and AN, resulting from the dissatisfaction with the body (Becker &
Mester, 1996). The core psychopathology of eating disorders is an over-
concern about one's body shape and body weight, along with the
patients' dissatisfaction with their body. In this regard studies have
found that GD subjects are more dissatisfied with their body compared
with controls even when it is concerned with their nonsexual parts
(Pauly & Lindgren, 1976/77; Vocks et al., 2009).
⁎ Corresponding author at: Department of Psychiatry, Cerrahpaşa Medical School,
Halaskargazi Cad. No: 81, Çiçek Apt. daire: 8, Osmanbey Istanbul, Turkey. Tel.: +90 532
715 95 04; fax: +90 212 473 26 34.
E-mail address: canaaksoy@yahoo.com (C.A. Poyraz).
prove the quality of life and psychological happiness of people with
GD. Yet, little is known about the impact of GD and hormonal/surgical
treatments on the course and treatment of eating disorder. In this
report, we present a case of female-to-male (FtM) TS patient who was
suffering from AN. Her history revealed that pathological eating behav-
iors were strongly associated with her GD. Reported cases described
predominantly MtF subjects, and additionally prolonged course of ED
for 20 years intertwined with GD and the complete remission of ED
after hormonal treatment were remarkable features of our case. We
will discuss the underlying aspects that induced eating disorder and
the impact of hormonal/surgical treatments on her AN.
2. Case
A 41-year-old FtM TS patient applied to court modify her sex indicat-
ed in the identity card. The court referred to our psychiatry clinic to have
her psychiatric assessment.
In her early childhood A.T, felt strongly that she belonged to the male
sex. She played boys' toys and games, preferred boys for playmates, and
she was interested in football. When she reached puberty the growth of
her breasts and the onset of menstruation caused her to have severe
stress, in order to hide her breasts she was wearing extra large size
clothes and she was pretending a kyphosis-like posture. During the
first year of her university education she had severe depressive symp-
toms connected with her gender dysphoria; she was spending the
greater part of her time at home as she was uneager to dress and live
like a woman. She gained 6 or 7 kg in those days and observed that
she had amenorrhea for the last few months; soon after she learned
that rapid weight gain or loss might cause missed periods.

http://dx.doi.org/10.1016/j.eatbeh.2015.03.012
1471-0153/© 2015 Published by Elsevier Ltd.
 Ş. Turan et al. / Eating Behaviors 18 (2015) 54–56
At that time she was 147 cm tall, and her weight was 54 kg, which
equated to a BMI of 24 kg/m2. The pathological eating attitude at first
was dietary restriction; she was performing a highly restricted calorie
intake of approximately 600–700 kcal per day and engaging in cardio-
vascular exercise for up to 2 h per day once or twice a week. This was
followed by self-induced vomiting. She discovered that whenever her
weight dropped to 43 kg her periods stopped; she always forced herself
to fix her weight under 43 kg. The lowest body weight she had was
41 kg (height: 1.47, BMI: 18 kg/m2). She soon started self-induced
vomiting, and whenever her weight increased to 44 kg her menstrua-
tion was starting. She had a serious suicide attempt after she has com-
pleted university education. She had to work to make a living and as
she did not want to dress like a woman she felt very depressed. After
the suicide attempt she consulted a psychiatrist for a few months yet
without mentioning anything about her eating disorder. Whenever
she felt more depressed she was eating more but eventually she was
trying to purge whenever she ate. Dietary restriction, binge-eating and
vomiting lasted for more than 20 years, beginning from 19 years of
age to 40 years. The major factor which triggered abnormal eating atti-
tudes was the emergence of menstruation over the years. Her abnormal
eating behaviors were largely determined by her menstrual cycle. She
observed that she found great relief in being unable to menstruate due
to her emaciation. She had a strong body dissatisfaction when she was
over 48 kg as her breasts and hips became more evident. She never
asked the help of a psychiatrist for eating disorder. She only had to
visit a dentist regularly as she had erosion of teeth enamel and many
fillings, due to vomiting.
