Exploring transgender adolescents’ body image concerns and disordered eating: Semi-structured interviews with nine gender minority youth

May combine two claims.

Casey reported binge eating to "fill" her emotional void and purging in order to avoid weight gain and maintain a boyish aesthetic.

“She reported binge eating to “fill” her emotional void and purging in order to avoid weight gain and maintain a boyish aesthetic.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Casey kept herself very thin to prevent any feminine features from developing.

“In order to emphasize the boyishness of her figure, she kept herself very thin to prevent any feminine features from developing (e.g., fleshiness in the breast/chest region).”

May combine two claims.

Casey described tying a corset so tight she could not breathe and wore it for hours to create an hourglass figure.

“For example, to create an hourglass figure, she described tying a corset so tight she could not breathe and wore it for hours.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Casey reported that just anticipating physical changes from hormone therapy helped her to feel a greater sense of control over her gender as well as increased wellbeing.

“She shared that just anticipating physical changes helped her to feel a greater sense of control over her gender as well as increased wellbeing.”

May combine two claims.

Tyler periodically tried to stop eating and strove to eat "healthy" to lose weight, noting that these behaviors were consciously driven by general body dissatisfaction prior to transition, but then continued in order to minimize feminine areas of the body.

“Tyler (genderqueer; AFAB) periodically tried to stop eating and strove to eat “healthy” to lose weight, noting that these behaviors were consciously driven by general body dissatisfaction prior to transition, but then continued in order to minimize feminine areas of the body.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Devon began questioning his gender identity in middle school, but before this time, he experienced body and mental health concerns independent of gender.

“Devon began questioning his gender identity in middle school, but before this time, he experienced body and mental health concerns independent of gender.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Devon reported seeing a psychiatrist for depression, with which he struggled since 5th grade.

“Devon reported seeing a psychiatrist for depression, with which he struggled since 5th grade.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Devon experienced significant self-loathing-especially regarding weight-until the fall of 10th grade.

“He experienced significant self-loathing—especially regarding weight—until the fall of 10th grade.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Devon perceived his desire to lose weight as independent from gender dysphoria and related more to feeling as if he did not look "aesthetically pleasing" or "cool" at a higher weight regardless of his gender presentation.

“He perceived his desire to lose weight as independent from gender dysphoria and related more to feeling as if he did not look “aesthetically pleasing” or “cool” at a higher weight regardless of his gender presentation.”

May combine two claims.

Max attempted exercising for weight loss and restricted their eating before coming out.

“Max (trans male, nonbinary; AFAB) attempted exercising for weight loss and restricted their eating before coming out.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Devon reported living with depression since elementary school, and he experienced increased appetite as a symptom.

“Devon (trans male, agender; AFAB) reported living with depression since elementary school, and he experienced increased appetite as a symptom.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Alex reported having learned to disentangle concerns about weight that were and were not related to gender, ultimately recognizing that "how I feel about my weight isn't just part of my dysphoria."

“She also reported having learned to disentangle concerns about weight that were and were not related to gender, ultimately recognizing that “how I feel about my weight isn’t just part of my dysphoria.””

May combine two claims.

Some participants described anxiety, depression, or apathy as driving their disordered eating behaviors but noted that these mental health concerns were related to their gender identity.

“Some participants described anxiety, depression, or apathy as driving their disordered eating behaviors but noted that these mental health concerns were related to their gender identity.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Alex reported that after beginning her transition, her depression and apathy lifted but she also began feeling concerned about passing.

“After beginning her transition, Alex noticed her depression and apathy lifting but also began feeling concerned about passing.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Devon mostly attributed his depression to genetics rather than gender dysphoria.

“While he acknowledged gender-related body image struggles contributed to his depression, he mostly attributed the condition to genetics rather than gender dysphoria.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Alex reported that with the resolution of her apathy came motivation to engage in disordered eating behaviors.

“While Alex’s depression had also reportedly improved since transitioning, with the resolution of her apathy came motivation to engage in disordered eating behaviors.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Jordan attributed anxiety and hopelessness to a desire for control but only mentioned gender as a contributing factor.

“Jordan (female to male, agender; AFAB) also attributed anxiety and hopelessness to a desire for control but only mentioned gender as a contributing factor.”

May combine two claims.

Alex attributed her depression to grappling with gender dysphoria, and she described occasionally not eating as a symptom.

“Alex (trans female; AMAB) attributed her depression to grappling with gender dysphoria, and she described occasionally not eating as a symptom.”

May combine two claims.

Many participants described their body-shape/weight behaviors as motivated by the goal to align their bodies with their gender identity, though each youth's behaviors were unique to their gender identity and transition.

“Many participants described these behaviors as being motivated by the goal to align their bodies with their gender identity, although each youth’s behaviors were unique to their gender identity and transition.”

May combine two claims.

