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

Disordered eating behaviors in gender-affirmative treatment seeking transgender people

This study aimed to explore disordered eating behaviors in gender-affirming treatment (GAT)-seeking transgender (TG) adults and cisgender people, in addition to analyzing the association between gender dysphoria intensity, body mass index, and disordered eating behaviors. Data were collected from 132 GAT-seeking TG people with gender dysphoria who had never received GAT (91 TG men, 41 TG women), and 153 cisgender (99 cisgender men, 54 cisgender women) participants from Turkey. The Utrecht Gender Dysphoria Scale was used to evaluate the intensity of gender dysphoria. Eating Disorder Examination Questionnaire and Questionnaire on Eating and Weight Patterns-5 were utilized to assess disordered eating. There was no difference between TG women and TG men in terms of ED psychopathology. The most prominent characteristic in all four groups was shape concern, which was significantly higher in TG men and TG women when compared to cisgender men and cisgender women. Binge eating was notably more frequent in TG men and TG women compared to cisgender men, with 11% of the TG men and 7.3% of the TG women meeting the criteria for possible binge eating disorder. Screening for disordered eating behaviors, particularly binge eating, may be recommended in routine care for TG people.

Analyzing body dissatisfaction and gender dysphoria in the context of minority stress among transgender adolescents

BACKGROUND

Gender dysphoria among transgender adolescents has predominantly been examined in relation to body dissatisfaction. While in adult transgender samples, body dissatisfaction is higher than in cisgender controls, this has so far rarely been investigated for adolescents. In the context of a cisnormative society, the impact of influences from the social environment on body dissatisfaction and gender dysphoria has been neglected in research. Therefore, this study aimed to (1) provide a detailed analysis of body dissatisfaction among young transgender people and (2) investigate whether body dissatisfaction and gender dysphoria are associated with experiences of minority stress such as trans hostility and poor peer relations (PPR).

METHODS

The paper presents a cross-sectional study among a sample of transgender adolescents, presenting at a specialized outpatient counseling clinic (N = 99; age M = 15.36, SD = 1.85). First, body dissatisfaction (assessed by the Body-Image-Scale; BIS), was explored and compared to data from a population-based control group of cisgender peers (N = 527; age M = 14.43, SD = 0.97). Second, within a clinic-referred transgender subsample (n = 74), associations between body dissatisfaction and gender dysphoria (measured by Utrecht Gender Dysphoria Scale; UGDS), PPR (measured by the Youth-Self-Report; YSR-R), and trans hostile experiences (assessed in clinical interview) were examined by correlations, t-tests and multivariate regression.

RESULTS

Transgender adolescents reported more body dissatisfaction than cisgender peers. The dissatisfaction with sex characteristics, non-hormonal reactive body regions and the total score for body dissatisfaction were positively related with gender dysphoria. The majority had experienced trans hostility in the present and/or past (54.1%) and PPR (63.5%). More body dissatisfaction was correlated with more PPR regarding visible body parts i.e., hair, overall appearance and muscles, whilst PPR and gender dysphoria were not associated. Transgender adolescents who experienced trans hostility showed higher gender dysphoria and PPR, but not more body dissatisfaction. In multiple regression, trans hostility predicted gender dysphoria, whilst age and PPR predicted body dissatisfaction.

DISCUSSION

Experiences of minority-stress differentially interact with body dissatisfaction and gender dysphoria among transgender adolescents. Social correlates of body dissatisfaction and gender dysphoria must be considered when working with young transgender people.

Emerging Evidence: A Systematic Literature Review of Disordered Eating Among Transgender and Nonbinary Youth

PURPOSE

This systematic literature review explores the evidence base related to the diagnosis and clinical management of eating disorders among transgender and gender nonbinary (TGNB) youth. Through an exploration of the literature, this review highlights key considerations for providers working with this population, including the complex relationship between body image and gender, the assessment of subthreshold eating disorder symptoms, the impact of gender-affirming care on eating disorder treatment outcomes, and available evidence-based metrics, with attention to factors impacting treatment, including family support, psychiatric comorbidities, and community safety.

METHODS

We conducted a search of the databases PubMed and Ovid MEDLINE for articles pertaining to eating disorders and TGNB youth, with forward citation chaining conducted via Google Scholar to provide a review of recent publications. Twenty-six articles published from 2017 to 2022 met the criteria for full-text review.

