Gender Dysphoria and Anorexia in Adolescent Females

The current trans-affirmative approach to gender dysphoria in youth is at odds with everything we know about female adolescent development.

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A new publication in Sexuologie (the journal of the German Society for Sexual Medicine, Sexual Therapy and Sexual Science/DGSMTW) takes on the issue of the sharp rise in transgender identification in adolescent females, which remains poorly understood. The authors, Korte and Gille, present an intriguing hypothesis for this novel phenomenon, comparing and contrasting gender dysphoria to anorexia nervosa, and finding a number of important similarities.

The authors conclude that clinicians working with gender-dysphoric adolescents must familiarize themselves with the complex dynamics of female adolescent development, and that trans-affirmative medical interventions should not be considered until adolescent development is complete.

Synopsis

“The development of a stable female identity in adolescence is highly complex, demanding, susceptible to disruption and accompanied by crises,” observe Korte and Gille. Female puberty presents serious challenges that every girl must find a way to navigate. Temporary crises during this stage are common as girls attempt to navigate their changing bodies and the ways families, peers, and society at large respond to these changes. The authors observe that successfully traversing this crucial phase of psychosocial and identity development requires “a high degree of willingness to change, flexibility and advanced emotional and self-regulation skills.”

When an adolescent girl fails to negotiate these challenges successfully, serious disorders, including anorexia and gender dysphoria, may arise, with psychological conflicts projecting onto the body. Either disorder may serve as an “exit strategy” employed when a girl cannot find a way to accept her developing female body. However, the diagnosis of “gender dysphoria” can offer several societal advantages in the current cultural moment:

... the trendy diagnosis of gender dysphoria or self-identification as trans offers two decisive advantages over anorexia and bulimia nervosa: first, in comparison to eating disorders, the projection surface for gender incongruence is more diverse, and the boundaries are not only sought, but crossed in a very concrete, not just symbolic way. Secondly, gender incongruence and “being trans” are currently extremely socially and politically legitimized and have been defined as a matter of human rights in recent years, which is also reflected in the planned “law of self-determination”. As a result, those affected experience strong external validation and positive reinforcement in their disorder – which, according to the proponents of a transaffirmative care, should no longer be described as such.

Korte and Gille note that “similar to anorexia, pubescent girls are offered another, albeit particularly drastic opportunity to avoid dealing with maturity-related changes and developmental tasks and to express their individual suffering in a form that is accepted in our time and culture.”

Drawing on their clinical work with such patients, Korte and Gille observe that trans identification in adolescent girls may reflect the desire to circumvent the challenges of female adolescence rather than a deep identification with maleness. They note that “although there is pronounced rejection of the female body and/or the female gender role,” there is frequently no pronounced desire for the primary or even secondary physical characteristics of the opposite sex. The authors do not assert that there is a single cause for the rise of gender dysphoria in all adolescent females. Instead, they suggest multiple pathways for the development of trans identity in adolescents, with a few common etiologies:

• Temporary adolescent maturation crisis (i.e., a result of failure in pubertal developmental tasks)

• Non-conformity with gender role expectations (i.e., the requirements, rules and norms of how girls/boys should behave in the respective culture)

• Sexuality-related problems (e.g., internalized homophobia or sexual preference peculiarities especially in male adolescents);

• Psychiatric conditions (e.g., autism spectrum disorder, trauma, personality disorder)

The authors note several similarities between anorexia and gender dysphoria. Both involve body image disorders where aggression is "turned against one’s own self, inward, but also outward, against important others." The authors note:

...in both anorexic eating disorders and gender identity disorders (gender dysphoria), relatives, especially parents, are exposed to strong feelings of helplessness and powerlessness in addition to the massive feelings of guilt and failure that often arise. In both disorders, this sometimes exacerbates the symptoms of the … patient within a correspondingly pathological relationship dynamic.

Korte and Gille conclude by outlining concrete steps that pediatricians, child and adolescent psychiatrists, gynecologists, and other medical providers can take to help girls navigate puberty in a way that averts or mitigates these developmental crises. They caution clinicians that in the vast majority of cases of gender dysphoria arising around adolescence, it is likely temporary and represents a maturation crisis or insecurity of “sexual, rather than gender identity.”

The authors criticize the “trans-affirmative” (gender-affirming) model of care for adolescents, which is focused on the provision of physical body modifications, as inconsistent with the principles of adolescent development. They highlight the importance of addressing adolescent gender dysphoria within a developmental framework, recognizing the complexity of adolescent experiences and the need for tailored interventions that address underlying conflicts and promote adaptive coping strategies.

SEGM Take-away

The German-language publication (English version here) is a brilliant and nuanced discussion of the topic of transgender identification in female adolescents. While the title “Elective Affinities” (or “Kindred by Choice”) may be confusing to English-speaking readers (the paper itself is eponymously titled Wahlverwandtschaften after a famous novel by Goethe), the authors’ nuanced exploration of the complexities surrounding female adolescent development is clear even in translation. 

The authors examine the complexities surrounding female adolescent development, including brain maturation, identity formation, and the quest for resolution during a period of dramatic developmental challenges. They propose that both gender dysphoria and anorexia nervosa should be viewed in the context of these developmental changes and opine that both conditions represent attempts to cope with developmental conflicts related to identity formation, autonomy, body image, and societal expectations.

This, in turn, suggests that the current trans-affirmative approach to gender dysphoria in youth and the focus on irreversible physical body modifications obtained before maturity has been achieved is not only at odds with adolescent development, but also may constitute direct iatrogenic harm. Clinicians caring for this population should familiarize themselves with the complexities of female adolescent development and heed the author’s advice not to “hastily collude in their use of trans-identification template.”

This article was originally published on the Society for Evidence-Based Gender Medicine’s website on March 10, 2024.

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