Anorexia Nervosa and Gender Identity Disorder

in 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 on
body 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 biologic
males who presented to an eating disorders service. Results: One was treated successfully as
an outpatient and subsequently underwent gender reassignment surgery. The other patient
required admission and prolonged psychotherapy. Discussion: Differences between the two
cases 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 Disord
36: 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 in
males 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 Psychiatric
Association, 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 transsexuals have a female pattern of somatostatin-expressing neurons in the stria terminalis of
the brain (Kruijver et al., 2000). Regarding psychosocial origins, hypotheses have
focussed on parental attitudes and gender preferences (Bradley & Zucker, 1997). Mothers
*Correspondence to: Dr. Anthony P. Winston, Eating Disorders Unit, Woodleigh Beeches Centre, Warwick
Hospital, Lakin Road, Warwick, CV34 5BW, United Kingdom. E-mail: anthony.winston@swarkpct.nhs.uk
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.20013
#

2004 by Wiley Periodicals, Inc.

110

Winston et al.

of boys with GID have more symptoms of depression and more often meet the criteria for
borderline personality disorder than controls. They are also more likely to have childrearing attitudes and practices that encourage symbiosis and discourage the development of autonomy (Marantz & Coates, 1991).
The emphasis in this disorder on body shape suggests that there may be an association
with anorexia nervosa (AN). Supporting this is the finding that a significant proportion
of male patients with AN have evidence of disturbed psychosexual and gender identity
development (Fichter & Daser, 1987). However, there have only been three reported cases
of 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 and
GID 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 Woodleigh
Beeches Centre (Warwick, United Kingdom) with a history of a long-standing eating
disorder. His symptoms included a desire to be thin, distorted body image, fear of
fatness, self-induced vomiting, and laxative abuse. He attributed his desire for thinness
to a wish to attain a more feminine physique. The onset of his eating disorder was
associated with the development of depressive symptoms, which he attributed to the
fact that he could not be a woman. Before referral, he had been treated by a clinical
psychologist 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 taking
up to 200 stimulant laxatives per week and occasionally using herbal diuretics. Despite
these behaviors, he had been unable to achieve sufficient weight loss and had recently
started exercising. He recognized that he was thin but continued to lose weight. Much of
his time was spent logged on to internet chat rooms related to eating disorders. He
appeared significantly depressed with anergia, anhedonia, early morning wakening, and
reduced concentration.
Patient 1 is the second of four brothers. He described most of his childhood memories
as blank. However, he recalled that as a child he had felt isolated from his family and
peers and was shown little affection by his mother. His mother had wanted a daughter
and he felt that he might have received more affection as a girl. His father, who was
described 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 at
the age of 6 or 7 years. He was unhappy at school, found it hard to form relationships
with peers, and was bullied. He was referred to an educational psychologist and placed
in a remedial class. During adolescence and early adulthood, he attempted to prove his
masculinity by drinking heavily and becoming involved in football-related violence.
However, he never felt comfortable with a male identity. He subsequently developed
strong religious beliefs, which conflicted with his wish to be female and resulted in
powerful feelings of guilt. These beliefs also prevented him from contemplating gender
reassignment 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 rather
than being clearly homosexual.
At assessment, he requested hospital admission as he felt that he would be unable to
make progress as an outpatient. He was subsequently admitted to the inpatient treatment

