In our service at Newbridge, we have experience of working with young people who have an eating disorder together with a gender identity which is different to their assigned identity from birth (or expressed difficulties with their biological gender). The relationship between the experience of transgender people and eating disorders is not yet fully understood, but through our work with a small cohort of patients, we can make some observations about issues raised and the treatment pathway.

Puberty delay

In the UK, the current average age for the onset of puberty is age 11 for girls and age 12 for boys (with a pattern of average onset becoming progressively younger over time).  Puberty is defined as delayed in girls if there is no menstruation by the age of 16 and no breast development by age 13. In boys, puberty is considered to be delayed if there are no signs of testicular development by the age of 14.

One of the many different causes for puberty to be delayed is anorexia nervosa. This is because in a state of severe undernourishment, the body chooses which functions are essential to life, shutting down less critical functions. The hypothalamus, the part of the brain which regulates functions suppresses the hormonal fluctuations which regulate sexual development and puberty. In girls, this is expressed by what is described as primary amenorrhea (periods not starting by the age of 16), or in girls who have started to menstruate, secondary amenorrhea (periods are missed for three consecutive months). In boys, the impact on puberty and sexual development may not not be as easily recognisable but is likely to manifest in delayed or slow progression of puberty, reduced sexual drive and poor height gain.

The challenge of puberty and identity

It is widely recognised that the onset of adolescence and puberty is a time of change, search for identity and often, increased anxiety and conflict. If gender identity is difficult and being explored or challenged, this may be expressed in the adolescent’s relationship with food. A young person may deliberately restrict food intake in order to delay puberty because of gender identity issues. The precise causal relationship between gender identity, food restriction and anorexia nervosa will vary for each individual and require careful assessment.

For other young people, the connection may be unclear; there is disordered eating and difficulty with food as part of other challenges the young person is experiencing, and these challenges may include gender identity.

Treatment approach

A key principle is that any decisions about gender identity cannot be taken at a low weight because cognitions are impaired. Our focus is to provide wide-ranging, personalised support for the young person as they weight restore. We have links with the Tavistock Clinic, London, who are the recognised national specialists in gender identity support and treatment. Our focus is upon safe and supported weight restoration before gender assignment treatment and decisions.