Vomiting stopped for 6 months before starting to receive hormonal
therapy with the primary motive that the doctor could find her healthy
enough to start hormonal treatment, yet she continued performing a
restricted calorie intake. She started hormonal treatment 2 years ago,
soon after she stopped menstruating and since that time her weight
has not changed, which was fixed at 45 kg (BMI: 20 kg/m2), and she
has not performed any dietary restriction or had binge-eating and
vomiting. On laboratory investigation, before starting hormonal therapy
her laboratory findings were within normal limits. Blood urea nitrogen
was 14 mmol/L and creatinine 0.70 mmol/L; electrocardiogram did not
show any pathology; liver enzymes were also within normal limits; her
testosterone level was 0.3 pg/ml. After a 6-month hormonal treatment
this rate was raised to 33.1 pg/mL, and she still had not any binge-
eating and vomiting and was then nearly having a healthy eating. A
year ago she underwent a sex reassignment surgery. Her weight is
currently 45 kg and she reported that she was not concerned with her
weight any longer since she has been living in the male role, and she
was then eating normally whatever she wanted to and paying attention
only to her weight.
3. Discussion
In the current case an FtM TS patient who was suffering from AN for
a disorder duration of 20 years has been described. Underweight en-
abled the suppression of the secondary sexual characteristics and the
menstruation. The rejection of femininity was the primary underlying
motivation for loss of weight, and not the wish to look slim. She stated
that her primary motive for purging was to stop menstruation and her
second motivation was to get rid of female body shape; the latter moti-
vation was so strong that she expressed that if she could look like a man
if she put on weight she would eagerly try to put on some weight. Thus
with this definite statement she was to be separated from the primary
cognition of AN which is an intense fear of gaining weight. Her eating
disorder symptoms were greatly alleviated after sex reassignment.
Few studies have investigated whether TS people display higher
rates of eating disorders compared with controls and their results are
inconsistent. In a study encompassing 131 persons male-to-female
(MtF) participants were reported to show higher levels of disturbed
eating attitude than both male and female controls, however FtM
55
participants were reported to have more disordered eating than male
controls, but no difference was detected between FtM participants and
female controls (Vocks et al., 2009); yet another study encompassing
571 persons reported that biological women with GD showed more dis-
ordered eating than female controls, while no difference between men
with GD and male controls was detected (Ålgars et al., 2010).
Different comments as to why GD may increase the risk for eating
disorders have been suggested. In accordance with our case it has
been inferred that FtM persons are struggling to lose weight in order
to suppress female sexual characteristics such as those in the breasts
and hips (Hepp & Milos, 2002; Hepp et al., 2004) along with having
menstruation (Hepp & Milos, 2002). In contrast, another view sug-
gested was that FtM persons who are overweight may not wish to
lose weight, as breasts and hips may appear relatively smaller than
the abdominal size (Vocks et al., 2009).
Another interesting feature of this case was that, whenever he felt
depressed he was eating more, although the outcome did not change
substantially. The affect regulation model of binge-eating posits that
binge eating reduces negative affect (Haedt-Matt & Keel, 2011) and
some recent studies found that negative mood increased pathological
eating behavior (De Young, Zander, & Anderson, 2014; Smyth et al.,
2007).
Distorted body image in our case was intertwined with GD. The
patient's main problem was not the pathological fear of becoming fat.
It was not being overweight per se but because being overweight result-
ed in a female-looking body which caused a deeper dissatisfaction in
her, apart from having menstruation which she regarded as a clear
sign of being a woman. GD and eating disorders both share a severe
body dissatisfaction in common. Bandini et al. (2013) evaluated quality
and intensity of body uneasiness in individuals with GD, eating disorder
patients and a control group, and they found that FtM TS without genital
reassignment surgery and patients with eating disorders showed higher
values of body dissatisfaction compared with both MtF and FtM who
underwent genital reassignment surgery and controls.
