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Keywords:

  • anorexia nervosa;
  • transsexual;
  • gender identity disorder;
  • eating disorder

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Case
  5. Discussion
  6. Conclusion
  7. References

Males comprise a minority of patients with eating disorders (ED). However, men who have sex with men, males with gender identity disorder, and transsexual (TS) males are at increased risk for ED. Little has been published about the unique treatment needs of TS patients with ED. A 19-year-old male-to-female TS patient presented with restrictive eating, purging, and weight loss. History revealed that her ED ideation and behaviors were strongly intertwined with her gender identity. She was admitted and during her hospitalization both her ED and TS status were addressed medically. Physicians treating patients with ED should be aware of patients' gender identities and the ways in which gender identity may impact management and recovery. When appropriate, providers should consider addressing medical treatment toward gender transition concurrently with treatment for ED to facilitate medical stabilization and weight restoration in the manner most consistent with the patient's identified gender. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2014; 47:112–115)


Introduction

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Case
  5. Discussion
  6. Conclusion
  7. References

Eating disorders (ED), in general, occur less frequently in males versus females; males comprise one in 10 cases of anorexia nervosa.[1] ED have a higher prevalence in certain populations of (genetically) male patients, including men who have sex with men and transsexual (TS) patients. Transsexuality is defined “a strong and persistent cross-gender identification, with the patient's persistent discomfort with his or her sex and a sense of inappropriateness in the gender role of that sex.”[2] Several case reports have been published noting the occurrence of ED among TS patients.[3-5] Less, however, has been written about the impact of transsexuality on the treatment of ED. Specifically, little has been published on how patients' fear of gaining weight in patterns typical of their natal sex may impede their recovery from ED. In this report, we present a case of a male-to-female (MtF) TS patient admitted with malnutrition secondary to an ED and discuss the need for and implications of addressing her transsexuality concurrently with treatment of her ED.

Case

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Case
  5. Discussion
  6. Conclusion
  7. References

DS1 is a 19-year-old Hispanic MtF TS patient who presented to the emergency center at a large, academic hospital with significant weight loss secondary to disordered eating and purging. Over the course of the year prior to presentation, she lost approximately 36 kg, from a weight of 75 kg (BMI 26.8 kg/m2) to a weight of 39 kg (BMI 13.8 kg/m2; 60.8 percent of estimated mean body weight for a male patient, as calculated by the Hamwi method). DS had restricted caloric intake, abused laxatives, taken diet aids including over-the-counter weight loss supplements and green tea pills, and had engaged in bingeing and purging via vomiting. Approximately 1 month prior to presentation, she attempted to stop restricting and purging. She did not seek medical attention at this time but was able to gain approximately 4–7 kg on her own, primarily through improved nutritional habits including cessation of bingeing and a significant reduction of restricting and purging.

In the several days prior to presentation, the frequency of DS's vomiting increased to multiple times daily; at the time of presentation, she had not kept down any food for approximately 3 days. She had also resumed abuse of laxatives and diet pills, although the frequency and amount of her use of these medications is not known. She was experiencing presyncope, cold intolerance, fatigue, chest pain, and tingling of the extremities. The chest pain was described as left-sided pressure with radiation down the left arm, lasting 1–2 minutes and resolving spontaneously. Extremity tingling had worsened over the prior 3 months and was occasionally associated with “stiffening” of her hands. She had not sought medical attention for these symptoms. Of note, DS had been living as a female for one year and desired cross-hormone therapy and surgery to further her MtF transition, but she had not begun any of these treatments at the time of her presentation to the emergency center.

In the emergency center, DS weighed 44.6 kg (BMI 16.0 kg/m2, 70.1% of estimated mean body weight per male norms). Pulse was 65 beats per minute, blood pressure was 115/78, and temperature was 36.5°C. Her overall appearance was feminine, with long hair, makeup, and manicured nails, though underlying masculine facial bone structure was noted. She had evidence of sparse, shaved facial hair on her face, cheeks, moustache, and chin. No chest hair was present. General physical examination was significant for emaciation and mild epigastric abdominal tenderness. Chest pain was not reproducible on examination. Genital examination revealed sexual maturity rating 5 male genitalia, with normal penis and testicles. Additional components of physical examination were unrevealing.

