Transgender Issues and Eating Disorders
By Alex Redcay, MSW, LSW, PhD (Candidate)
Note: Each term that is blue and underlined is a hyperlink that once clicked will either define the term or go to the referenced story, person, video, or website.
Keeping up with the Kardashians became popular long after I stopped paying attention to popular things. I certainly never paid attention to the gold medalist who was in and out of the Kardashian circle. However, when Caitlyn Jenner shattered the cover of Vanity Fair, I got whiplash. Vanity Fair had a record breaking 9 million unique visitors within 24 hours, 45 million visitors later, and the print copy was the highest selling cover in five years.  Never before had a transgender person ever been 1) consistently visible in the media, 2) come out as trans, 3) completely transform, and 4) proclaim a new identity with a full photo shoot, new wardrobe, and full media press.
Transgender is an umbrella term for people whose gender identity differs from what is typically associated with the sex they were assigned at birth. Trans is also perfectly acceptable to use as a shortened version of transgender. However, transgenderism, transgendered, transgenders, or most other variations are definitely NOT okay. Research indicates that there are approximately 1% of trans identified individuals within the general population, but others suggest that numbers are increasing, particularly among youth. 
As millions of skeptics googled for the first picture, they speculated what Bruce would look like with long hair, red lipstick, and a dress. “Wow, Damn, is that him-her, uh, I mean, her, uh, wow…,” was usually the first response to the picture of the beautiful Caitlyn in her very sexy red dress sitting in the black Porsche.  Many spoke of how her pictures revealed a Caitlyn who was refined, elegant, and yes, sexy. It was shocking, unexpected. She was so feminine and is an inspiration to transgender individuals worldwide. Our expectations about gender are very specific and narrow no matter how much of a feminist or how evolved we may or may not claim to be. Sam Killermann, creator of the Genderbread Person, also did a Tedx talk on Understanding the Complexities of Gender which may help us reflect more on our assumptions and bias about gender.
I find that the full Genderbread Person is the most helpful reference when trying to dissect gender and sexuality. First, the most important aspect to understand is that gender has nothing to do with sexuality. Let me say that again, gender (male, female, transgender, etc.) has nothing to do with sexuality (heterosexual, gay, lesbian, bisexual, etc.). Experts are partly to blame for our confusion because whoever came up with the acronym LGBT (Lesbian, Gay, Bisexual, Transgender) married the two very different ideas of sexuality (LGB) and gender (T) so much that we are thoroughly confused. Let’s divorce LGB (sexual minority) from T (gender minority) as we move forward.
The Genderbread Person, helps us to understand gender. The red heart of “attraction” is the only part that refers to sexuality or sexual orientation. This red heart is focused on whom we love and to whom we may be attracted, but this is unrelated to gender. Gender Expression forms a dotted line over the entire outside of the gender bread person from head to toe showing that the way we look, act, and are perceived by others is our gender expression. However, our Gender identity is in our brain, our internal, deeply held sense of being male or female which is unknown and invisible to others, while biological sex is assigned at birth, mainly based on the appearance of anatomy. If we apply this to Caitlyn Jenner, her red heart of attraction is towards women. Gender expression: very feminine; Gender identity: female (we know this ONLY because she has told us); biological sex: male. It is appropriate to refer to Caitlyn as a trans female or better yet, just female, but definitely not trans male or male.
Prior to Caitlyn’s transition, we may have said her gender expression was much more masculine. However, there are many surgeons available to assist trans individuals to realign their gender expression with their gender identity. Caitlyn, who has a reported net worth of 100 million dollars, had no trouble paying for numerous surgeries. One Hollywood gossip magazine speculates that she spent four million dollars on her transformation while another reports that she had six surgeries to feminize her face. The majority of trans folks are not in the top 1%, but Caitlyn still provides the hope that they can transition into their authentic self. Caitlyn was celebrated and praised for her bravery, even awarded “Women of the Year” by Glamour magazine.
Yet, some expressed passionate hatred, disgust, rage, and even one psychiatrist, insisted that Caitlyn’s desire to transition was a product of mental health issues and just by being trans, individuals committed suicide (accurate info here). Dr. Paul McHugh, the former psychiatrist in chief for Johns Hopkins Hospital, claimed that Caitlyn’s transition was “biologically impossible,” and that the trans person’s Gender identity is as inaccurate as the person who suffers with anorexia or bulimia believing that they are overweight. Dr. McHugh argues, that one’s personal truth, whether their sense of being overweight or sense of gender, does not overrule the physical reality of being dangerously thin or being physically born as one biological sex. Cisgender individuals, like Dr. McHugh, have a hard time understanding the trans experience. Cisgender is a term for a person whose biological sex matches their Gender identity. Despite his lack of updated research, offensive terminology, and poorly informed comments (by the way, the Huffpost has a response to him here, not to mention that every other major mental health and medical association disagrees with him), Dr. McHugh did point out an interesting connection between trans folks and those with eating disorders: a strong dislike for one’s body. For the trans person, the feeling is literally that one was born in the wrong body. Just imagine for a second, for an hour, that you are in the body of the opposite sex. Now imagine living that way for a year. Imagine all of your mannerisms, the way you do your hair, the clothes you prefer, the way you talk, walk, etc. Pretty awful right? This is what trans people deal with daily. For them, it is not a choice. It’s not a fad. Who would ever choose this?