Hormonal and surgical sex reassignment have been reported to im-
prove quality of life and psychological happiness (Motmans, Meier,
Ponnet, & T'sjoen, 2012; Wierckx et al., 2011), but their impact on eating
disorder has not been elucidated so far. In a recent study in a sample of
20 (11 FtM, 9 MtF) transgender Finnish adults, it was found that sex
reassignment was primarily perceived as alleviating symptoms of disor-
dered eating (Ålgars, Alanko, Santtila, & Sandnabba, 2012). Likewise,
a recently published case report draws attention to the importance
of hormonal treatment on the prognosis of the eating disorder as hor-
monal treatment of transsexuality facilitated remarkably the inpatient
treatment of an eating disorder in that case (Ewan, Middleman, &
Feldmann, 2014). In a recently published study among MtF individuals,
those using cross-hormonal treatment reported less body uneasiness
compared with individuals who were not using it, however, no signifi-
cant differences were observed between the two groups in the FtM
sample (Fisher et al., 2014). Within this context whether body dissatis-
faction is a key mediator between gender dysphoria and eating disorder
should be further investigated. Body dissatisfaction in people with gen-
der dysphoria is strongly associated with secondary sex characteristics
and in this regard hormonal treatment via eliminating secondary sex
characteristics/menstruation might reduce body dissatisfaction. In our
case as body dissatisfaction was strongly associated with menstruation
and female body shape, hormonal treatment via gaining the patient
male body shape and preventing menstruation might have greatly con-
tributed to remission of eating disorder.
4. Conclusion
TS patients predominantly MtF TS suffering from eating disorders
especially AN secondary to the GD have been described in literature.
FtM and MtF transsexuals may have different motives to lose weight
although the body dissatisfaction is the major common aspect. Some
56 Ş. Turan et al. / Eating Behaviors 18 (2015) 54–56
studies have found that femininity, independently from the biological
sex (Cella, Iannaccone, & Cotrufo, 2013), is related to disordered eating
whereas some do not (Pritchard, 2008). FtM subjects are at risk as
weight loss may help to suppress the menstruation and may make the
subjects look more masculine. The body dissatisfaction intertwined
with the GD in itself may predispose to eating disorders; however as
in our case some subclinical prolonged types of AN may exist and may
not manifest themselves as a clinical case. Given our experience and
based on the literature, treatment of GD, especially the impact of hor-
monal treatment appears to be substantial in alleviating symptoms of
disordered eating.
Role of funding sources
This was a non-funding case report.
Contributors
Author Şenol Turan performed psychiatric interviews and clinical assessments. Cana
Aksoy Poyraz, Şenol Turan and Alaattin Duran managed literature searches. Cana Aksoy
Poyraz wrote the first draft of the manuscript. All authors contributed to and have
approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
References
Ålgars, M., Alanko, K., Santtila, P., & Sandnabba, N. K. (2012). Disordered eating and
gender identity disorder: A qualitative study. Eating Disorders, 20(4), 300–311.
Ålgars, M., Santtila, P., & Sandnabba, N. K. (2010). Conflicted gender identity, body dissat-
isfaction, and disordered eating in adult men and women. Sex Roles, 63, 118–125.
Bandini, E., Fisher, A. D., Castellini, G., Lo Sauro, C., Lelli, L., Meriggiola, M. C., et al. (2013
Aprr). Gender identity disorder and eating disorders: Similarities and differences in
terms of body uneasiness. The Journal of Sexual Medicine, 10(4), 1012–1023.
Becker, D., & Mester, R. (1996). Further insight into transsexualism. Psychopathology, 29,
1–6.
Cella, S., Iannaccone, M., & Cotrufo, P. (2013 Junn). Influence of gender role orientation
(masculinity versus femininity) on body satisfaction and eating attitudes in homo-
sexuals, heterosexuals and transsexuals. Eating and Weight Disorders, 18(2), 115–124.
