anorexia nervosa and gender identity disorder in biologic males- a report of two cases

8/10/2019 Anorexia Nervosa and Gender Identity Disorder in Biologic Males- A Report of Two Cases

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Anorexia Nervosa and Gender Identity Disorderin Biologic Males: A Report of Two Cases

Anthony P. Winston,1,2,* Sudha Acharya,1 Shreemantee Chaudhuri,1

and Lynette Fellowes1

1 Eating Disorders Unit, Woodleigh Beeches Centre, Warwick Hospital,Warwick, United Kingdom

2 Division of Psychiatry, University of Warwick,Coventry, United Kingdom

Accepted 28 November 2003

Abstract:Gender identity disorder is a rare disorder of uncertain etiology. The emphasis onbody shape in this disorder suggests that there may be an association with anorexia nervosa.Method: We report two cases of anorexia nervosa and gender identity disorder in biologicmales who presented to an eating disorders service.Results:One was treated successfully asan outpatient and subsequently underwent gender reassignment surgery. The other patientrequired admission and prolonged psychotherapy.Discussion:Differences between the twocases are discussed. Issues of gender identity should be considered in the assessment of male

patients presenting with anorexia nervosa. #2004 by Wiley Periodicals, Inc.Int J Eat Disord36: 109113, 2004.

Key words:gender identity disorder; anorexia nervosa; biologic males

INTRODUCTION

Gender identity disorder (GID) is a rare disorder with a prevalence of 1 in 10,000 inmales and 1 in 30,000 in females (Kesteren, Gooren, & Megens, 1996). Diagnostic criteria

include persistent cross-dressing, persistent discomfort with the biologic gender,and clinically significant distress or functional impairment (American PsychiatricAssociation, 1994).

The etiology is unclear and both biologic and psychosocial origins have been proposed(Money, 1994). Regarding biologic etiology, there is evidence for a genetic component(Coolidge, Thede, & Young, 2002). It has also been found that male-to-female transsex-uals have a female pattern of somatostatin-expressing neurons in the stria terminalis ofthe brain (Kruijver et al., 2000). Regarding psychosocial origins, hypotheses havefocussed on parental attitudes and gender preferences (Bradley & Zucker, 1997). Mothers

*Correspondence to: Dr. Anthony P. Winston, Eating Disorders Unit, Woodleigh Beeches Centre, WarwickHospital, Lakin Road, Warwick, CV34 5BW, United Kingdom. E-mail: [email protected]

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of boys with GID have more symptoms of depression and more often meet the criteria forborderline personality disorder than controls. They are also more likely to have child-rearing attitudes and practices that encourage symbiosis and discourage the develop-ment of autonomy (Marantz & Coates, 1991).

The emphasis in this disorder on body shape suggests that there may be an associationwith anorexia nervosa (AN). Supporting this is the finding that a significant proportionof male patients with AN have evidence of disturbed psychosexual and gender identitydevelopment (Fichter & Daser, 1987). However, there have only been three reported casesof AN occurring in adult biologic males with GID (Hepp & Milos, 2002; Surgenor & Fear,1998) and one in a child (Walters & Whitehead, 1997). We report two cases of AN andGID in biologic males who presented to an eating disorders service.

PATIENT 1

A 46-year-old Caucasian man was referred to the Eating Disorders Unit at the WoodleighBeeches Centre (Warwick, United Kingdom) with a history of a long-standing eatingdisorder. His symptoms included a desire to be thin, distorted body image, fear offatness, self-induced vomiting, and laxative abuse. He attributed his desire for thinnessto a wish to attain a more feminine physique. The onset of his eating disorder wasassociated with the development of depressive symptoms, which he attributed to thefact that he could not be a woman. Before referral, he had been treated by a clinicalpsychologist and had been prescribed antidepressants.