Gender Identity Disorder

111

program for AN. Although concerned about his weight, he was able to enjoy eating and
gained weight without difficulty. However, he became increasingly disturbed in other
ways. He began harming himself by self-laceration and expressed increasingly forceful
suicidal thoughts.
He formed a strong transference to a female therapist. Within individual psychotherapy, he explored issues of masculinity and maternal neglect. He appeared to experience
the hospital as providing the nurturing that he had lacked as a child. It became clear that
his motivation for weight loss reflected a need for a sense of internal control and clarity in
the face of a confused identity. In addition, he felt that he was attempting to starve the
masculine part of himself.
Although he reached a normal weight of 65.8 kg (BMI of 22.3 kg/m2) and completed a
weight stabilization program, he found discharge from hospital traumatic and immediately began to lose weight. This eventually necessitated readmission. He is now maintaining 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 Unit
for assessment of long-standing eating problems. He described a marked preoccupation
with shape, including a desire to have a more feminine physique. He reported a stable
pattern 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 psychotherapy
service. There, he shared his concerns about his gender identity. However, he did not
believe that his problems were taken seriously and failed to engage with treatment. He
was also treated with antidepressants.
Patient 2 is the only child of elderly parents. He has always lived with his parents, with
whom he has a very close relationship. He described a happy and caring home life. He
referred to his father as a mans man who was secure in his own male identity but also
sensitive and understanding. From the time he started school, Patient 2 felt that he did
not fit into the male gender. At school, he was bullied for being passive and sensitive. He
had no friends and felt he had more in common with girls than boys. He had difficulty
with some subjects at school. As an adult, he was diagnosed as dyslexic but this was not
recognized in childhood. He completed a qualification in electronic engineering and
worked for many years as an engineer. He denied sexual feelings of any sort and has
never had a sexual relationship.
Following assessment, he was offered individual psychotherapy and was able to
establish a trusting relationship with a female therapist. He described AN as providing
an escape from emotional pain, confusion, and dissatisfaction with his life. He eventually
expressed his belief that his AN and depression would not resolve until his concerns
regarding gender identity were addressed. He was subsequently referred to a gender
identity 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-confidence
has increased and she feels more at ease with herself. Her mood has stabilized. Although
she remains underweight (weight 52.4 kg, BMI 16.2 kg/m2), she now feels more satisfied
with her body shape. Her only current concern in terms of body image is that her breasts

112

Winston et al.

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

DISCUSSION
Our cases resemble one reported by Surgenor and Fear (1998). All three patients
reported a desire to achieve a more feminine shape, which appeared to be a factor
motivating weight loss. However, the patients in the current study differed from those
reported by Hepp and Milos (2002) because they presented to an eating disorders service
rather 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 both
cases, the desire for thinness was associated with a wish to achieve a more feminine
physique. Both patients had educational difficulties. However, their early experiences
differ markedly. Patient 2 had a secure and caring family, whereas the childhood of
Patient 1 seems to have been characterized by significant emotional deprivation.
This difference seems to have been reflected in the clinical presentation and response
to treatment. Patient 2 was able to make good use of outpatient psychotherapy and
subsequently showed a good response to gender reassignment surgery. Patient 1, by
contrast, had a complicated clinical course and required inpatient treatment on two
occasions. 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 served
to express more complex issues of personal identity. GID, like AN, may have provided
the 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 successful
response to gender reassignment surgery. Furthermore, the lack of major personality
disturbance 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 diagnostic
entity, it may, at least in association with AN, be heterogeneous in its etiology and clinical
presentation. We recommend that issues of gender identity be considered in the assessment 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 the
American 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 and
adolescent twin sample. Behavior Genetics, 32(4), 251257.
Fichter, M.M., & Daser, C. (1987). Symptomatology, psychosexual development and gender identity in
42 anorexic males. Psychological Medicine, 17(2), 409418.

Gender Identity Disorder

113

Hepp, U., & Milos, G. (2002). Gender identity disorder and eating disorders. International Journal of Eating
Disorders, 32, 473478.
Kesteren, P., Gooren, L., & Megens, J. (1996). An epidemiological and demographic study of transsexuals in The
Netherlands. 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-female
transsexuals have female neuron numbers in a limbic nucleus. Journal of Clinical Endocrinology and
Metabolism, 85(5), 20342041.
Marantz, S., & Coates, S. (1991). Mothers of boys with gender identity disorder: A comparison of matched
controls. 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 of
Sex and Marital Therapy, 20(3), 163177.
Surgenor, L.J., & Fear, J.L. (1998). Eating disorder in a transgendered patient: A case report. International Journal
of Eating Disorders, 24, 449452.
Walters, E., & Whitehead, L. (1997). Anorexia nervosa in a young boy with gender identity disorder of childhood: A case report. Clinical Child Psychology and Psychiatry, 2(3), 463467.