Cole, C. M., O’Boyle, M., Emory, L. E., & Meyer, W. J., III (1997). Comorbidity of GID and
other major psychiatric diagnoses. Archives of Sexual Behavior, 26, 13–26.
De Young, K. P., Zander, M., & Anderson, D. A. (2014 Jann). Beliefs about the emotional
consequences of eating and binge eating frequency. Eating Behaviors, 15(1), 31–36.
Ewan, L. A., Middleman, A. B., & Feldmann, J. (2014). Treatment of anorexia nervosa in the
context of transsexuality: A case report. International Journal of Eating Disorders,
47(1), 112–115.
Factor, R. J., & Rothblum, E. D. (2007). A study of transgender adults and their non-
transgender siblings on demographic characteristics, social support, and experiences
of violence. Journal of LGBT Health Research, 3, 11–30.
Fernández-Aranda, F., Peri, J. M., Navarro, V., Badia-Casanovas, A., Turón-Gil, V., & Vallejo-
Ruiloba, J. (2000). Transsexualism and anorexia nervosa: A case report. Eating
Disorders, 8, 63–66.
Fisher, A. D., Castellini, G., Bandini, E., Casale, H., Fanni, E., Benni, L., et al. (2014). Cross-sex
hormonal treatment and body uneasiness in individuals with gender dysphoria. The
Journal of Sexual Medicine, 11(3), 709–719.
Gómez-Gil, E., Trilla, A., Salamero, M., Godás, T., & Valdés, M. (2009). Sociodemographic,
clinical, and psychiatric characteristics of transsexuals from Spain. Archives of Sexual
Behavior, 38, 378–392.
Haedt-Matt, A. A., & Keel, P. K. (2011 Jull). Revisiting the affect regulation model of binge
eating: A meta-analysis of studies using ecological momentary assessment.
Psychological Bulletin, 137(4), 660–681.
Hepp, U., & Milos, G. (2002). Gender identity disorder and eating disorders. International
Journal of Eating Disorders, 32, 473–478.
Hepp, U., Milos, G., & Braun-Scharm, H. (2004). Gender identity disorder and anorexia
nervosa in male monozygotic twins. International Journal of Eating Disorders, 35,
239–243.
Hoshiai, M., Matsumoto, Y., Sato, T., Ohnishi, M., Okabe, N., Kishimoto, Y., et al. (2010).
Psychiatric comorbidity among patients with gender identity disorder. Psychiatry
and Clinical Neurosciences, 64, 514–519.
Motmans, J., Meier, P., Ponnet, K., & T'sjoen, G. (2012). Female and male transgender
quality of life: Socioeconomic and medical differences. The Journal of Sexual Medicine,
9, 743–750.
Pauly, L. B., & Lindgren, T. W. (1976/77). Body image and gender identity. Journal of
Homosexuality, 2, 133–134.
Pritchard, M. (2008). Disordered eating in undergraduates: Does gender role orientation
influence men and women the same way? Sex Roles, 59, 282–289.
Smyth, J. M., Wonderlich, S. A., Heron, K. E., Sliwinski, M. J., Crosby, R. D., Mitchell, J. E.,
et al. (2007). Daily and momentary mood and stress predict binge eating and
vomiting in bulimia nervosa patients in the natural environment. Journal of
Consulting and Clinical Psychology, 75, 629–638.
Vocks, S., Stahn, C., Loenser, K., & Legenbauer, T. (2009). Eating and body image distur-
bances in male-to-female and female-to-male transsexuals. Archives of Sexual
Behavior, 38, 364–377.
Wierckx, K., Van Caenegem, E., Elaut, E., Dedecker, D., Van de Peer, F., Toye, K., et al.
(2011). Quality of life and sexual health after sex reassignment surgery in transsexual
men. The Journal of Sexual Medicine, 8, 3379–3388.
Winston, A., Acharya, S., Chaudhuri, S., & Fellowes, L. (2004). Anorexia nervosa and
gender identity disorder in biologic males: A report of two cases. International
Journal of Eating Disorders, 36, 109–113.