At presentation, he weighed 49.1 kg (body mass index [BMI] of 17.0 kg/m2). He

described marked dietary restriction and frequent self-induced vomiting. He was takingup to 200 stimulant laxatives per week and occasionally using herbal diuretics. Despitethese behaviors, he had been unable to achieve sufficient weight loss and had recentlystarted exercising. He recognized that he was thin but continued to lose weight. Much ofhis time was spent logged on to internet chat rooms related to eating disorders. Heappeared significantly depressed with anergia, anhedonia, early morning wakening, andreduced concentration.

Patient 1 is the second of four brothers. He described most of his childhood memoriesas blank. However, he recalled that as a child he had felt isolated from his family andpeers and was shown little affection by his mother. His mother had wanted a daughterand he felt that he might have received more affection as a girl. His father, who wasdescribed as stern and authoritarian, died when he was 15 years old.

As a child, Patient 1 regularly took the female role in play and began cross-dressing atthe age of 6 or 7 years. He was unhappy at school, found it hard to form relationshipswith peers, and was bullied. He was referred to an educational psychologist and placedin a remedial class. During adolescence and early adulthood, he attempted to prove hismasculinity by drinking heavily and becoming involved in football-related violence.However, he never felt comfortable with a male identity. He subsequently developedstrong religious beliefs, which conflicted with his wish to be female and resulted inpowerful feelings of guilt. These beliefs also prevented him from contemplating genderreassignment surgery. He has had one short-term heterosexual relationship. His sexual

fantasies are directed towards men but take the form of being treated like a woman ratherthan being clearly homosexual.

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program for AN. Although concerned about his weight, he was able to enjoy eating andgained weight without difficulty. However, he became increasingly disturbed in otherways. He began harming himself by self-laceration and expressed increasingly forcefulsuicidal thoughts.

He formed a strong transference to a female therapist. Within individual psychother-apy, he explored issues of masculinity and maternal neglect. He appeared to experiencethe hospital as providing the nurturing that he had lacked as a child. It became clear thathis motivation for weight loss reflected a need for a sense of internal control and clarity inthe face of a confused identity. In addition, he felt that he was attempting to starve themasculine part of himself.

Although he reached a normal weight of 65.8 kg (BMI of 22.3 kg/m2) and completed aweight stabilization program, he found discharge from hospital traumatic and immedi-ately began to lose weight. This eventually necessitated readmission. He is now maintain-ing a normal weight as an outpatient and has been referred to a gender identity clinic.

PATIENT 2

A 41-year-old biologic Caucasian male was referred to the same Eating Disorders Unitfor assessment of long-standing eating problems. He described a marked preoccupationwith shape, including a desire to have a more feminine physique. He reported a stablepattern of dietary restraint since the age of 28 and there were no other weight-regulatory

behaviors. His weight at assessment was 62.1 kg (BMI of 18.8 kg/m2).He had first presented to psychiatric services 7 years previously. He was referred

initially to the general psychiatric services and, subsequently, to the psychotherapyservice. There, he shared his concerns about his gender identity. However, he did notbelieve that his problems were taken seriously and failed to engage with treatment. Hewas also treated with antidepressants.

Patient 2 is the only child of elderly parents. He has always lived with his parents, withwhom he has a very close relationship. He described a happy and caring home life. Hereferred to his father as a mans man who was secure in his own male identity but alsosensitive and understanding. From the time he started school, Patient 2 felt that he didnot fit into the male gender. At school, he was bullied for being passive and sensitive. Hehad no friends and felt he had more in common with girls than boys. He had difficultywith some subjects at school. As an adult, he was diagnosed as dyslexic but this was notrecognized in childhood. He completed a qualification in electronic engineering andworked for many years as an engineer. He denied sexual feelings of any sort and hasnever had a sexual relationship.

Following assessment, he was offered individual psychotherapy and was able toestablish a trusting relationship with a female therapist. He described AN as providingan escape from emotional pain, confusion, and dissatisfaction with his life. He eventuallyexpressed his belief that his AN and depression would not resolve until his concernsregarding gender identity were addressed. He was subsequently referred to a genderidentity clinic.

