"While I had the sense of being male [growing up], I didn’t know that was a possibility, " says Ryan Sallans, 37, speaker, activist, and author of Second Son: Transitioning Toward My Destiny, Love, and Life.
"When I started to recognize that my body was different from how I felt, I turned to body hate," he says. "And when puberty began, as my body started to change more into the female form, I became even more scared and felt even more alien in my skin." By 18, those negative feelings had developed into anorexia nervosa.
Stories like Sallans' are distressingly common. In fact, according to recent research, the rate of eating disorders among transgender people is much higher than among cisgender people. And experts are only just beginning to understand why.
"There’s been very limited research on psychiatric health in transgender people and specifically on eating disorders in transgender people," says Elizabeth Diemer, now a graduate student at Harvard T.H. Chan School of Public Health. Her work has examined the role of gender identity and sexuality in the development of eating disorders.
In one of her recent studies, published in 2015 in the Journal of Adolescent Health, she went through a large set of health data from a survey given to students at 223 colleges and universities in the U.S. The survey asked about all kinds of health diagnoses and behaviors, including whether or not participants had been diagnosed with an eating disorder in the last year and whether or not they had engaged in any compensatory behaviors (e.g. vomiting or using diet pills or laxatives to control their weight) in the past 30 days. And, unlike the vast majority of these surveys, this one included "transgender" as a gender selection option.
"We found that transgender people were much more likely to say that they had received a diagnosis of an eating disorder in the past year," explains Alexis Duncan, MPH, Phd, senior author on the study. Indeed, almost 16% of transgender participants reported being diagnosed with an eating disorder within the last year, compared to 1.85% of cisgender heterosexual women and 0.55% of cisgender heterosexual men.
Transgender participants were also more likely to report those compensatory behaviors, suggesting that their increased rate of diagnosis isn't simply due to them seeing health professionals more often than cisgender people — they actually are suffering from the symptoms of these disorders more frequently.
One potential explanation for these drastically higher rates is that transgender people are more likely to have higher rates of body dysphoria, explains Diemer. "This [could result] in a generalized body discomfort," she says. "They then start to engage in disordered eating behaviors to try to alleviate body discomfort or conform their body to what we socially conceive of as appropriate for a female or male body."
The idea seems to make sense for Sallans. "When I moved into college, a new environment, I felt completely out of control," he says. "By the end of my freshman year, I was taking on behaviors to transform my body. I believed that if my body was skinny, people would accept me — and I could accept myself."
Another hypothesis, known as the minority stress model, suggests that those who belong to gender, sexual, or other types of minorities tend to feel more stress overall. That puts them at a higher risk for all kinds of health conditions, including eating disorders and other mental health issues. This also rings true for Sallans — especially now, as the conversation around trans issues, particularly which bathrooms people use, has become fodder for intense political controversy. He says he still feels anxious about using public restrooms, even though "no one questions me now."
But there are many other factors which determine whether or not you develop an eating disorder, says Dr. Duncan. Genetics, a history of trauma, bullying, other mental illnesses, and environmental factors (e.g. how your parents treated you) all play a role. "We're so new as a field that it’s hard for us to say that we have any factors that are really established [causes]," Diemer says.
There's even less understanding about the best way to treat eating disorders among transgender people. But it's not hard to see how facilities that are gender-specific or require patients to be monitored in the bathroom could be particularly uncomfortable — and how they could be made more inclusive — for transgender people.
As of today, Sallans hasn't engaged in disordered eating behaviors for 12 years — they stopped when he realized he was transgender — but he says he continues to struggle with the thoughts and feelings that once fueled the disorder. "The transition didn’t take that away," he says. "I’m just in a place where I feel more like myself."