On laboratory investigation, DS had significant electrolyte abnormalities; potassium level was 2.5 mmol/L, chloride was 79 mmol/L, and bicarbonate was 39 mmol/L. She also had evidence of dehydration; blood urea nitrogen was 32 mmol/L and creatinine was 1.54 mmol/L. Electrocardiogram showed a prolonged corrected QT interval of 458 ms with early repolarization. DEXA revealed lumbar spine bone density of 0.926 g/cm2 which correlates with a Z-score of −2.4 using age-matched male controls or −2.2 using age-matched female controls. Testosterone was low at 127 ng/dL; the normal range for adult males is 250–1,100 ng/dL. Liver enzymes were within normal limits. She was admitted to the inpatient ED treatment program which includes structured medical care and nutrition, physical therapy, and psychotherapy.

DS expressed that the onset of her desire to lose weight and eating-disordered behaviors coincided with her decision to dress and live as a woman. With weight loss, she appeared more “feminine” and also noted decreased hair growth and decreased need to shave her face and legs.

After initial refeeding, DS experienced increasing distress, crying, depression, and urge to exercise as she gained weight. DS indicated that she did not want gain weight due to fear of appearing increasingly masculine. However, if she were able to gain weight in a typical female distribution on her hips and breasts, she would be willing to gain to a healthy target weight.

DS's testosterone level assessed 4 weeks into hospitalization had increased to 403 ng/dL, within the normal adult male range. The patient noted increased growth of facial hair and the need to increase the frequency of shaving her face and legs. Several members of the medical team saw her exercising surreptitiously and her weight gain ceased. At this point, treatment options toward gender transition were discussed with DS, including the potential risks and benefits of each, and she consented to initiate gonadotropin-releasing hormone (GnRH) agonist therapy to suppress testosterone production. She was given a three-month dose (11.25 mg IM) of leuprolide. Spironolactone was added for additional antiandrogenic effect. DS described feelings of relief with her treatment team regarding the physical effects of suppressing her testosterone levels.

DS progressed well after initiating this regimen. She met discharge goals and was discharged home with follow-up scheduled at a local counseling center specializing in the transgendered population and follow-up with an endocrinologist specializing in gender transition. Upon follow-up in the adolescent medicine clinic, DS initially continued to gain weight and reached 86% of estimated (male) mean body weight (BMI 19.6 kg/m2). However, when she resumed working, she lost weight down to 78% of estimated (male) mean body weight (BMI 17.8 kg/m2). DS attributed this to physical activity at her workplace in combination with minimal time allowed for meal breaks. She met with the clinic dietician who helped her make adjustments to her meal plan and the clinic provided her with documentation urging her employer to allow appropriate meal breaks. DS's weight then stabilized.

DS was evaluated by a pediatric endocrinologist who assessed her as an appropriate candidate for estrogen therapy. She was asked to seek counseling at a local center specializing in transgender youth and to provide a letter from them documenting her psychological readiness for gender transition. Unfortunately, in the interim she lost her medical insurance and to date has not had the resources to continue follow-up with either the endocrine clinic or the adolescent medicine clinic.

Discussion

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Case
  5. Discussion
  6. Conclusion
  7. References

Several case reports about MtF patients with ED discuss the patients' perception that their drive for thinness is related to their identification as TS. However, little is published about the unique treatment needs of these patients. To our knowledge, this is the first case report to discuss treatment of transsexuality facilitating the simultaneous inpatient treatment of an ED.

We conducted a review of the literature on treatment of Gender Identity Disorder and Transsexualism in the young adult population. Goals of cross-sex hormone treatment are to reduce hormonally-induced secondary sex characteristics of the natal sex to the extent possible and to induce secondary sex characteristics of the desired sex. Initiating such treatment is contingent upon several factors, referred to as “readiness criteria.”[6] The diagnosis of Gender Identity Disorder or Transsexualism must be confirmed; patients should understand the benefits and risks of treatment, should have reasonable expectations regarding treatment outcomes, and should undergo a “real life test” coincident with or prior to the initiation of cross-sex hormonal therapy.[6]

DS easily satisfied the readiness criteria. She had conducted her own research into treatment possibilities and was eager to pursue transition as soon as her health status would allow it. She had been living as female for over a year, satisfying the “real life test” requirement. She had a supportive family and supportive coworkers to help her cope with the stresses of her transition.