RESULTS

The selected articles primarily explored data from the United States and varied widely in methodology, including a systematic literature review (n = 1), narrative literature reviews (n = 3), case series (n = 4), case studies (n = 2), cross-sectional population surveys (n = 7), cross-sectional patient surveys (n = 3), other cross-sectional studies (n = 3), retrospective chart reviews (n = 2), and a retrospective longitudinal cohort study (n = 1). Most commonly, researchers sampled patients within the setting of gender clinics. Researchers used a range of validated measures in clinical settings, with the Eating Disorder Examination Questionnaire most frequently reported. The literature highlights several considerations unique to transgender populations, including the complex relationship between gender dysphoria, body dissatisfaction, disordered eating behavior, and gender-affirming care.

DISCUSSION

In clinical settings with TGNB youth, providers may consider implementing validated screening measures to assess for eating disorders. Future research should emphasize a nuanced understanding of the heterogeneity among TGNB patient populations and the impact of gender identity on treatment of eating disorders.

Transgender body image: Weight dissatisfaction, objectification & identity - Complex interplay explored via matched group

In the context of body image and mental health, transgender individuals face distinctive challenges stemming from the complexities of their gender identity journey, societal expectations, and body norms. However, the existing line of research on this topic remains limited. This study explores the complex relationship in transgender individuals between body objectification, body weight dissatisfaction, and eating concerns. A sample of 154 individuals (77 transgenders paired with 77 cisgenders) was recruited via LGBTQ+ groups' mailing lists. Participants completed various questionnaires assessing body image, eating psychopathology, depression, and body objectification. Propensity score matching was performed with different variables: age, current BMI, years of education, current self-identified gender, and sexual orientation. The results revealed that transgender individuals experienced higher levels of body objectification, body weight dissatisfaction, and eating concerns compared to their cisgender counterparts. Additionally, age emerged as a protective factor, as older transgender individuals demonstrated improved body acceptance and self-esteem. Logistic regression analyzes indicated that bulimic behaviors, depressive symptoms, and appearance control beliefs were specific factors significantly associated with being transgender. Our findings highlight the unique challenges faced by transgender individuals in navigating their gender identity and body image, underscoring the importance of targeted interventions and support systems.

Intersectionality of demographic characteristics in self-reported anorexia nervosa, bulimia nervosa, and probable eating disorders among college students

OBJECTIVE

To investigate associations between identity intersectionality, with a primary focus on minority identity, and probable eating disorders (EDs) within the US college student population.

METHOD

Data consisting of n = 414,299 college students' responses to the American College Health Association's National College Health Assessment between fall 2015 and spring 2019 were utilized for this study. Overall and stratified adjusted odds ratios (aORs) were used to assess the association between different facets of identity (i.e., race/ethnicity, gender identity, and sexual orientation) and probable EDs.

RESULTS

Among all, in our analytic sample, 7.15% reported a probable ED. Interactions between all three identity variables were significant, and thus stratified odds ratios were evaluated. Transgender men were significantly more likely to report probable ED than cisgender male peers within the following racial/ethnic groups: non-Hispanic White (aOR: 3.33; 95% CI: 2.79, 3.96; p < .0001), non-Hispanic Black (aOR: 3.29; 95% CI: 1.72, 6.28; p = .0003), Hispanic (aOR: 2.31; 95% CI: 1.55, 3.43; p < .0001), Asian or Pacific Islander (aOR: 2.19; 95% CI: 1.45, 3.30; p = .0002), Biracial or Multicultural (aOR: 3.36; 95% CI: 2.17, 5.22; p < .0001), and other (aOR: 4.19; 95% CI: 2.25, 7.79; p < .0001).

CONCLUSIONS

This study underscores the importance of increasing our understanding of interactions between marginalized identities and the ways in which minority identity informs ED risk.

PUBLIC SIGNIFICANCE

The impact of multiple marginalized identities on ED outcomes is not well understood. Our study expands on previous ACHA-NCHA studies by addressing identity intersectionality, looking at more than one identity at a time (i.e., specifically race/ethnicity, gender identity, and sexual orientation). Our results contribute unique risk profiles for students who identify with multiple marginalized groups. Further, they indicate that that these associations vary based on the compounded effect of the demographic factors considered.

