Eating Disorders In Transgender And Gender Diverse Youth

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10/9/2020 Eating Disorders in Transgender and Gender Diverse Youth Anderson Still, MD (He/him/his) Attending Psychiatrist Department of Child and Adolescent Psychiatry and Behavioral Sciences The Children’s Hospital of Philadelphia 1 Objectives for Today Overview of diagnostic criteria for eating disorders Review data on eating disorders in transgender youth and relevant information regarding diagnosis, treatment and special considerations Understand basics of Family Based Treatment for Eating Disorders and considerations for trans population Understand role of multidisciplinary care in supporting this population 2 Diagnostic Criteria 3 1

10/9/2020 DSM-5: Feeding and Eating Disorders Pica Rumination Disorder Anorexia Nervosa Restricting Type Binge/Purge Type Bulimia Nervosa Avoidant/Restrictive Food Intake Disorder Binge Eating Disorder Other Specified Feeding or Eating Disorder Unspecified Feeding or Eating Disorder 4 Anorexia Nervosa (AN): Basic Criteria A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on selfevaluation, or persistent lack of recognition of the seriousness of the current low body weight. 5 Anorexia Nervosa: Subtypes Binge-Eating/ Purging Type Restricting Type During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Level of Severity -BM I Percentile in Children 6 2

10/9/2020 Anorexia Nervosa: Key Facts Lifetime Prevalence: 1% for cis women Female/Male ratio: Peak incidence: 10:1 15-19 yrs for women 10-24 yrs for men Standardized mortality ratio (SMR ratio of observed to expected deaths) In comparison Recovery: 50-60% recover 30% improved 7-15% chronic course SMR for AN 5.86 (about 20% due to suicide). Highest of any psychiatric disorder. SMR for schizophrenia 2.8 for males and 2.5 for females SMR for bipolar disorder 1.9 for males and 2.1 for females SMR for unipolar depression 1.5 7 Bulimia Nervosa (BN): Basic Criteria A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most indiv iduals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control ov er eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. 8 Bulimia Nervosa: Basic Criteria continued C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. 9 3

10/9/2020 What constitutes a binge? Three principles Objective binge eating Subjective binge eating Context of binge eating Actual quantity of food Personal feeling about quantity of food The amount of food consumed is larger than what would be expected for the context in which it occurred (e.g., Thanksgiving) Level of Severity -Based on frequency of compensatory behaviors 10 Bulimia Nervosa: Key Facts Lifetime Prevalence: 1.5 -3% Female/Male Ratio: Peak incidence: 10:1 16-20 years old in women Recovery: Short-term success of treatment: 50-70% High relapse rates 30-85% at 6 months-6 years Standardized mortality ratio (SMR) 1.9 ( 20% due to suicide) 11 Avoidant/Restrictive Food Intake Disorder (ARFID) A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by the persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following: 1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children). 2. Significant nutritional deficiency. 3. Dependence on enteral feeding or oral nutritional supplements. 4. Marked interference with psychosocial functioning. B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice. C. The eating disturbance does not occur exclusively during the course of AN or BN, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced. 12 4

10/9/2020 Binge Eating Disorder (BED): Basic Criteria A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most indiv iduals would eat in a similar period of time under similar circumstances. 2. A sense of lack of control ov er eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). This is exactly the same as for bulimia nervosa, but without compensatory behaviors. 13 Binge Eating Disorder: Basic Criteria continued B. The binge-eating episodes are associated with 3 (or more) of the following: 1. Eating much more rapidly than normal 2. Eating until feeling uncomfortably full 3. Eating large amounts of food when not feeling physically hungry 4. Eating alone because of feeling embarrassed by how much one is eating 5. Feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for 3 months. E. Not part of AN/BN 14 Binge Eating Disorder: Key Facts Lifetime Prevalence: Age of onset: teens-20s (retrospective data) Strong association with obesity High rates of medical and psychiatric comorbidities 3% women 2% men Level of Severity Most often based on frequency of binges Mild, Moderate, Severe, Extreme 15 5

10/9/2020 Rates of Eating Disorders in Trans Youth Limited data regarding rates of EDs in this population Study of almost 2,500 high school students Transgender students had highest prevalence of diet pill and laxative use (4.8%) Fasting 24 hours in last 30 days (9.5%) Similar to cisgender female students 16 Rates of Eating Disorders in Trans Youth Diemer et al, 2015 Roughly 290,000 college students Transgender Students: 4.6 times more likely to be diagnosed with an Eating Disorder in the last year vs cisgender heterosexual women (15.82%) Roughly 2 times more likely to use diet pills in the last month Roughly 2.4 times more likely to engage in vomiting or laxative use in the last month Limitations No breakdown in transgender females vs males No breakdown regarding specific ED diagnosis 17 Etiology: Eating Disorders Unknown, but likely Multifactorial Biological Psychological Familial/Social Sociocultural Why could rates be elevated in trans youth? 18 6