After living as a female for 2 years, he underwent gender reassignment surgery. Since

the surgery, she describes herself as feeling complete and normal. Her self-confidencehas increased and she feels more at ease with herself. Her mood has stabilized. Although

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are too small. She has completed professional training in counseling and adult educationin the female role. Although she feels the need to be in a relationship, she has no desirefor a sexual relationship.

DISCUSSION

Our cases resemble one reported by Surgenor and Fear (1998). All three patientsreported a desire to achieve a more feminine shape, which appeared to be a factormotivating weight loss. However, the patients in the current study differed from thosereported by Hepp and Milos (2002) because they presented to an eating disorders servicerather than to a gender clinic. In contrast to the patients described by Hepp and Milos(2002), Patient 2 responded to gender reassignment surgery with an improvement in

body satisfaction and self-esteem.

The two cases reported here share some similarities and significant differences. In bothcases, the desire for thinness was associated with a wish to achieve a more femininephysique. Both patients had educational difficulties. However, their early experiencesdiffer markedly. Patient 2 had a secure and caring family, whereas the childhood ofPatient 1 seems to have been characterized by significant emotional deprivation.

This difference seems to have been reflected in the clinical presentation and responseto treatment. Patient 2 was able to make good use of outpatient psychotherapy andsubsequently showed a good response to gender reassignment surgery. Patient 1, bycontrast, had a complicated clinical course and required inpatient treatment on twooccasions. In his case, GID was associated with disturbed early relationships and a global

disturbance of identity which was not restricted to gender.We suggest that GID in Patient 1 may have had its origins in early psychological

development. We speculate that, in his case, the issue of gender identify may have servedto express more complex issues of personal identity. GID, like AN, may have providedthe patient with a sense of structure in a chaotic internal world. Patient 2, however, may

be thought of as having a more biologic form of GID, which accounts for the successfulresponse to gender reassignment surgery. Furthermore, the lack of major personalitydisturbance in her case enabled her to be treated as an outpatient.

The two cases reported here, together with those reported recently by Hepp and Milos(2002), suggest that GID may be more commonly associated with AN in males than has

been previously recognized. Although GID is generally believed to be a single diagnosticentity, it may, at least in association with AN, be heterogeneous in its etiology and clinicalpresentation. We recommend that issues of gender identity be considered in the assess-ment of male patients presenting with AN.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).Washington, DC: Author.

Bradley, S.J., & Zucker, K.J. (1997). Gender identity disorder: A review of the past 10 years. Journal of theAmerican Academy of Child and Adolescent Psychiatry, 36(7), 872880.

Coolidge, F.L., Thede, L.L., & Young, S.E. (2002). The heritability of gender identity disorder in a child andadolescent twin sample Behavior Genetics 32(4) 251257

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Hepp, U., & Milos, G. (2002). Gender identity disorder and eating disorders. International Journal of EatingDisorders, 32, 473478.

Kesteren, P., Gooren, L., & Megens, J. (1996). An epidemiological and demographic study of transsexuals in TheNetherlands. Archives of Sexual Behaviour, 17, 547548.

Kruijver, F.P.M., Zhou, J.-N., Pool, C.W., Hofman, M.A., Gooren, L.J.G., & Swaab, D.F. (2000). Male-to-femaletranssexuals have female neuron numbers in a limbic nucleus. Journal of Clinical Endocrinology andMetabolism, 85(5), 20342041.

Marantz, S., & Coates, S. (1991). Mothers of boys with gender identity disorder: A comparison of matchedcontrols. Journal of the American Academy of Child and Adolescent Psychiatry, 30(2), 310315.

Money, J. (1994). The concept of gender identity disorder in childhood and adolescence after 39 years. Journal ofSex and Marital Therapy, 20(3), 163177.

Surgenor, L.J., & Fear, J.L. (1998). Eating disorder in a transgendered patient: A case report. International Journalof Eating Disorders, 24, 449452.

Walters, E., & Whitehead, L. (1997). Anorexia nervosa in a young boy with gender identity disorder of child-hood: A case report. Clinical Child Psychology and Psychiatry, 2(3), 463467.

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anorexia nervosa and gender identity disorder in biologic males- a report of two cases

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