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.

Moving toward targeted eating disorder care for transgender, non-binary, and gender expansive patients in the United States

OBJECTIVE

Literature suggests that transgender, non-binary, and/or gender expansive (TNG) people are more likely than cisgender peers to experience eating disorders (EDs) and engage in dangerous weight control behaviors. TNG individuals with EDs are dramatically higher risk for self-harm behaviors, suicidal ideation, and suicidal behaviors than cisgender peers with EDs or TNG peers without EDs, and often engage in ED symptoms/behaviors to alleviate gender dysphoria. Yet, no treatment paradigms have yet been adapted for TNG-specific ED care. This qualitative study aims to identify stakeholder needs from such care to inform future clinical interventions.

METHODS

We elicited patient (n = 12) and mental health clinician (n = 9) stakeholder needs and preferences regarding TNG-specific ED care. Semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR) and a behavioral insights framework, EAST, were developed to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. Using a rapid analysis procedure, we produced a descriptive analysis for each group identifying challenges of and opportunities in providing ED care for TNG adults.

RESULTS

Stakeholders expressed needs and preferences for TNG-specific treatment including that it be: (1) TNG-affirming, weight-inclusive, trauma-informed, and anti-racist; (2) delivered by an interdisciplinary team, including gender-affirming care clinicians; (3) focused on parsing gender dysphoria from other body image concerns, building distress tolerance, and working toward gender euphoria (rather than body acceptance).

DISCUSSION

Future work is needed exploring ED care delivery models that integrate gender-affirming care services with mental health care. Such models may improve TNG access to ED treatment and recovery.

PUBLIC SIGNIFICANCE

Transgender, non-binary, and/or gender expansive (TNG) experience disproportionately high rates of eating disorders and have unique barriers to accessing care. In individual interviews, TNG adults with eating disorders and mental health clinicians who provide psychotherapy for eating disorders voiced desire for greater availability of TNG-affirming, weight-inclusive eating disorder care, integrated with other gender-affirming care services. This informs future research developing eating disorder care for TNG individuals.

Nutrition and Health in the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning Community: A Narrative Review

Sexual and gender minorities have a higher risk for health and nutrition-related disparities across the life course compared to the heterosexual or cisgender population. Experiences of stigmatization and discrimination are associated with diminished mental health quality and psychological distress, which are risk factors for developing various eating disorders. Other nutrition disparities include increased risk for food insecurity, body dissatisfaction, and weight complications, such as those experienced by the transgender population in association with gender-affirming hormone therapies. Despite the need for tailored nutrition recommendations that address the unique needs of the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) community, there are currently no such guidelines in North America. The purpose of this review is to summarize major LGBTQ+ nutrition disparities and highlight the need for tailored recommendations. We examine the evidence on mental health and social disparities in this group, including vulnerabilities to disordered eating, food insecurity, and healthcare provider discrimination. Importantly, we identify a scarcity of literature on dietary concerns and nutrition care guidelines for LGBTQ+ groups, including studies that address intersectionality and differences among specific gender and sexual orientations. These gaps underline the urgency of prioritizing nutrition for LGBTQ+ health needs and for developing tailored public health nutrition recommendations for this underserved population. Our review suggests that future LGBTQ+ health and nutrition research agendas should include personalized and precision nutrition, social determinants of health, diet quality, body image, and healthcare provider cultural competency and responsiveness. Moreover, the current evidence on LGBTQ+ nutrition and health will be strengthened when research studies (including clinical trials) with robust methodologies amplify inclusion and representation of this community to elucidate health and nutrition disparities in sexual and gender minorities.

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.

Prevalence of suicidal thoughts and attempts in the transgender population of the world: a systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to determine global pooled prevalence of suicide thoughts and attempts in transgender population.

METHODS

For doing comprehensive search strategy related to objectives in the presence meta-analysis, all international databases like PubMed (Medline), Scopus, Embase, Web of Sciences, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINHAL) were searched from January 1990 to December 2022. The quality of the final selected studies was evaluated according to Newcastle-Ottawa Quality Assessment Scale for cross-sectional studies. The subgroup analysis was done based on type of transgender (female to male, male to female) and prevalence (point, period, and lifetime), country, and criteria of diagnosis. All analysis was done in STATA version 17.