Because her identity as TS and desire to appear more feminine were inextricable from her disordered eating, we felt that her recovery from her ED would be aided by supporting her gender transition. After consulting the Endocrine Society Guidelines on Treatment of Transsexual Persons and discussing treatment possibilities with experts in transsexual youth, medical treatment options included cross-hormone (i.e., estrogen) therapy (which would also suppress testosterone release) and/or suppression of testosterone with GnRH agonists with or without the use of spironolactone as an antiandrogen agent.[6] Treatment with cross-hormone therapy requires close follow-up with an endocrinologist familiar with this treatment; the children's hospital to which DS was admitted is not a site experienced in cross-hormone therapy for transsexual youth. For this reason, GnRH agonist therapy with spironolactone was chosen to suppress testosterone at the level of the pituitary and delay resurgence of testosterone-related changes until the patient could access appropriate TS medical care and follow-up.

To our knowledge, there are no studies describing the patterns of weight gain in TS patients who receive antiandrogens in comparison to those who do not. However, studies of antiandrogen use for other medical conditions have shown that patients receiving antiandrogens tend to gain subcutaneous adiposity, as opposed to primarily intra-abdominal adiposity gained by patients not on antiandrogens.[7] One could theorize that this subcutaneous pattern of weight gain would be more tolerable to MtF transsexual patients who strive for a more feminine appearance, which would support the use of GnRH agonists in these patients. This is an interesting area for future inquiry.

Possible adverse effects of GnRH agonists include decrease in bone density. This is of particular concern in malnourished patients, as malnutrition alone can adversely affect bone density. This potential drawback of GnRH therapy for DS was discussed at length as a team, and it was determined that the benefits of GnRH use outweighed the risks for two primary reasons: (1) the expected duration of GnRH therapy was brief, as it was being used as a bridge to initiation of cross-hormone therapy; and (2) suppression of DS's testosterone level would likely facilitate her willingness to achieve weight restoration. In studies of malnourished patients with low bone density, weight restoration is the most important factor in improving bone density.[8] Spironolactone was added to DS's therapy regimen for additional anti-androgen effects. This medical plan enabled DS to continue to improve her nutritional status while avoiding the unwanted increase in testosterone and consequent physical changes.

Conclusion

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Case
  5. Discussion
  6. Conclusion
  7. References

Several case reports of patients with ED and simultaneous TS have described the patients' disordered eating and weight loss as secondary to their gender identity concerns. Based on this association, patients (particularly male patients) presenting with gender dysphoria should be screened for symptoms of an ED. Likewise, when treating male patients with ED, one should be aware of the possible association with gender identity concerns and providers should consider screening for gender dysphoria when appropriate. For patients with simultaneous ED and TS who meet transsexual “readiness criteria,” initiating medical therapy supporting gender transition with cross-hormone therapy and/or GnRH analog therapy to suppress unwanted natal sex phenotypic changes in the inpatient ED treatment setting may make the process of weight restoration more tolerable, thereby facilitating medical recovery.

Given our experience, we strongly recommend that treatment teams consider the initiation of medical treatment using the Endocrine Society Guidelines on treatment of TS persons simultaneously with ED treatment for patients meeting the readiness criteria. Care should be taken to ensure patients are prepared to begin such treatment, and consideration should be given to the risks and benefits of any treatment regimen with respect to both diagnoses. Understanding of the best practices in treating ED and simultaneous TS would benefit from studies evaluating weight gain and weight distribution patterns of patients receiving hormone therapy versus those not receiving such therapy.

  1. 1

    Name changed and identifying information removed. Case was discussed with local IRB who informed the authors that no patient authorization was necessary for publication.

References

  1. Top of page
  2. ABSTRACT
  3. Introduction
  4. Case
  5. Discussion
  6. Conclusion
  7. References