Although, by 2013, there was research documenting that a significant number of natal males experienced gender dysphoria that began during or after puberty, there was little information about this type of presentation for natal females [5]. Athletes and eating disorders tend to go hand in hand, especially the sports where weight is a competitive factor. We are psychologists, social workers, doctors, medical ethicists, and academics. In follow up studies on this topic, an even wider variety of recruitment sources should be attempted. Neurosyphilis: Considerations for a Psychiatrist. The argument to surface from this study is not that the insider perspectives of AYAs presenting with signs of a rapid onset of gender dysphoria should be set aside by clinicians, but that the insights of parents are a pre-requisite for robust triangulation of evidence and fully informed diagnosis. We come from diverse backgrounds, some with expertise in child development and psychology, some who were themselves extreme gender non-conforming children and adolescents, some whose own children have self-diagnosed as ‘trans’ and some who know supportive trans adults who are also questioning recent theories of ‘transgenderism’” [49]. [47] However, dissatisfaction with body shape is not of diagnostic significance as it is sometimes present in individuals with no eating disorder. Aquí nos gustaría mostrarte una descripción, pero el sitio web que estás mirando no lo permite. Thus, while the focal AYAs did not experience childhood gender dysphoria, the majority of those who were the focus of this study were indeed gender dysphoric at the time of the survey completion. [301] Rates of death in bulimia and other disorders are similar at about a 2 fold increase. [133], To try to address unhealthy body image in the fashion world, in 2015, France passed a law requiring models to be declared healthy by a doctor to participate in fashion shows. Most of the parents (80.9%) answered affirmatively that their child’s announcement of being transgender came “out of the blue without significant prior evidence of gender dysphoria.” Respondents were asked to pinpoint a time when their child seemed not at all gender dysphoric and to estimate the length of time between that point and their child’s announcement of a transgender-identity. She learned things to say that would push our buttons and get what she wanted and she has told us now that she learned that from trans discussion sites.”, https://doi.org/10.1371/journal.pone.0202330.t007, Parents identified the sources they thought were most influential for their child becoming gender dysphoric. Some researchers also use the terminology “assigned at birth”.). Just as friendship cliques can set the level of preoccupation with one’s body, body image, weight, and techniques for weight loss [37–39], so too may friendship cliques set a level of preoccupation with one’s body, body image, gender, and the techniques to transition. ).Washington, DC: National Academies Press. In 2014, the IOC published a consensus statement entitled ‘Beyond the Female Athlete Triad: Relative Energy Deficiency in Sport (RED-S)’. Moreover, the need for accurate scales and tele-medicine testing and diagnosis is of high importance during the COVID-19 pandemic as youth are at particular risk being psychologically affected due to disrupted education and social interactions - at a critical time. "Teen girls' concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior", says psychologist Eleanor Mackey of the Children's National Medical Center in Washington and lead author of the study. A 14-year-old natal female and three of her natal female friends are part of a larger friend group that spends much of their time talking about gender and sexuality. The findings that the majority of clinicians described in this study did not explore trauma or mental health disorders as possible causes of gender dysphoria or request medical records in patients with atypical presentations of gender dysphoria is alarming. [147] Similar to studies conducted on Polynesian groups, ethnic Fijian traditional aesthetic ideals reflected a preference for a robust body shape; thus, the prevailing ‘pressure to be slim,’ thought to be associated with diet and disordered eating in many Western societies was absent in traditional Fiji. All our academic papers are written from scratch. We feel she was highly influenced by the ‘if you are even questioning your gender-you are probably transgender’ philosophy…In the ‘real world’ her friends, other trans peers, and newfound popularity were additional areas of reinforcement.” Another respondent described the online influence as part of a different question, “I believe my child experienced what many kids experience on the cusp of puberty—uncomfortableness!—but there was an online world at the ready to tell her that those very normal feelings meant she's in the wrong body.”. Respondent accounts of clinicians who ignored or disregarded information (such as mental health symptoms and diagnoses, medical and trauma histories) that did not support the conclusion that the patient was transgender, suggests the possibility of motivated reasoning and confirmatory biases on the part of clinicians. [One of them] was [then] bullied, harassed and denounced online.”, Parents observed the behaviors both in-person and in online settings, and specifically mentioned seeing posts and conversations on Tumblr, Twitter, Facebook, and Instagram. In the 1990s, the beliefs and practices of many mental health professionals may have contributed to their patients’ creation of false childhood memories consistent with a child sexual abuse narrative and research since then has shown that false childhood memories of mundane events can be implanted in laboratory settings [65–67]. A child's perception of external pressure to achieve the ideal body that is represented by the media predicts the child's body image dissatisfaction, body dysmorphic disorder and an eating disorder. A grounded theory approach was selected as the analytic strategy of choice for handling the qualitative responses because it allowed the researcher to assemble the data in accordance with the salient points the respondents were making without forcing the data