RESULTS

From the total number of 65 selected studies, 71 prevalence of suicidal thoughts, including point, period, and lifetime prevalence were extracted and combined. After combining these values, the prevalence of suicidal thoughts in the transgender population in the world was 39% in the past month (pooled point prevalence: 39%; 95% CI 35-43%), 45% in the past year (pooled period prevalence: 45%; % 95 CI 35-54%) and 50% during lifetime (pooled lifetime prevalence: 50%; % 95 CI 42-57%). Also, the prevalence of suicide attempt in the transgender population of the world was 16% in the past month (pooled point prevalence: 16%; 95% CI 13-19%), 11% in the past year (pooled period prevalence: 11%; % 95 CI 5-19%) and 29% during lifetime (pooled lifetime prevalence: 29%; % 95 CI 25-34%).

CONCLUSION

The present meta-analysis results showed the prevalence of suicidal thoughts and attempts in the transgender community was high, and more importantly, about 50% of transgenders who had suicidal thoughts, committed suicide.

A Longitudinal Study on Disordered Eating in Transgender and Nonbinary Adolescents

OBJECTIVE

We longitudinally explored frequency of disordered eating among transgender and nonbinary (TGNB) adolescents and explored trends by gender identity and gender-affirming care.

METHODS

Participants completed an abbreviated version of the Eating Disorder Examination Questionnaire (EDE-Q) at baseline, 3, 6, and 12 months after establishing care in a gender clinic. We analyzed descriptive statistics and multivariate linear regression analyses.

RESULTS

Of the 91 TGNB adolescent participants, 61% were transmasculine, 30% transfeminine, and 7% nonbinary/gender-fluid. Among TGNB adolescents, disordered eating thoughts/behaviors were frequently endorsed with 26% of participants engaging in any occurrence of binge eating, 27% limiting the amount of food they ate, and 30% excluding foods from their diet. Forty percent of participants reported any occurrence of at least 1 disordered eating behavior and 17% at least 3 behaviors. Abbreviated EDE-Q responses did not differ significantly by sex assigned at birth, gender identity, gender-affirming medications, or time spent receiving gender-affirming care. There was a significant effect of age (P value = .003) on abbreviated EDE-Q scores.

CONCLUSIONS

There were no significant changes in disordered eating after initiating gender-affirming medical care, possibly due to the limited study time frame of 12 months. Given the high prevalence of disordered eating behaviors, clinicians should consider screening all TGNB adolescents for disordered eating thoughts/behaviors throughout gender-affirming care. Future longitudinal research should recruit larger samples with a diverse range of gender identities and survey disordered eating thoughts/behaviors at least one year after starting gender-affirming medications.

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.

Disordered eating and considerations for the transgender community: a review of the literature and clinical guidance for assessment and treatment

BACKGROUND

It has been well established that individuals who identify as lesbian, gay, bisexual, transgender, and queer are at increased risk for mental health pathology, including eating disorders/disordered eating behaviors (ED/DEB). However, less is understood about the unique experiences of transgender and gender diverse (TGD) people who struggle with ED/DEB.

AIMS

The purpose of this literature review is to examine the literature regarding the unique risk factors for TGD individuals who experience ED/DEB through a lens informed by the minority stress model. Additionally, guidance around the assessment and clinical management of eating disorders for TGD individuals will be presented.

RESULTS

TGD people are at increased risk for developing ED/DEB due to a number of factors including: gender dysphoria, minority stress, the desire to pass, and barriers to gender affirming care.

CONCLUSION

While guidance around assessment and treatment of ED/DEB for TGD individuals is still limited, adhering to a gender affirmative care model is essential.

Understanding the Complex Relationship Between One's Body, Eating, Exercise, and Gender-Affirming Medical Care Among Transgender and Nonbinary Adolescents and Young Adults

Purpose

Gender dysphoria has been linked to body dissatisfaction, which can affect an individual's eating and exercise habits and increase their risk for disordered eating. The prevalence of eating disorders among transgender and nonbinary (TGNB) adolescents and young adults (AYA) ranges from 5% to 18% and studies have found a higher risk of disordered eating among these AYA in comparison to their cisgender peers. However, there is minimal research on why TGNB AYA are at higher risk. The aim of this study is to understand unique factors that define a TGNB AYA's relationship between their body and food, how this relationship may be affected by gender-affirming medical care, and how these relationships may contribute to disordered eating.