10/9/2020 Etiology: Eating Disorders in Trans and GNC Youth Important to Note First: Although they are risk factors, sexual orientation and gender identity concerns are neither necessary nor sufficient to cause eating disorders Most transgender or gender diverse youth never develop an eating disorder Those that do are likely influenced by same genetic and neurobiologic vulnerabilities as their peers 19 Theorized Factors Specific to Transgender Population Body Image/Dissatisfaction Minority Stress Higher rates of harassment and discrimination linked to higher odds of binge eating and fasting or vomiting Protective Factors: family and school connectedness, social support, caring friends Non-affirmation of Gender Identity Increased Contact with MH providers? 20 Body Image/Dissatisfaction Body image plays a central role in both Gender Dysphoria and Eating Disorders Association between body dissatisfaction and Gender Dysphoria Lower congruence between external and internal representations of self associated with lower body satisfaction (Kozee et al, 2012) Area of Focus Sex-specific body parts vs all gender-related parts Latter may be associated with increased risk of disordered eating 21 7

10/9/2020 Body Image/Dissatisfaction Effects of GD Treatment Bandini et al, 2013 Trans individuals who had not received any genderaffirming surgeries had levels of body uneasiness similar to those with EDs De Vries et al, 2011/2014, Jones et al 2018 Decreased body dissatisfaction and ED symptoms after beginning of hormone treatment De Vries - Additional improvement 1 year after gender-affirming surgery Addressing body image Psychological and social aspect Challenging negative thoughts, positive reframing, challenging perceived negative reactions from society 22 Body Image and Disordered Eating Witcomb et al, 2015 Trans, ED, control populations Results: Body Dissatisfaction: ED trans control Cis female TMS Cis male and TFS TMS ED cis males Disordered Eating TMS TFS participants cisgender participants However, still lower than ED patients TMS - highest risk 23 Trans Patients’ Perceived Causes of Disordered Eating 35% - Suppression of characteristics associated with non-identified gender 21% - Accentuation of characteristics associated with identified gender Other Noted Causes Being an outcast Feelings of control Expression of autonomy 24 8

10/9/2020 Relationship between Gender Identity and ED Testa et al, 2017 25 Presentation and Screening 26 Assessment Considerations for Trans Patients M ay appear in either ED treatment or GD treatment setting If you don’t ask, you won’t know Important to assess for gender concerns in adolescents with EDs and eating concerns during and after GD treatment Trans youth – body dissatisfaction, eating ED patients – Underlying motivations Clinical Presentation (AN) Thinness vs Muscularity Eating Disorders can be severe and enduring Very important to continue assessing/screening 27 9

10/9/2020 Screening Questions Donaldson AA, Hall A, Neukirch J, et al., 2018 28 Treatment 29 Treatment for AN Weight Restoration Cornerstone of treatment for low weight patients Psychotherapy Family-Based Treatment (FBT) Adolescent-Focused Therapy Cognitive Behavioral Therapy (CBT)– for adults Pharmacotherapy Not primary treatment Possibly helpful in comorbid conditions M ixed data with antipsychotics Aripiprazole and Olanzapine most commonly used No evidence for appetite stimulants Appetite reducers should be avoided 30 10

10/9/2020 Treatment for BN Psychotherapy CBT (gold standard in adults) FBT Interpersonal Therapy (IPT) Dialectical Behavioral Therapy (DBT) Self-help Nutritional counseling Possibly helpful (but not supported in the literature) Pharmacotherapy Fluoxetine (Prozac) FDA approved All SSRIs used 31 Common Components of Effective ED Interventions Psycho-Education and Psychotherapy True mainstay No medication has been shown to be equivalent to psychotherapy in the treatment of eating disorders Behavioral interventions Weight checks Self-monitoring of intake and eating disorder behaviors (e.g., binge eating, purging, exercise) with daily logs For low weight, emphasis on weight restoration 2-3 lb/wk inpatient or 1-2 lb/wk outpatient 32 “Maudsley Model” Family-Based Treatment (FBT) Developed at the M audsley Hospital in London Manualized by Jim Lock and Daniel Le Grange Designed to be delivered for a 6-12 month period with 10-20 sessions total. Assumptions Adolescent is embedded in the family Adolescent with AN is regressed Family must focus on refeeding to free adolescent from eating disorder The goal of M audsley family therapy is to mobilize and empower parents to refeed their child Family issues unrelated to the eating disorder are deferred 33 11

