- Email: [email protected]
Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report
Eating Behaviors 18 (2015) 54–56
Contents lists available at ScienceDirect
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
Article history: Received 16 October 2014 Received in revised form 9 January 2015 Accepted 25 March 2015 Available online 1 April 2015 Keywords: Transsexual Gender dysphoria Eating disorder
a b s t r a c t Transsexual (TS) individuals seem to display an increased risk in having eating disorders. Several case reports describe TS individuals with anorexia nervosa (AN). In order to understand better the impact of gender dysphoria (GD) and hormonal/surgical treatments on the occurrence and course of eating disorders in TS patients long term follow-up studies are needed. We present here a 41-year-old female-to-male TS patient suffering from AN. History revealed that pathological eating habits could strongly be associated with her GD. Hormonal and surgical treatments resulted in substantial improvement in the given eating disorder. The impact of GD on the development and treatment of eating disorder is discussed in this report. © 2015 Published by Elsevier Ltd.
1. Introduction 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 (GómezGil, 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 overconcern 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: [email protected] (C.A. Poyraz).
http://dx.doi.org/10.1016/j.eatbeh.2015.03.012 1471-0153/© 2015 Published by Elsevier Ltd.
Hormonal and surgical reassignments have been reported to improve 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 behaviors 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 indicated 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 symptoms 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.
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 cardiovascular 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 menstruation was starting. She had a serious suicide attempt after she has completed 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 attitudes 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 bingeeating 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 enabled 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 motivation 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 disordered 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 suggested 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 resulted 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 improve 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 disordered 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 hormonal 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 significant differences were observed between the two groups in the FtM sample (Fisher et al., 2014). Within this context whether body dissatisfaction is a key mediator between gender dysphoria and eating disorder should be further investigated. Body dissatisfaction in people with gender 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 contributed 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 hormonal 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 dissatisfaction, 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 homosexuals, 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 nontransgender 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., & VallejoRuiloba, 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 disturbances 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.
Contents lists available at ScienceDirect
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
Article history: Received 16 October 2014 Received in revised form 9 January 2015 Accepted 25 March 2015 Available online 1 April 2015 Keywords: Transsexual Gender dysphoria Eating disorder
a b s t r a c t Transsexual (TS) individuals seem to display an increased risk in having eating disorders. Several case reports describe TS individuals with anorexia nervosa (AN). In order to understand better the impact of gender dysphoria (GD) and hormonal/surgical treatments on the occurrence and course of eating disorders in TS patients long term follow-up studies are needed. We present here a 41-year-old female-to-male TS patient suffering from AN. History revealed that pathological eating habits could strongly be associated with her GD. Hormonal and surgical treatments resulted in substantial improvement in the given eating disorder. The impact of GD on the development and treatment of eating disorder is discussed in this report. © 2015 Published by Elsevier Ltd.
1. Introduction 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 (GómezGil, 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 overconcern 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: [email protected] (C.A. Poyraz).
http://dx.doi.org/10.1016/j.eatbeh.2015.03.012 1471-0153/© 2015 Published by Elsevier Ltd.
Hormonal and surgical reassignments have been reported to improve 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 behaviors 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 indicated 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 symptoms 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.
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 cardiovascular 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 menstruation was starting. She had a serious suicide attempt after she has completed 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 attitudes 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 bingeeating 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 enabled 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 motivation 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 disordered 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 suggested 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 resulted 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 improve 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 disordered 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 hormonal 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 significant differences were observed between the two groups in the FtM sample (Fisher et al., 2014). Within this context whether body dissatisfaction is a key mediator between gender dysphoria and eating disorder should be further investigated. Body dissatisfaction in people with gender 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 contributed 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 hormonal 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.
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