Methods

A total of 23 TGNB AYA were recruited from a multidisciplinary gender-affirming clinic to participate in semistructured interviews. Transcripts were analyzed using Braun and Clarke's theory of thematic analysis (2006).

Results

The average age of participants was 16.9 years. Forty-four percent of participants identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Five themes emerged regarding TGNB participants' relationship to food and exercise: gender dysphoria and control over one's body, societal expectations of gender, mental health and safety concerns, emotional and physical changes with gender-affirming medical care, and recommended resources for TGNB AYA.

Conclusion

By understanding these unique factors, clinicians can provide targeted and sensitive care when screening and managing disordered eating among TGNB AYA.

Provider perceptions of barriers and facilitators to care in eating disorder treatment for transgender and gender diverse patients: a qualitative study

BACKGROUND

The prevalence of eating disorders is higher in transgender and non-binary compared to cisgender people. Gender diverse people who seek eating disorder treatment often report struggling to find affirming and inclusive treatment from healthcare clinicians. We sought to understand eating disorder care clinicians' perceptions of facilitators of and barriers to effective eating disorder treatment for transgender and gender diverse patients.

METHODS

In 2022, nineteen US-based licensed mental health clinicians who specialized in eating disorder treatment participated in semi-structured interviews. We used inductive thematic analysis to identify themes around perceptions and knowledge of facilitators and barriers to care for transgender and gender diverse patients diagnosed with eating disorders.

RESULTS

Two broad themes were identified: (1) factors affecting access to care; and (2) factors affecting care while in treatment. Within the first theme, the following subthemes were found: stigmatization, family support, financial factors, gendered clinics, scarcity of gender-competent care, and religious communities. Within the second theme, prominent subthemes included discrimination and microaggressions, provider lived experience and education, other patients and parents, institutions of higher education, family-centered care, gendered-centered care, and traditional therapeutic techniques.

CONCLUSION

Many barriers and facilitators have potential to be improved upon, especially those caused by clinicians' lack of knowledge or attitudes towards gender minority patients in treatment. Future research is needed to identify how provider-driven barriers manifest and how they can be improved upon to better patient care experiences.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization

BACKGROUND

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.

METHODS

A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.

RESULTS

Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).

CONCLUSIONS

Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

Medical considerations in the care of transgender and gender diverse patients with eating disorders

Transgender and gender diverse (TGD) individuals are at increased risk for the development of eating disorders, but very little has been published with regards to the unique aspects of their medical care in eating disorder treatment. Providing gender affirming care is a critical component of culturally competent eating disorder treatment. This includes knowledge of gender affirming medical and surgical interventions and how such interventions may be impacted by eating disordered behaviors, as well as the role of such interventions in eating disorder treatment and recovery. TGD individuals face barriers to care, and one of these can be provider knowledge. By better understanding these needs, clinicians can actively reduce barriers and ensure TGD individuals are provided with appropriate care. This review synthesizes the available literature regarding the medical care of TGD patients and those of patients with eating disorders and highlights areas for further research.

Comparing eating disorder treatment outcomes of transgender and nonbinary individuals with cisgender individuals

OBJECTIVE

The purpose of this study was to compare symptom severity of eating disorders (EDs), depression and anxiety at admission and discharge for transgender and nonbinary (TNB) individuals and cisgender adult individuals receiving treatment for EDs at higher levels of care (HLOC), adding to the limited research in this area.

METHOD

Participants were 25 TNB individuals and 376 cisgender individuals admitted to a HLOC ED treatment facility. Participants completed the Eating Disorder Examination Questionnaire (EDE-Q), Patient Health Questionnaire-9, and Beck Anxiety Inventory at admission and discharge.

RESULTS

TNB individuals showed significant improvements on EDE-Q global scores between admission and discharge (Cohen's d = 1.27), and showed similar improvements on the EDE-Q over the course of treatment (Cohen's d = 0.06) when compared to cisgender individuals. TNB individuals had more severe depression at admission (Cohen's d = 0.61). Although depression improved over the course of treatment for both groups, TNB individuals showed less improvement (Cohen's d = 0.59). Suicidality was higher for TNB individuals on admission and discharge and did not improve significantly over the course of treatment (Cohen's d = 0.38).

