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Gender, Embodiment, and Eating Disorders

      See Related Article on p. 461
      Duffy et al. [
      • Duffy M.E.
      • Henkel K.E.
      • Joiner T.E.
      Prevalence of self-injurious thoughts and behaviors in transgender individuals with eating disorders: A national study.
      ] have published an important study in the Journal of Adolescent Health about the health of transgender individuals. In a survey of 365,749 college students living in the United States, 678 (.2%) self-identified as transgender. Among those identifying as transgender, Duffy et al. observed a past-year eating disorders prevalence rate of 18% (nearly one in five) compared with rates of 1.8% and .2% for cisgender women and men, respectively. Of those transgender individuals with eating disorders, the authors observed a past-year suicide attempt prevalence rate of 75%—a figure both shocking and compelling. The authors accurately state that the high rate of suicidality among transgender individuals with eating disorders is likely the result of multiple compounding issues, including the widespread discrimination and violence perpetrated toward transgender individuals [
      • Stotzer R.L.
      Violence against transgender people: A review of United States data.
      ] and the intrinsic pathos of eating disorders, which are known to potentiate suicidality [
      • Franko D.L.
      • Keel P.K.
      Suicidality in eating disorders: Occurrence, correlates, and clinical implications.
      ]. But why are eating disorders so common among transgender individuals in the first place? In this editorial, we articulate one potential answer by drawing on two inter-related psychological concepts: gender and embodiment.
      In the eyes of many, eating disorders are synonymous with females, anorexia, and an intense desire to be thin [
      • Russell G.
      • Treasure J.
      The modern history of anorexia nervosa: An interpretation of why the illness has changed.
      ]. Meanwhile, the field of eating disorders is contending with new manifestations of eating disorders that arise from different yet equally intense desires. Muscle dysmorphia, a psychological disorder nicknamed “reverse anorexia,” is the manifestation of an intense, psychopathological desire to be muscular [
      • Pope H.G.
      • Gruber A.
      • Choi P.
      • et al.
      Muscle dysmorphia: An underrecognized form of body dysmorphic disorder.
      ]. Gender differences in the prevalence of anorexia nervosa and muscle dysmorphia accord with gender differences in the types of bodies that women and men covet [
      • Murray S.B.
      • Nagata J.M.
      • Griffiths S.
      • et al.
      The enigma of male eating disorders: A critical review and synthesis.
      ]. Generally speaking, women desire to be thin, whereas men desire to be muscular. By extension, women are overrepresented in anorexia, and men are overrepresented in muscle dysmorphia [
      • Murray S.B.
      • Nagata J.M.
      • Griffiths S.
      • et al.
      The enigma of male eating disorders: A critical review and synthesis.
      ].
      Eating disorders can be understood as moving targets [
      • Griffiths S.
      • Castle D.
      • Cunningham M.
      • et al.
      How does exposure to thinspiration and fitspiration relate to symptom severity among individuals with eating disorders? Evaluation of a proposed model.
      ]. Different desires for different bodies motivate different attitudes and behaviors. If we are willing to accept that different people desire different bodies, then we must also accept different manifestations of the psychopathology that arises when these desires become unsustainable. Furthermore, because individuals' desires about their own bodies and others' bodies are changing over time [
      • Bozsik F.
      • Whisenhunt B.L.
      • Hudson D.L.
      • et al.
      Thin is in? Think again: The rising importance of muscularity in the thin ideal female body.
      ], the manifestation of eating disorders will also change over time. Construal of eating disorders as moving targets provides a coherent framework to understand the salient and interconnected issues of gender, embodiment, and eating disorders among transgender individuals.
      Transgender individuals have a gender identity that is different from their birth-assigned sex. For example, birth-assigned males may have a female gender identity, whereas birth-assigned females may have a male gender identity. Common among transgender individuals is a desire to embody their identified gender [
      • Testa R.J.
      • Rider G.N.
      • Haug N.A.
      • et al.
      Gender confirming medical interventions and eating disorder symptoms among transgender individuals.
