Treating bulimia nervosa in the context of gender dysphoria using 10-session cognitive behavior therapy

Reviewed by Ileana Calinoiu, MD

Cibich, M. & Wade, T. D. (2019). Treating bulimia nervosa in the context of gender dysphoria using 10-session cognitive behavior therapy. International Journal of Eating Disorders, 52(5), 602-606.

https://doi.org/10.1002/eat.23068

Eating disorders (disordered eating behaviors) peak during the psychosocial developmental period of adolescence. Adolescence is also a critical developmental period for sexual orientation. Given the proximity of emergence of eating disorders and sexual orientation during this critical developmental stage, it is not surprising that eating disorders may disproportionately affect vulnerable youth, particularly sexual minority youth. Although body image distortion and disordered eating were considered to affect only a small subset of society, largely affluent females, they are now recognized to impact millions, including individuals along the sexual orientation and gender identity spectrum.  However, most research on eating disorders and body image has focused on heterosexual, cisgender individuals. The limited amount of research on sexual minority adolescents and non-binary youth suggests associations between sexual orientation and gender identity and eating-related pathology.

The focus of this article is a case report by Australian authors Cibich and Wade (2019) describing the psychological treatment for bulimia nervosa of a 16-year old with co-occurring gender dysphoria who reported restricting his food intake and purging for approximately 1 year prior to therapy commencing.

The patient was born female and identified as male. At the time of treatment, he was living as a male (e.g., using a gender-neutral name, using male pronouns, and wearing masculine clothing) and without hormonal or surgical reassignment.

He described episodes of restricting his food intake during childhood in response to stress. The patient described “always” knowing he was male.  When he was 15 years old, he began taking steps toward living as male. At the same time, his restricting progressed to binge-eating and self-induced vomiting.  He also reported a history of suicidal ideation, with one failed suicide attempt as an adolescent.

During the assessment, he reported body dissatisfaction, particularly relat­ing to his feminine body shape. He viewed restrictive eating as a means for de-emphasizing feminine fat distribution in the pursuit of a masculine physique, a motivation common but not ubiquitous among female to male patients with gender dysphoria who have an eating disorder (Ålgars, Alanko, Santtila, & Sandnabba, 2012; Duffy et al., 2016; Strandjord, Ng, & Rome, 2015).

In addition to gender dysphoria, additional diagnoses included Cannabis dependence in remission and unspecified Major Depres­sive Disorder.

Ten sessions of cognitive behavioral therapy for eating disorders (CBT-T) were conducted with accommodations for gender-specific body dissatisfaction.

Initial sessions focused on regulating the patient's food intake for nutritional adequacy. When this was established, sessions focused on using cognitive and behavioral strategies to challenge unhelpful beliefs about food and eating (i.e., behavioral experiments to test previously avoided food or food that appeared in the binge episodes), as well as body image concerns (i.e., survey to test beliefs such as “I am fat” and “I am ugly,” positivity logging, behavioral experiments to test perceived benefits of upward social comparison). The patient's beliefs relating to his feminine appearance (i.e., “I look feminine”), however, were not challenged using behavioral experiments. Instead, motivational interviewing techniques were introduced in session seven so that the patient sat with the discomfort of his feminine appearance without to engaging in eating disordered behaviors. These skills included reviewing the pros and cons, checking the facts and modified TIPP (Temperature, Intense exercise, Paced breathing and Paired muscle relaxation: Linehan, 2018). Intense exercise was not recommended to this patient given its potential for use as a compensatory behavior.

The patient eliminated binging and purging from the second treatment session and had maintained this at the 3-month follow-up. He increased the quantity and variety of foods he was eating, and in doing so challenged his beliefs that feared foods would lead to weight gain and bingeing. He reported that the feelings of shame associated with eating had reduced and this change was also reflected in an elimination of subjective binges. In relation to body image concerns, he successfully reduced the frequency he compared himself to masculine males (his desired ideal) and became less concerned with what others were thinking about his appearance. He also reported that he was more easily able to sit with the discomfort associated with his feminine body type.

Why is this important?

The existing literature suggests that LGBT youth are particularly vulnerable to eating disorders and body dissatisfaction. Because of this, medical providers should screen for disordered eating in LGBT youth and should know that effective treatments are available. Sexual minority males have greater body dissatisfaction, and more frequently report unhealthy weight control practices, disordered eating behaviors, and classic eating disorders. Transgender individuals are also at risk of eating disorders. Furthermore, disordered eating in LGBT and non-binary youth may be associated with poorer quality of life and mental health outcomes.

This case report suggests treatments already available for eating disorders may be suitable for this population with accommodations for gender-specific body dissatisfaction.

In addition, the case report draws attention to a growing topic of debate in the LGBTQ and eating disorders recovery circles centered around gender dysphoria, body dysmorphia and their relationship to clinical diagnoses of a mental health disorder.  Even beyond the similarity in 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.  Understanding gender dysphoria is essential to helping this higher-risk community get the help they need because 7% female-to-male and 3% male-to-female individuals with gender dysphoria meet criteria for a comorbid eating disorder (Feder, Isserlin, Seale, Hammond & Norris, 2017), and the reported fears and difficul­ties of those with gender dysphoria seeking psychological treatment for eating disor­ders.

More research is needed to determine whether there are specific interventions or targets for sexual minority youth that may be most effective; for now, treatment should focus on therapies that have empiric support in generalized youth populations.