Resolution of Severe Anorexia Nervosa Associated with Gender Dysphoria (Dysphorexia) by Testosterone Therapy| Stephy Publishers

 

SOJ Diabetes and Endocrinology Care - (SOJDEC) | Stephy Publishers

Abstract

Anorexia nervosa is a severe and potentially lethal eating disorder. In transgender youth with severe gender dysphoria, a severe eating disorder (proposed name: dysphorexia), coherent with anorexia nervosa may be triggered by the desire to avoid the cisgender pubertal transition. In these patients, gender-affirming hormone therapy can be extremely effective. We report hereby the cases of two female-to-male transsexual patients with severe gender dysphoria whose anorexia nervosa was related to their pubertal development and who promptly recovered when they started gender-affirming hormone therapy with testosterone, after very limited success with standard psychotherapy and pharmacotherapy for anorexia nervosa. Our patients could not access pubertal suppression due to lack of parental consent in one case and failure to express the conflict in the other. We postulate that avoiding the cisgender pubertal transition with GnRH agonist treatment might also be able to prevent the development of dysphorexia.

Introduction

For many adolescents with gender incongruence, the pubertal physical changes are a cause of intense dysphoria and unbearable suffering.¹ Early treatment (typically beginning in the Tanner pubertal II stage) with GnRH analogues in order to suppress puberty has been shown to improve psychological functioning and physical outcome.² Anorexia nervosa is a severe and potentially lethal eating disorder, characterized by a restriction of energy intake relative to requirements leading to an abnormally low body weight; an intense fear of gaining weight and a distorted perception of body shape.³

The general cause of anorexia nervosa is unknown,² but in the case of adolescent transgender people, a specific issue with the perception of body shape and development is apparent. The restriction of energy intake (often associated with excessive exercise, vomit induction or use of laxatives) may impede or delay the pubertal development of the secondary sex characteristics associated with gender dysphoria, alleviating the suffering of the patient. Although the present American Psychological Association⁴ guidelines for practice with transgender and gender nonconforming people do not mention anorexia nervosa, there appears to be a higher prevalence of documented eating disorder symptoms in transgender youth compared to cisgender youth.⁵ Reportedly, transgender youth with eating disorders are at particularly high risk for self-injury and suicidal behaviours.^6,7 In a few of the reported cases,^8,9 the pathological eating behaviour of the patients was explicitly reported as a way to manage gender expression (menstruation cessation, loss of secondary sexual characters). In a report, puberty suppression with a GnRH agonist quickly restored healthy eating habits and normal psychological functioning in two transgender adolescents.¹⁰ There is also a paucity of reports of the effect of gender-affirming therapy in post pubertal patients. In one case report, a patient initially presented as a 16 year-old typical female with anorexia nervosa was later revealed as a male transgender subject in whom treatment with testosterone plus bilateral mastectomy alleviated his eating disorder.¹¹ Another case report describes the partial recovery of a 19-year old female transgender subject with anorexia nervosa after she received suppressive therapy with leuprolide and spironolactone, although she did not receive estrogen therapy.¹² The association between gender dysphoria and eating disorders has been explored in two recent reviews^13,14 but the conscious link between caloric restriction and the avoidance of pubertal cisgender development has very rarely been reported.


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