Jordan reported some excessive exercising but used mainly bingeing, purging, and caloric restriction to shrink their body and detract from any gendered presentation; these behaviors occurred while Jordan identified as nonbinary, before beginning hormone therapy.

“Jordan (female to male, agender; AFAB) likewise reported some excessive exercising but used mainly bingeing, purging, and caloric restriction to shrink their body and detract from any gendered presentation; these behaviors occurred while Jordan identified as nonbinary, before beginning hormone therapy.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

While hormones had not completely resolved Casey's body dissatisfaction by the time of the interview, she described feeling less urgency to engage in weight- or shape-related behaviors.

“While hormones had not completely resolved Casey’s body dissatisfaction by the time of the interview, she described feeling less urgency to engage in weight- or shape-related behaviors.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Devon described feeling distressed about bingeing, which he described as a depressive symptom, and stated that he wished he could stop eating.

“However, he also described feeling distressed about bingeing, which he described as a depressive symptom, and he stated that he wished he could stop eating.”

May combine two claims.

For Frankie, mental health concerns were both related and unrelated to gender, and he reported restricting food and walking compulsively to relieve his unhappiness and regain a sense of "control."

“For Frankie (trans male, genderfluid; AFAB), mental health concerns were both related and unrelated to gender, and he reported restricting food and walking compulsively to relieve his unhappiness and regain a sense of “control.””

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Alex reported that when she began questioning her gender pre-transition, her dysphoria revolved mainly around her face, shoulders, and body hair; however, she did not consciously engage in disordered eating behaviors.

“Alex reported that when she began questioning her gender pre-transition, her dysphoria revolved mainly around her face, shoulders, and body hair; however, she did not consciously engage in disordered eating behaviors.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Tyler was supported by a dating partner in coming out, whereas Alex delayed coming out for fear of losing her dating partner.

“Tyler, however, was also supported by a dating partner in coming out, whereas Alex delayed coming out for fear of losing her dating partner.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Tyler stated their mother was not entirely receptive to their nonbinary gender identity or to planning top surgery.

“Tyler (genderqueer; AFAB) stated their mother was not entirely receptive to their nonbinary gender identity or to planning top surgery.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Parker, Devon, and Max discussed comparing themselves to cisgender individuals.

“Parker, Devon, and Max discussed comparing themselves to cisgender individuals.”

May combine two claims.

Max, Frankie, and Skyler reported their parents limited their ability to pursue hormone therapy and/or did not use their chosen pronouns.

“However, Max, as well as Frankie (trans male, genderfluid; AFAB) and Skyler (genderqueer; AFAB), reported their parents limited their ability to pursue hormone therapy and/or did not use their chosen pronouns.”

May combine two claims.

Tyler and Frankie reported a desire to halt puberty, as well as a growing discomfort with gendered body parts such as breasts.

“Tyler (genderqueer; AFAB) and Frankie (trans male, genderfluid; AFAB) reported a desire to halt puberty, as well as a growing discomfort with gendered body parts such as breasts.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

After embracing his trans male identity, Frankie reported letting go of these expectations, feeling greater freedom.

“However, after embracing his trans male identity, he reported letting go of these expectations, feeling greater freedom.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Max's father provided support in the form of gender-affirming clothing.

“In contrast, Max’s (trans male, nonbinary; AFAB) father provided support in the form of gender-affirming clothing.”

May combine two claims.

Coming out at school generated anxiety for Tyler as well as for Max, both of whom gained courage upon entering what they perceived to be more accepting peer groups.

“Coming out at school generated anxiety for Tyler as well as for Max, both of whom gained courage upon entering what they perceived to be more accepting peer groups.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Casey went from working hard at presenting as a feminine boy to presenting as female.

“For example, Casey went from working hard at presenting as a feminine boy to presenting as female.”

May combine two claims.

Casey reported that as she approached adolescence and puberty, she felt she could no longer suppress her gender identity; having previously engaged in disordered eating with the goal of appearing thin and boyish, she began wanting to alter her shape to appear more feminine.

“Casey (trans female; AMAB) reported that as she approached adolescence and puberty, she felt she could no longer suppress her gender identity; having previously engaged in disordered eating with the goal of appearing thin and boyish, she began wanting to alter her shape to appear more feminine.”

May combine two claims.

Devon experienced increased appetite as a symptom of depression, while Alex described occasionally not eating as a symptom of depression-which she in turn attributed to gender dysphoria.

“Devon experienced increased appetite as a symptom of depression, while Alex described occasionally not eating as a symptom of depression—which she in turn attributed to gender dysphoria.”

May combine two claims.

Parker gaining weight while taking testosterone simultaneously brought him closer to his gender identity and further from societal body ideals, leading Parker to monitor his weight more closely.