10/9/2020 Who Benefits from FBT? Adolescents with a short duration of AN ( 3 years) Older adolescents (aged 17 years) and those with a longer duration of illness don’t do as well Family must be willing to invest the time and effort necessary to refeed an underweight child Parents and siblings need to be on-board Greatest benefit in those who respond quickly (within first 4 weeks) 34 Members of the Treatment Team Primary clinician: Therapist experienced in the treatment of adolescent eating disorders, e.g., social worker, psychologist, psychiatrist Consultants: Medical providers, dietitian Family Patient Other Medical/BH providers First and foremost, team members need to be on the same page (and communicate!) 35 Role of the Medical Provider Help establish diagnosis Identify any acute and chronic medical complications and treat as appropriate Explain medical seriousness of ED to family Consultant to parents – empower to make decisions for their child Consultant to primary therapist – update on medical status and family interactions Assess safety, need for hospitalization if necessary 36 12

10/9/2020 Treatment Considerations for Trans/Gender Diverse Youth Family Support Considerations Utilize non-parental family and friends Priority of Treatment? ED ”versus” GD treatment? Addressing body dissatisfaction Need for more research 37 Treatment Considerations for Trans/Gender Diverse Youth Growth Curve? 38 Treatment Considerations for Trans/Gender Diverse Youth In the end, it’s most important for clinicians to focus on effective treatment in an affirming environment Good news: Recovery is possible with effective specialist treatment 39 13

10/9/2020 Questions? 40 Thanks!! 41 Resources Fairburn, C. (2008). Cognitive Behavior Therapy and Eating Disorders. Guilford Press Fairburn, C. (2013). Overcoming Binge Eating (2 nd Edition). Guilford Press Le Grange & Lock. (2007). Treating Bulimia in Adolescents: A Family-Based Approach. Gurze Books. Le Grange, D. & Lock, J. (2005). Help Your Teenager Beat An Eating Disorder. Guilford Press. Lock, J. & Le Grange, D. (2013). Treatment Manual for Anorexia Nervosa: A Family Based Approach (2 nd Edition). Guilford Press. Treasure, J., Smith, G., & Crane, A. (2007). Skills-based Learning for Caring for a Loved One with an Eating Disorder. Routledge Walsh, B.T., & Cameron, V.L. (2005). If Your Adolescent Has an Eating Disorder: An Essential Resource for Parents. Oxford University Press. 42 14

10/9/2020 Resources, continued UPMC Center for Eating Disorders:; ng-disorders/why-upmc/Pages/default.aspx *Inclusion on t he list below does not mean we are endorsing t hese sit es. CED is not responsible for t he cont ent of t hese sit es. AED – Academy For Eating Disorders NEDA - National Eating Disorders Association ANAD - National Association of Anorexia Nervosa and Associated Disorders ANRED – Anorexia Nervosa and Related Eating Disorders NAMI – National Alliance for the Mentally Ill NIMH -National Institute of Mental Health fm EDAP - Eating Disorders Awareness & Prevention Eating Disorder Referral and Information Center Maudsley Parents The New Maudsley Approach 43 References 44 1. Campbell K and Peebles R. Eating Disorders in Children and Adolescents: State of the Art Review. Pediatrics. 2014; 134 582-592. 2. Heaner MK and Walsh, BT. A history of the identification of the characteristic eating disturbances of Bulimia Nervosa, Binge Eating Disorder and Anorexia Nervosa. Appetite 65 (2013) 185–188. 3. Martine F. Flament, Hany Bissada, and Wendy Spettigue. Evidence-based pharmacotherapy of eating disorders. International Journal of Neuropsychopharmacology (2012), 15, 189–207. 4. Mehler P.S. and Andersen A. E. (2010) Eating Disorders: A Guide to Medical Care and Complications (2nd edn) Johns Hopkins University Press: Baltimore. 5. National Collaborating Centre for Mental Health 2004: Eating Disorders Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. 6. Walsh BT and Boudreau G. Laboratory Studies of Binge Eating Disorder. Int J Eat Disord. 2003; 34 Suppl:S30-8. 7. Watson HJ and Bulik CM. Update on the treatment of anorexia nervosa: review of clinical trials, practice guidelines and emerging interventions. Psychological Medicine. March 2013, pp 1- 24. 8. Yager J and Anderson AE. Anorexia Nervosa. N Engl J Med 2005; 353:14811488. 9. Yanovski SZ, Leet M, Yanovski JA, Flood M, Gold PW, Kissileff HR, Walsh BT. Food selection and intake of obese women with binge-eating disorder. Am J Clin Nutr. 1992 Dec;56(6):975-80. Erratum in: Am J Clin Nutr 1993 Mar;57(3):456. 45 15