DISCUSSION

This study provides preliminary evidence that TNB and cisgender individuals show similar improvement in ED symptoms during HLOC treatment. However, TNB individuals have more severe depression and less improvement in depression compared to cisgender individuals, without improvement in suicidality. TNB individuals may benefit from care targeting depression and suicidality during ED treatment.

PUBLIC SIGNIFICANCE STATEMENT

TNB individuals have increased risk of EDs. Little research addresses how TNB individuals respond to ED treatment, which was traditionally created for cisgender individuals. We present one of the first studies examining ED treatment outcomes for TNB adults. TNB individuals showed improved ED symptoms with treatment, but less improvement in depression and their suicidality remained elevated. This suggests the need for targeted treatment.

Adolescent and emerging adult perceptions of eating disorder severity and stigma

OBJECTIVE

Eating disorders are one of the deadliest mental health conditions, yet most individuals with eating disorders never receive treatment. Previous research has explored barriers to treatment among individuals diagnosed with eating disorders, but little is known about general adolescent and emerging adult perceptions of eating disorders, as compared to other mental health illnesses, a population at greatest risk for developing an eating disorder, and a population that may be important sources of information or support for peers.

METHOD

A sample of adolescents and emerging adults aged 14-24 years (mean age 19 years) from MyVoice, a national text-message-based cohort (53% female, 38% male, 9% other, race/ethnicity 63% White, 10% Black or African American, 13% Asian, 9% Mixed Race, and 5% Other) provided open-ended responses to questions on the severity of eating disorders as compared to other mental health diagnoses, others' perceptions of eating disorders and potential treatment barriers. Responses were collected using a secure online platform and analyzed using content analysis.

RESULTS

Among respondents (n = 792/1283), 91% felt that eating disorders were a mental health condition and 65% felt that eating disorders were as serious as other mental health conditions, while 21% said they were more serious than other mental health conditions. Responses to questions related to perception and barriers illustrated that beliefs of eating disorders involve blame, stigma, and overall lack of understanding.

DISCUSSION

Findings from this study illustrate that there is a lack of understanding around eating disorders that could be addressed in youth-focused initiatives.

PUBLIC SIGNIFICANCE

Adolescents and emerging adults understand that eating disorders are severe mental illnesses that are not taken seriously by others, especially in comparison with other mental health diagnoses. Adolescents and emerging adults report that individuals with eating disorders are blamed for their condition and face shame and stigma. The lack of understanding around eating disorders should be addressed in youth-focused prevention initiatives.

Psychiatric and medical comorbidities of eating disorders: findings from a rapid review of the literature

BACKGROUND

Eating disorders (EDs) are potentially severe, complex, and life-threatening illnesses. The mortality rate of EDs is significantly elevated compared to other psychiatric conditions, primarily due to medical complications and suicide. The current rapid review aimed to summarise the literature and identify gaps in knowledge relating to any psychiatric and medical comorbidities of eating disorders.

METHODS

This paper forms part of a rapid review) series scoping the evidence base for the field of EDs, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for English-language studies focused on the psychiatric and medical comorbidities of EDs, published between 2009 and 2021. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised.

RESULTS

A total of 202 studies were included in this review, with 58% pertaining to psychiatric comorbidities and 42% to medical comorbidities. For EDs in general, the most prevalent psychiatric comorbidities were anxiety (up to 62%), mood (up to 54%) and substance use and post-traumatic stress disorders (similar comorbidity rates up to 27%). The review also noted associations between specific EDs and non-suicidal self-injury, personality disorders, and neurodevelopmental disorders. EDs were complicated by medical comorbidities across the neuroendocrine, skeletal, nutritional, gastrointestinal, dental, and reproductive systems. Medical comorbidities can precede, occur alongside or emerge as a complication of the ED.

CONCLUSIONS

This review provides a thorough overview of the comorbid psychiatric and medical conditions co-occurring with EDs. High psychiatric and medical comorbidity rates were observed in people with EDs, with comorbidities contributing to increased ED symptom severity, maintenance of some ED behaviours, and poorer functioning as well as treatment outcomes. Early identification and management of psychiatric and medical comorbidities in people with an ED may improve response to treatment and overall outcomes.