      ]. To achieve embodiment, transgender individuals may undergo sex reassignment surgery, a wide variety of masculinizing and feminizing body-modification cosmetic procedures, and hormone replacement therapy. However, one of the least invasive measures that transgender individuals might first attempt is the alteration of their body shape and body weight through dieting and exercise, as these can be done with little expense and without the need for medical supervision. Ultimately, these behaviors may help to affirm one's gender identify whilst also satisfying other peoples' normative expectations about the embodiment of gender (i.e., what male and female bodies are “supposed” to look like). Of primary concern to the field of eating disorders, however, are the body image issues that may facilitate, accompany, and be exacerbated by these body-altering behaviors.
      Body dissatisfaction (i.e., not liking one's body) is perhaps the strongest predictor of eating disorder development [
      • Stice E.
      • Shaw H.E.
      Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings.
      ]. In the presence of body dissatisfaction, seemingly benign dieting and exercise behaviors can progress to (1) eating disorder behaviors, including fasting, skipping meals, self-induced vomiting, and laxative and diuretic misuse, and (2) eating disorder attitudes, such as the belief that one's self-worth is wholly contingent on achieving a particular body shape or weight. Given that eating disorders are centrally characterized by such behaviors and attitudes, it makes sense that eating disorders will be a salient issue for transgender individuals, for whom the issue of embodiment is fundamental. Continual monitoring of eating and exercise behaviors may arise from a combination of body-related pressures placed on oneself and pressures applied by others and by society more generally [
      • Jones B.A.
      • Haycraft E.
      • Murjan S.
      • et al.
      Body dissatisfaction and disordered eating in trans people: A systematic review of the literature.
      ]. Regarding the latter, transgender individuals who decline to affirm other peoples' expectations of normative gender embodiment by manipulating their body through diet and exercise may be subject to discrimination and violence, compounding the impact on their health and well-being [
      • Stotzer R.L.
      Violence against transgender people: A review of United States data.
      ].
      Duffy et al.'s study compels us to reflect on research design and conduct in the field of eating disorders. Survey-based research on eating disorders has only recently begun asking participants whether they identify their gender as anything other than male or female. If asked, researchers have excluded transgender individuals from substantive data analyses due to statistical considerations stemming from the (typically) very small number of said individuals recruited into research samples. To some extent, this progression parallels the historical neglect of cisgender males in the eating disorders field, who were also regularly excluded from eating disorders research [
      • Cohn L.
      • Murray S.B.
      • Walen A.
      • et al.
      Including the excluded: Males and gender minorities in eating disorder prevention.
      ,
      • Wooldridge T.
      Understanding anorexia nervosa in males: An integrative approach.
      ]. Beyond inclusion, the issue of gender extends to the development of eating disorder measurement instruments and diagnostic criteria, which were largely developed and evaluated with samples of (cisgender) females. Continued efforts to fundamentally incorporate gender into eating disorders theory, research, and practice are necessary. Clearly, there is a great and urgent need for eating disorder and suicide prevention screening, and intervention with transgender individuals, something that is well suited to college and university environments [
      • Yager Z.
      • O'Dea J.A.
      Prevention programs for body image and eating disorders on university campuses: A review of large, controlled interventions.
      ].
      In conclusion, eating disorders researchers and clinicians must be increasingly cognizant of (1) the different ways that individuals seek to embody their gender, (2) the different pressures that individuals experience due to other peoples' expectations of gender embodiment, and (3) the different ways that eating disorders can manifest among diverse individuals with diverse desires for diverse body types. Research and clinical work that is cognizant of these differences will greatly advance the understanding, treatment, and prevention of eating disorders among transgender individuals. Indeed, understanding these differences will benefit all individuals with eating disorders for whom narrow, historical, and stereotyped assumptions do not apply.

      Funding Sources

      S.G. is supported by a National Health and Medical Research Council Early Career Fellowship (grant number: 1121538) and a University of Melbourne Early Career Researcher Grant (grant number: 603758). S.G. and Z.Y. are supported by a World Anti-Doping Agency Social Science Research Grant.

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