“A hallmark example is that of Parker gaining weight while taking testosterone. The hormone therapy simultaneously brought him closer to his gender identity and further from societal body ideals, leading Parker to monitor his weight more closely.”

May combine two claims.

Disordered eating and efforts toward body alteration were prevalent among our participants, and their perceived motivations for these behaviors varied.

“Disordered eating and efforts toward body alteration were prevalent among our participants, and their perceived motivations for these behaviors varied.”

May combine two claims.

Participants such as Tyler, who had not made significant progress toward transition, continued to feel dissatisfied with their bodies and harbored concerns about passing.

“Participants such as Tyler, however, who had not made significant progress toward transition, continued to feel dissatisfied with their bodies and harbored concerns about passing.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Skyler said they "guess" their recent experience with disordered eating was motivated by appearance but could not identify specific appearance-related concerns.

“Skyler said they “guess” their recent experience with disordered eating was motivated by appearance but could not identify specific appearance-related concerns.”

May combine two claims.

Despite the variation in disordered eating behaviors, disordered eating was prevalent and the factors that motivated these behaviors were complex in this participant group.

“Despite the variation in disordered eating behaviors, it is clear that disordered eating was prevalent and that the factors that motivated these behaviors were complex in this participant group.”

May combine two claims.

The interviews highlight complex associations among gender identity, gender transitioning, body image, and disordered eating during adolescence, suggesting that disentangling transgender-specific factors from other individual factors is difficult.

“The interviews highlight complex associations among gender identity, gender transitioning, body image, and disordered eating during adolescence, suggesting that disentangling transgender-specific factors from other individual factors is difficult.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Adolescence is a developmental period of heightened risk for body dissatisfaction and disordered eating.

“It is clear that the unique combination of biological changes and sociocultural pressures experienced during this time establishes adolescence as a developmental period of heightened risk for body dissatisfaction and disordered eating (Eisenberg et al., 2006; Rohde et al., 2015).”

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Probably not a substantial claim: may not pass S3 (load-bearing).

A large study of U.S. college students found transgender students were significantly more likely to report a past-year diagnosis of anorexia nervosa or bulimia nervosa and past-month compensatory behaviors than cisgender peers.

“Similarly, a large study of U.S. college students found transgender students were significantly more likely to report a past-year diagnosis of anorexia nervosa or bulimia nervosa and past-month compensatory behaviors than cisgender peers (Diemer et al., 2015).”

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Probably not a substantial claim: may not pass S3 (load-bearing).

The themes identified in cross-case analysis were reviewed by the second and fourth authors.

“These themes were then reviewed by the second and fourth authors.”

May combine two claims.

Disordered eating behaviors could be used to alleviate feelings of gender incongruence and/or align the body with one's gender identity.

“In particular, disordered eating behaviors could be used to alleviate feelings of gender incongruence and/or align the body with one’s gender identity.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A recent study of Canadian TGAs aged 14-18 found high rates of disordered eating, with up to 48% reporting a disordered eating behavior.

“For example, a recent study of Canadian TGAs aged 14–18 found high rates of disordered eating, with up to 48% reporting a disordered eating behavior (Watson et al., 2017).”

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May combine two claims.

A review of research on eating disorder symptoms and diagnoses among transgender youth ages 8-25 found significantly higher rates of symptoms compared to cisgender peers, and some studies showed a higher likelihood of eating disorder diagnoses.

“A review of research on eating disorder symptoms and diagnoses among transgender youth ages 8–25 found significantly higher rates of symptoms compared to cisgender peers, and some studies showed a higher likelihood of eating disorder diagnoses (Coelho et al., 2019).”

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Probably not a substantial claim: may not pass S3 (load-bearing).

To verify reliability, the case summaries were reviewed by the second and fourth authors.

“To verify reliability, the case summaries were then reviewed by the second and fourth authors (Ph.D. clinical psychologists who comprised the other two members of the interviewing team).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The narratives highlight interpersonal and developmental contexts.

“These narratives also highlight interpersonal and developmental contexts.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Adolescence is a period of life characterized by increased autonomy from parents and increased reliance on peers for sense of self.

“adolescence is a period of life characterized by increased autonomy from parents and increased reliance on peers for sense of self (Brechwald & Prinstein, 2011)”

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Probably not a substantial claim: may not pass S3 (load-bearing).

These normative developmental processes may affect TGAs in unique ways.

“these normative developmental processes may affect TGAs in unique ways.”

May combine two claims.

Previous case studies have also found TGAs restricting intake to conform to gender norms as well as to minimize secondary sex characteristics.

“Previous case studies have also found TGAs restricting intake to conform to gender norms (Gordon et al., 2016) as well as to minimize secondary sex characteristics (Couturier et al., 2015; Strandjord et al., 2015).”

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Probably not a substantial claim: may not pass S3 (load-bearing).

Our obtaining a waiver of parental consent allowed for a broader range of participants.