Dr. McHugh definitely got another part wrong about trans individuals. He said that their sense of gender, Gender identity, was just in their mind. Well, in some ways he was right. There is neurological and genetic evidence to show that the trans experience is actually in the brain. For example, a set of studies showed neurological evidence for gender identity when MRI scans revealed that the white matter microstructure pattern of pre-hormonal trans men (think Chaz Bono) looked like a biological male rather than a biological female (Rametti et al, 2010). Therefore, Chaz’s brain looks exactly like Dr. McHugh’s brain in terms of gender. Another study showed genetic evidence by examining the Androgen Receptor (AR) gene for trans females (think Caitlyn Jenner or Jazz). It was found that the AR gene in trans females was longer which results in weaker and less effective testosterone signaling (also in the womb) (Hare et al., 2009). These researchers theorize the weaker testosterone signaling results in an incomplete masculinization of the brain resulting in a female gender identity. There are still several articles and many more that are currently being published on possible biological influences of the trans gender identity. Caitlyn and Chaz didn’t just make up the experience of being male or female. Their Gender identity is not merely a subjective personal feeling resulting from trauma or mental health problems. Despite Dr. McHugh’s offensive comments about individuals who are trans and individuals who suffer from eating disorders, we can learn something from this. The public continues to need education, even the experts.
Combined prevalence of eating disorders is approximately 13% and there have been several published articles highlighting a connection between transgender individuals and eating disorders. One study by Algars (2012) showed that trans males (think Chaz Bono) were vulnerable to disordered eating because of a strong desire to have a male body free of female breasts, large hips, and the presence of hormones that support menstruation (Hepp, 2002). If trans males used disordered eating, they would lose the feminine curves, achieving a squarer, strong male shape. Likewise, trans women (think Caitlyn Jenner) would also be prone to disordered eating because they also want to suppress their muscular, large, square bodies. Trans women have a strong desire to be delicate, thin, due to the media’s portrayal of the female model as frail, without muscle, and all bones. A study with American college students found the trans students reported significantly higher past year eating disorder diagnosis rates, past month use of diet pills, vomiting, and laxative use when compared to all other groups (Diemer, 2015). However, Algars (2012) found that after surgical transition, both trans men and women reported that the disordered eating symptoms subsided. Therefore, it is critically important to assist trans individuals with suppressing their secondary sex characteristics with hormones rather than the trans person using disordered eating to achieve their goal without medical intervention or supervision. Young trans youth are particularly at risk for disordered eating to prevent puberty. It is important to assess trans clients for eating disorders or at least for the degree to which their gender dysphoria impacts their behavior.
Unfortunately, trans individuals who have eating disorders may never initiate or maintain treatment because they report providers often misunderstand the trans experience. Transgender persons have reported a full range of experiences when seeking medical treatment ranging from provider lack of knowledge, micro-aggressions, to refusal of care, harassment, discrimination, and violence in the medical setting. As a result, trans individuals postpone care for all medical needs and suffer as a result. We often think about the other provider who may be committing these offenses and acts of abuse and would be shocked that a trans person has experienced actual violence in an office very similar to ours. I may know the difference, but the trans persons can’t tell the difference between my office and the office where they will be assaulted unless they can see and hear the difference. What do they see in our office that tells them that we are different? What do they hear from us that tells them that we are different? The World Professional Association for Transgender Health (WPATH) has made numerous recommendations for Trans Health some of which would be useful to read for any clinician or medical provider. Trans health is important and we have an obligation to pay attention to the research, to be informed about best practices, and to provide the best care we can.
About the author –
Alexandra Redcay is the executive director for Serise (www.seriseinc.com). Alex works as an expert witness, trainer, therapist, program evaluator, and consultant. She is a Licensed Clinical Social Worker working part time as a primary therapist for the Princeton healthcare system. Alex is expected to complete her PhD in Social Work from Rutgers University in NJ by May 2016. Her interests include mental health, addiction, child welfare, diversity issues and effective social work education & training.