10/9/2020 11. Monica Ålgars, Katarina Alanko, Pekka Santtila & N. Kenneth Sandnabba (2012) Disordered Eating and Gender Identity Disorder: A Qualitative Study, Eating Disorders, 20:4, 300311, DOI: 10.1080/10640266.2012.668482 12. Bethany Alice Jones, Emma Haycraft, Sarah Murjan, Jon Arcelus. (2016) Body dissatisfaction and disordered eating in trans people: A systematic review of the literature. International Review of Psychiatry 28:1, pages 81-94. 13. Şenol Turan, Cana Aksoy Poyraz, Nazife Gamze Usta Sağlam, Ömer Faruk Demirel, Özlem Haliloğlu, Pınar Kadıoğlu, Alaattin Duran. (2018) Alterations in Body Uneasiness, Eating Attitudes, and Psychopathology Before and After Cross-Sex Hormonal Treatment in Patients with Female-to-Male Gender Dysphoria. Archives of Sexual Behavior 160. 14. Elizabeth W. Diemer, Jaclyn M. White Hughto, Allegra R. Gordon, Carly Guss, S. Bryn Austin, Sari L. Reisner. (2018) Beyond the Binary: Differences in Eating Disorder Prevalence by Gender Identity in a Transgender Sample. Transgender Health 3:1, pages 17-23. 15. Bethany Alice Jones, Emma Haycraft, Walter Pierre Bouman, Nicola Brewin, Laurence Claes, Jon Arcelus. (2018) Risk Factors for Eating Disorder Psychopathology within the Treatment Seeking Transgender Population: The Role of Cross-Sex Hormone Treatment. European Eating Disorders Review 26:2, pages 120-128. 16. Sarah E. Strandjord, Henry Ng, Ellen S. Rome. (2015) Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned. International Journal of Eating Disorders 48:7, pages 942-945. 17. Gemma L. W itcomb, Walter Pierre Bouman, Nicola Brewin, Christina Richards, Fernando Fernandez-Aranda, Jon Arcelus. (2015) Body Image Dissatisfaction and Eating-Related Psychopathology in Trans Individuals: A Matched Control Study. European Eating Disorders Review 23:4, pages 287-293. 18. Elisa Bandini, Alessandra Daphne Fisher, Giovanni Castellini, Carolina Lo Sauro, Lorenzo Lelli, Maria Cristina Meriggiola, Helen Casale, Laura Benni, Naika Ferruccio, Carlo Faravelli, Davide Dettore, Mario Maggi, Valdo Ricca. (2013) Gender Identity Disorder and Eating Disorders: Similarities and Differences in Terms of Body Uneasiness. The Journal of Sexual Medicine 10:4, pages 1012-1023. 19. U. Hepp, G. MilosGender identity disorder and eating disorders. Int J Eat Disord, 32 (2002), pp. 473-478 46 20. Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students. Journal of Adolescent Health, 57(2), 144-149. DOI: 10.1016/j.jadohealth.2015.03.003 21. Guss CE, Williams DN, Reisner SL, et al. Disordered weight management behaviors and nonprescription steroid use in Massachusetts transgender youth. J Adolesc Health 2016;58:S102– S103. 22. Donaldson AA, Hall A, Neukirch J, et al. Multidisciplinary care considerations for gender nonconforming adolescents with eating disorders: A case series. Int J Eat Disord. 2018;51:475– 479. 23. Jones, B. A., Haycraft, E., Murjan, S., & Arcelus, J. (2016). Body dissatis-faction and disordered eating in trans people: A systematic review of literature. International Review of Psychiatry, 28(1), 81–94. 24. Murray, S. B., Boon, E., & Touyz, S. W. (2013). Diverging eating psychopathology in transgendered eating disorder patients: A report of two cases. Eating Disorders 21(1), 70–74. 47 16

Binge Eating Disorder: Basic Criteria continued B. The binge-eating episodes are associated with 3 (or more) of the following: 1. Eating much more rapidly than normal 2. Eating until feeling uncomfortably full 3. Eating large amounts of food when not feeling physically hungry 4. Eating alone because of feeling embarrassed by how much one is .

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