Dysphoria vs. Dysmorphia: Mental Health Discussions in Transgender Anorexia Nervosa Treatment

A growing topic of debate in the LGBTQ and anorexia nervosa recovery circles is centered around gender dysphoria, body dysmorphia and their relationship to clinical diagnoses of a mental health disorder.  Even beyond the similarities of the terms, there has been confusion over why one description (gender dysphoria) is not considered a mental health disorder, and the other (body dysmorphia) is.  This confusion, even among medical professionals, can result in the further marginalization of an already marginalized population, transgender men and women.  Considering that the need for anorexia treatment is estimated to be four times higher in the transgender community than in the general population, understanding this issue is essential to helping this higher-risk community get the help they need at residential eating disorder treatment centers and elsewhere.

Defining Terms

• Gender Dysphoria

Gender dysphoria is the feeling of distress or discomfort because of the difference between a person’s gender (assigned at birth) and their gender identity.  This applies to both males who are assigned a female gender at birth and females who were assigned the male gender at birth.  People with gender dysphoria are normally transgender.  However, there are cases of non-binary gender identities in which gender dysphoria is present.

• Body Dysmorphia

Body dysmorphia is the sense of dissatisfaction with one’s body, and the perception that their body is flawed or defective. This can manifest in perceptions of “bad” skin or hair, or more commonly, the perception that one is “fat” despite evidence to the contrary. Body dysmorphia is a common contributing factor to mental health complications which can require anorexia nervosa treatment. Body dysmorphic disorder is present in at least 25% of people with anorexia nervosa, and body image distortions are almost always present in these cases.

Relationships to Eating Disorders

Both gender dysphoria and body dysmorphia are linked in the development of eating disorders, based on clinical studies and the in-practice studies at anorexia treatment centers.  The link between anorexia nervosa and bulimia nervosa and a distorted body image is well established – body dysmorphia is almost always present in cases requiring anorexia nervosa treatment. At times body dysmorphia co-occurring with anorexia can be so extreme that the individual will continue to restrict caloric intake even when medically deemed underweight or even malnourished. In most clinical definitions, a distorted body image is a key contributing factor in disordered eating behaviors.

While body dysmorphia disorder is classified as a mental health disorder by the APA and listed as such in the DSM – V (the official listing of mental health disorders), and it can be comorbid with a variety of eating disorders, gender dysphoria is not listed as a disorder or a mental health illness.  Despite this, the incidence of eating disorders (including those severe enough to require residential eating disorder treatment) in the transgender community is much higher than in the cisgender population. In fact, 16% of college-aged transgender students surveyed in a 2015 survey had experienced or were experiencing an eating disorder.

In some ways, body dysmorphia and gender dysphoria can be connected, just as eating disorders and body dysmorphia are connected.  For example, female-to-male transgender people have been known to perceive typically female physical characteristics such as curves in the hip and the breasts as more prominent than an impartial observer might. A male-to-female transgender person may be dissatisfied with their musculature, body hair, or other male characteristics such as an Adam’s apple.

Many of these dissatisfactions can be addressed medically through hormone treatments and surgery associated with gender reassignment, and this marks an important distinction between dysmorphia and dysphoria. A transgender person experiences distress because their body does not reflect their true gender. Conversely, a person with body dysmorphia experiences distress because they perceive flaws in their body or weight that do not exist. The latter can lead to the development of eating disorders like anorexia nervosa because despite the steps taken like extreme weight loss or cosmetic surgery, the negative body image persists.

In cases like these it’s important to separate the sincere desire to fulfill their gender identity from the distorted perception of their body.  This is the crux where much of the confusion between the two terms comes from.

Identity and Self-Image

In a situation like the female-to-male transition described above, it’s still far too common for both laypeople and medical professionals, though rarely in mental health professionals) to conflate the body-image issues arising from a gender identity dissatisfaction with those resulting from a mental health disorder like body dysmorphia.

To put in simpler terms, a person with gender dysphoria is not mentally ill; they are dissatisfied with the gender assigned at their birth.

A person with body dysmorphia has a disorder in which they perceive their body or face as “ugly,” “fat,” or otherwise unattractive despite medical or personal reassurances.

Gender identity and self-image are inextricably linked; for a woman to look in the mirror and see a man is disorienting and distressing. Discrepancies between a person’s assigned gender and their true gender, in addition to the presence of discrimination and misunderstandings by the general public towards transgender issues, can lead to other mental health disorders, such as anxiety, depression and OCD, all of which are more prevalent in the transgender community than the non-trans community.

This all ties back in to the main distinction this article makes about the difference between gender dysphoria and body dysmorphia – one involves a distorted perception of their body and the other doesn’t.

Health Risks

Eating disorders are among the most dangerous mental health conditions, resulting in gastrointestinal, endocrine, cardiopulmonary and neurological complications.  Without receiving anorexia treatment, there may be a mortality rate of as much as 4%.  Other eating disorders such as bulimia nervosa can result in dental problems and issues with the esophagus due to frequent vomiting. In all eating disorders, poor nutritional balance or even malnutrition are risks.