Prevalence of diagnosed eating disorders in US transgender adults and youth in insurance claims

OBJECTIVE

We estimated the prevalence of diagnosed eating disorders, overall and by select demographics, among commercially insured individuals identified as transgender in a national claims database.

METHODS

From the 2018 IBM® MarketScan® Commercial Database, there were 10,415 people identifiable as transgender based on International Classification of Disease (ICD-10) codes and procedure codes, specific to gender-affirming care, from inpatient and outpatient claims. Eating disorders were identified from ICD-10 codes and included anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified, avoidant restrictive feeding and intake disorder, and other specified feeding and eating disorders. We estimated the prevalence of specific eating disorders diagnoses by selecting patient characteristics.

RESULTS

Of individuals receiving some form of gender-affirming care, 2.43% (95% confidence interval: 2.14%-2.74%) were diagnosed with an eating disorder: 0.84% anorexia nervosa, 0.36% bulimia nervosa, 0.36% binge eating disorder, 0.15% avoidant restrictive feeding and intake disorder, 0.41% other specified feeding and eating disorders, and 1.37% with an unspecified eating disorder. Among transgender-identifiable patients aged 12-15 years, 5.60% had an eating disorder diagnosis, whereas 0.52% had an eating disorder diagnosis in patients aged 45-64 years.

DISCUSSION

In patients identifiable as transgender, with receipt of gender-affirming care, the prevalence of diagnosed eating disorders was low compared to extant self-reported data for eating disorder diagnosis in transgender individuals. Among this population, eating disorders were highest in adolescents and young adults. Clinically verified prevalence estimates for eating disorder diagnosis in transgender people with a history of gender-affirming care warrant further investigation.

PUBLIC SIGNIFICANCE

The present study aims to provide clinically validated, contemporary prevalence estimates for diagnosed eating disorders among a medically affirmed population of transgender adults and children in the United States. We report low prevalence of having any eating disorder relative to prevalence estimates reported in prior literature without clinical validation. These findings may be explained by access to affirming care and medical care generally.

A Plea for Diversity in Eating Disorders Research

Eating disorders (EDs) are often stereotyped as affecting the SWAG, that is, as affecting mostly skinny, White, affluent girls. Over the last decade, however, significant progress has been made toward increasing diversity in ED research. There is consensus that EDs affect individuals of all genders, ages, sexual orientations, ethnic, and socio-economic backgrounds, with recent studies exploring social determinants of ED etiology, ED presentation, and developing diversity-affirming ED assessments. This article provides a brief summary of current developments related to diversity as a research theme, and proposes different perspectives toward further improving diversity in ED research. Specifically, we argue for exploring the role of diversity in ED treatment settings and outcomes, for pursuing diversity-oriented research pro-actively rather than as a reaction to issues of under-representation, and for integrating diversity across different areas of medical education and trainings in psychotherapy. Limitations with respect to the paucity of research, and the link between diversity as a research theme and ED-related workforce diversity are discussed.

Gender-Affirmative Eating Disorder Care: Clinical Considerations for Transgender and Gender Expansive Children and Youth

Transgender and gender expansive (TGE) children and youth suffer staggering rates of discrimination and are at higher risk of developing eating disorder symptoms and behaviors than cisgender youth. This article presents an overview of current research on identified risk factors for the development of eating disorders for TGE children and youth; provides clinical considerations for professionals in providing gender-affirming, collaborative eating disorder care; outlines specific concepts for staff training and for developing gender-affirming systems of care including policies and practices; and identifies numerous resources for TGE children and youth and their families. The clinical considerations and suggested practices reflect current research and clinical practice. Both the gender-affirmative clinical field and the eating disorder field are constantly evolving, and the recommendations and resources will need ongoing updates to reflect developments in these fields. [Pediatr Ann. 2021;50(9):e371-e378.].