“however, our obtaining a waiver of parental consent allowed for a broader range of participants.”

May combine two claims.

While the participants represented some diversity in gender identity, fewer participants identified as transfeminine versus transmasculine, and several participants identified as both transgender on a binary scale as well as "agender," "genderfluid," "genderqueer," or "nonbinary."

“while the participants represented some diversity in gender identity, fewer participants identified as transfeminine versus transmasculine, and several participants identified as both transgender on a binary scale as well as “agender,” “genderfluid,” “genderqueer,” or “nonbinary.””

Probably not a substantial claim: may not pass S3 (load-bearing).

Prior research documents high rates of depression among TGAs.

“Given prior research documenting high rates of depression among TGAs (Connolly et al., 2016)”

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May combine two claims.

Adolescence is a time of identity exploration, and the resolution of identity has been associated with better adolescent mental health and wellbeing.

“Adolescence is a time of identity exploration (Dahl et al., 2018), and the resolution of identity has been associated with better adolescent mental health and wellbeing (Dumas et al., 2009; Schwartz & Petrova, 2018).”

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May combine two claims.

Disordered eating may be the presenting symptom in some adolescents with gender incongruence and therefore screening for gender-related concerns may be valuable in clinical assessment for eating disorders.

“This suggests disordered eating may be the presenting symptom in some adolescents with gender incongruence and therefore screening for gender-related concerns may be valuable in clinical assessment for eating disorders.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Our study protocol did not include a member checking component, so interviewees did not have an opportunity to comment on the transcripts from our interviews.

“Our study protocol also did not include a member checking component, so interviewees did not have an opportunity to comment on the transcripts from our interviews.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A separate body of work links depression and disordered eating among cisgender youth.

“a separate body of work linking depression and disordered eating among cisgender youth (e.g., Presnell et al., 2009)”

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May combine two claims.

TGAs such as Alex who are better able to transition into their desired gender identity may experience the benefits of greater emotional stability and decreased anxiety and depressive symptoms, which are seen with adolescents who reach a stage of achieved identity.

“TGAs such as Alex who are better able to transition into their desired gender identity may experience the benefits of greater emotional stability and decreased anxiety and depressive symptoms, which are seen with adolescents who reach a stage of achieved identity (Crocetti et al., 2008).”

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Probably not a substantial claim: may not pass S3 (load-bearing).

Our disproportionate number of participants assigned female at birth is consistent with recent quantitative work.

“Our disproportionate number of participants assigned female at birth is consistent with recent quantitative work (e.g., Zucker, 2017).”

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Classified as probably not a substantial claim.

The findings from this qualitative inquiry allow researchers and clinicians to learn about the lived experiences of TGAs, in their own words.

“The findings from this qualitative inquiry allow researchers and clinicians to learn about the lived experiences of TGAs, in their own words.”

May combine two claims.

The participant group included only nine participants, all of whom lived in and attended school in a specific geographic region of the United States, and the majority of whom were White.

“The participant group included only nine participants, all of whom lived in and attended school in a specific geographic region of the United States, and the majority of whom were White.”

May combine two claims.

When the adolescents in these prior cases began hormone therapy or puberty blockers, they experienced improvement in body image and a reduction in disordered eating behaviors.

“when the adolescents in these prior cases began hormone therapy or puberty blockers, they experienced improvement in body image and a reduction in disordered eating behaviors.”

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• cites Strandjord et al., 2015 sourceNot checked yet

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May combine two claims.

A TGA engaging in restricted eating behaviors may experience a combination of motivations related to masking secondary sex characteristics and adhering to sociocultural beauty norms, and/or their behaviors may be driven by broader mental health concerns such as depressive symptoms.

“a TGA engaging in restricted eating behaviors may experience a combination of motivations related to masking secondary sex characteristics and adhering to sociocultural beauty norms, and/or their behaviors may be driven by broader mental health concerns such as depressive symptoms.”

Probably not a substantial claim: may not pass S3 (load-bearing).

We did not ask adolescents questions about how their gender minority identity intersects with other minority identities.

“we did not ask adolescents questions about how their gender minority identity intersects with other minority identities.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A second interview may have facilitated prolonged engagement among participants and led to additional insights.

“a second interview may have facilitated prolonged engagement among participants and led to additional insights (Yin, 2017).”

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May combine two claims.

The factors contributing to disordered eating among TGAs may therefore present greater complexity than those among cisgender adolescents, pointing to a unique set of needs for effective detection and treatment of concurrent gender incongruence, body dissatisfaction, and disordered eating in TGAs.

“The factors contributing to disordered eating among TGAs may therefore present greater complexity than those among cisgender adolescents, pointing to a unique set of needs for effective detection and treatment of concurrent gender incongruence, body dissatisfaction, and disordered eating in TGAs.”