A transgender identity in and of itself carries no inherent health risks.  However, when a person decides to make the transition, they normally begin with hormone treatments, whether reassignment surgery is slated to happen or not. By introducing estrogen or testosterone, there is a slightly increased risk of cancer, and more common risks of low or high blood pressure, blood clots, dehydration and electrolyte imbalance, and liver damage. An important thing to note is that due to discrimination and societal pressure, transgender people are less likely to go through “above the board” healthcare providers, meaning the hormone treatments they receive may not be properly balanced for their body, exacerbating some of the issues raised above.

Both transgender people and people with body dysmorphia have higher than average rates of mental health and behavioral health disorders.  Prominent among these are depression and anxiety.  Both of these mental health disorders are normally caused by a combination of genetic and environmental factors, just like gender dysphoria and body dysmorphia.  In many cases, a specific trigger such as a traumatic event (i.e. abuse, a bad breakup, being in a car accident, etc.) sets off a previously hidden disorder.

The One Common Health Risk

Depression and anxiety are contributing factors in the one health risk that’s common to both gender dysphoria and body dysmorphia: suicide.  Rates of suicidal ideation (that is, thoughts of suicide), attempted suicide, and actual suicide are all much higher in transgender populations and in populations experiencing body dysmorphia than in the larger populace.

• Body dysmorphia

  • 80% of individuals have suicidal thoughts
  • 24-26% have attempted suicide
  • Complete suicides percentage is unknown, but thought to be very high

• Transgender population

  • More than 50% of transgender males have attempted suicide
  • 30% of transgender females have attempted suicide
  • More than 40 % of non-binary adults have attempted suicide

The combination of a negative or distorted self-image and a severe mental health disorder like depression, or the combination of a mental health disorder and the societal pressures and discrimination received by transgender people, put an already at-risk group of communities even further at risk.  With the already high risk of medical complications resulting in fatalities that are associated with anorexia nervosa and other eating disorders, this creates the need for specialized, intersectional strategies for anorexia treatment in the transgender population.

Anorexia Nervosa Treatment, Dysphoria, and Dysmorphia

The high occurrence of health and suicide risks present in people with, respectively, anorexia nervosa, body dysmorphia and gender dysphoria mean that combined treatment plans must be designed with sensitivity.  Typically, experts at anorexia nervosa treatment centers have plenty of experience with treating co-occurring eating disorders and body dysmorphia; as mentioned before, a distorted body image is a very common occurrence in cases of anorexia nervosa and bulimia nervosa.  A personally designed treatment plan including psychiatric treatment (if necessary) with body positivity training and behavioral therapy like Dialectical Behavior Therapy (DBT) or Cognitive Behavioral Therapy (CBT) can help people rehabilitate their body image and break out of the repeated patterns of behavior that come with both eating disorders and body dysmorphia.

While the journey to eating disorder recovery is rarely an easy one, it can be made even more difficult when added to the societal pressure and stigma associated with a transgender identity. The professional team of doctors, nurses, therapists, and psychiatrists treating a transgender individual must take into account factors beyond those which normally accompany a diagnosis of anorexia nervosa or another eating disorder. These include:

• Hormone treatments

For some extreme cases of anorexia nervosa, hormone therapy is used to counteract osteoporosis and other symptoms coming from a nutritional deficiency. For transgender individuals who have begun hormone treatments to hasten their transition, medical professionals must coordinate these two type of hormone treatments to meet the client’s needs.

• Body dysmorphia treatment without judgment

At the center of any effective treatment program for a trans person with an eating disorder has to be a strong understanding that gender dysphoria is not a mental health disorder.  Trans people are already at higher risk for developing body dysmorphia disorder and subsequently an eating disorder, and they face enough discrimination that they are less likely to seek medical care or psychiatric care. They need a care provider which can treat the actual disorders with sensitivity to gender dysphoria.

• Gender-specific treatment

Quite often, people seeking eating disorder treatment are more comfortable among their own gender (the distorted perceptions of “attractiveness” or past triggers of abuse are common reasons behind this), and this remains true in the trans population.  The person’s true gender must be accounted for and their wishes respected during treatment.  For example, a non-binary trans person may be uncomfortable in a female-only treatment program.  For this reason, an anorexia treatment center should be flexible enough to accommodate each client’s needs as regard gender identity.

Achieving a Full Recovery Regardless of Gender

At Monte Nido, we believe that every person deserves to find hope that their eating disorder can be treated, and a full recovery can be achieved. The compassionate, empathetic staff at each of our many locations are experienced in helping people of all genders regain their lives and move on to a brighter future, free of disordered body image.  If you or a loved one has received a diagnosis of an eating disorder, or simply feel you need help, contact us today to get started on the gender-affirming path to a recovered life.