Eating disorder screening and treatment experiences in transgender and gender diverse young adults

Transgender and gender diverse (TGD) young adults have elevated risk for disordered eating, unhealthy weight control behaviors, and eating disorders (EDs). Little is known about TGD young adult experiences with ED screening and treatment; this qualitative study aimed to address this gap. This study used data from eight asynchronous online focus groups, a dynamic online bulletin board method (N = 66). Participants posted responses to moderator-posed questions over a 4-day period. Participants were TGD young adults ages 18-30 years old, were recruited using social media and outreach to community organizations, and resided in 25 US states. We conducted inductive thematic analysis of all focus group excerpts that described experiences with ED screening or treatment (n = 32). Participants were of diverse gender identities (25% transgender woman, 41% transgender man, 28% non-binary, 6% another gender) and racial/ethnic identities (62% White, 13% Latinx, 13% Multiracial, 6% Asian, 6% Black). Three major themes emerged from the analysis: (1) Barriers to ED screening/treatment; (2) Complexity of the relationship between EDs and gender dysphoria; (3) Need for provider education in gender affirming care practices for ED screening and treatment. Results indicate an ongoing need for gender affirming care for TGD young adults in ED screening and treatment. Health care systems must address barriers to screening and treatment for TGD young adults, including enhancing understanding of the intersection of gender dysphoria and eating disorders as well as improvements in health care provider training.

Living Up to a Name: Gender Role Behavior Varies With Forename Gender Typicality

Forenames serve as proxies for gender labels that activate gender stereotypes and gender socialization. Unlike rigid binary gender categories, they differ in the degree to which they are perceived as "masculine" or "feminine." We examined the novel hypothesis that the ability of a forename to signal gender is associated with gender role behavior in women (n = 215) and men (n = 127; M = 19.32, SD = 2.11) as part of a larger study evaluating forenames used in resume research. Compared to individuals endorsing a "gender-strong" forename, those perceiving their forename as relatively "gender-weak" reported less gender-typical childhood social behavior and a weaker expression of gender-linked personality traits. Our findings suggest that forenames strengthen or weaken gender socialization, gender identification, and so contribute to the variable expression of gender role behavior within binary gender groups.

The relationship of the UPPS model of impulsivity on bulimic symptoms and non-suicidal self-injury in transgender youth

OBJECTIVE

This brief report examined the relationship of negative urgency (the tendency to act rashly in response to negative emotional states), (lack of) perseverance, (lack of) premeditation, and sensation seeking in association with non-suicidal self-injury (NSSI) and symptoms of bulimia nervosa (BN) in a sample of treatment-seeking transgender (TG) youth.

METHOD

Eighty-six TG youth with a mean age of 17 (sd = 3.2) agreed to participate in the study. The majority of our sample identified as TG male (n = 60) with 20 participants identifying as TG female and 6 identifying as non-binary. The racial ethnic breakdown of our sample was 8.2% Black, 8.2% Multi-racial, 1.2% Native American, and 82.4% White. Over ¼ of our sample endorsed at least one episode of objective binge eating in the last 28 days and 62% endorsed a history of NSSI.

RESULTS

Negative urgency was significantly associated with the odds of NSSI, objective binge eating, and general eating disorder symptoms. Lack of premeditation was significantly related to the odds of NSSI only. No other factors were significantly associated with NSSI or symptoms of BN.

CONCLUSIONS

Negative urgency appears to be an important personality construct in understanding increased risk for NSSI and BN symptoms in transgender youth.

Eating Disorder Diagnoses and Symptom Presentation in Transgender Youth: a Scoping Review

PURPOSE OF REVIEW

This scoping review includes recent literature on eating disorder diagnoses and evaluation of eating disorder symptom presentation among transgender youth (ages 8-25).

RECENT FINDINGS

A total of 20 publications from the previous 5 years were identified, including case reports, retrospective chart reviews, and surveys. Significantly higher rates of eating disorder symptoms were documented in transgender youth compared to cisgender youth. Similarly, some studies reported transgender youth were more likely to be diagnosed with an eating disorder than cisgender youth, though the proportion of youth with eating disorder diagnoses varied across studies. A consistent theme across case studies was engagement in food restriction and/or compensatory eating behaviors to prevent puberty onset or progression, suggesting that for some transgender youth, these behaviors may be understood as a means of coping with gender-related distress. Clinical care could be enhanced through establishment of best practices for screening in settings offering eating disorder treatment and gender-affirming care, as well as greater collaboration among these programs. Research is needed to validate eating disorder measures for use with transgender youth and evaluate the effects of eating disorder treatment and gender-affirming medical interventions on the well-being of transgender youth.