into a preconceived theoretical framework of the researcher’s own choosing [58]. Eating disorders among individuals that participate in competitive activities, especially women, often lead to having physical and biological changes related to their weight that often mimic prepubescent stages. [47] In contrast, a necessary diagnostic feature for anorexia nervosa and bulimia nervosa is having overvalued ideas about shape and weight are relatively stable and closely related to the patients’ low self-esteem. This page was last edited on 12 March 2021, at 00:57. The purpose of this descriptive, exploratory research is to (1) collect data about parents’ observations, experiences, and perspectives about their AYA children showing signs of a rapid onset of gender dysphoria that began during or after puberty, and (2) develop hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among this demographic group. Of the 23 individuals who had a psychiatric diagnosis made within two years of assuming a transgender-identification, 91.3% (21/23) were diagnosed with depression; 73.9% (17/23) with anxiety; 26.0% (6/23) with bipolar disorder; 17.4% (4/23) with borderline personality disorder; 8.7% (2/23) with psychosis/psychotic episode: and 8.7% (2/23) with an eating disorder. This will cause the individual to begin feeling faint, drowsy, and weak. 2. Women are more likely than men to acquire an eating disorder between the ages of 13–25. Two types of gender dysphoria studied include early-onset gender dysphoria, where the symptoms of gender dysphoria begin in early childhood, and late-onset gender dysphoria, where the symptoms begin after puberty [11]. If our daughter wanted to be male, then that was enough.” And a third parent said. [299], Eating disorders result in about 7,000 deaths a year as of 2010, making them the mental illnesses with the highest mortality rate. Additionally, per parent report, almost half of the AYAs withdrew from family, 28.5% refused to speak to a parent, and 6.8% tried to run away. Two questions about the AYAs’ ability to cope with negative and strong emotions were included. Late-onset gender dysphoria that occurs during adolescence is now called adolescent-onset gender dysphoria. A total of 63.8% of the parents have been called “transphobic” or “bigoted” by their children for one or more reasons, the most common being for: disagreeing with the child about the child’s self-assessment of being transgender (51.2%); recommending that the child take more time to figure out if their feelings of gender dysphoria persist or go away (44.6%); expressing concerns for the child’s future if they take hormones and/or have surgery (40.4%); calling their child by the pronouns they used to use (37.9%); telling the child they thought that hormones or surgery would not help them (37.5%); recommending that their child work on other mental health issues first to determine if they are the cause of the dysphoria (33.3%); calling the child by their birth name (33.3%); or recommending a comprehensive mental health evaluation before starting hormones and/or surgery (20.8%) (Table 10). [125] Some studies have also shown a relationship between increasing body dissatisfaction with increasing SES. https://doi.org/10.1371/journal.pone.0202330.s001, https://doi.org/10.1371/journal.pone.0202330.s002. In addition to refusing food, fasting girls claimed to have special religious or magical powers. Axis II disorders are subtyped into 3 "clusters": A, B and C. The causality between personality disorders and eating disorders has yet to be fully established. Although the parent discussions and comments are not viewable to non-members [52], this group is perceived to be pro -gender-affirming. [307] Based on surveys, BED appears to affected about 1-2% at some point in their life, with 0.1-1% of people affected in a given year. It is the duty of the clinician, when seeing a new AYA patient seeking transition, to perform their own evaluation and differential diagnosis to determine if the patient is correct or incorrect in their self-assessment of their symptoms and their conviction that they would benefit from transition. [2] Rates of other eating disorders are not clear. It is possible that some teens and young adults may have requested that their discussions with the clinicians addressing gender issues be kept confidential from their parents, as is their right (except for information that would put themselves or others at harm). [307] There have been no published studies investigating the effects of BED on mortality, although it is comorbid with disorders that are known to increase mortality risks. [2] Hospitalization may be needed in more serious cases. The digitally archived screenshot from the April 2016 “About” section stated the following: “This website is a community of professionals “thinking critically about the youth transgender movement. [1] They include binge eating disorder, where people eat a large amount in a short period of time; anorexia nervosa, where people eat very little due to a fear of gaining weight and thus have a low body weight; bulimia nervosa, where people eat a lot and then try to rid themselves of the food; pica, where people eat non-food items; rumination syndrome, where people regurgitate food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons (see below); and a group of other specified feeding or eating disorders. In recent years, a number of parents have begun reporting in online discussion groups such as 4thwavenow in the US (https://4thwavenow.com) and Transgender Trend in the UK (https://www.transgendertrend.com) that their adolescent and young adult (AYA) children, who have had no histories of childhood gender identity issues, experienced a perceived sudden or rapid onset of gender dysphoria. For Ontario, Canada patients who received specialized inpatient care for an eating disorder both out of country and in province, annual total healthcare costs were about $11 million before 2007 and $6.5 million in the years afterwards. Parents reported subjective declines in their AYAs’ mental health (47.2%) and in parent-child relationships (57.3%) since the AYA “came out” and that AYAs expressed a range of behaviors that included: expressing distrust of non-transgender people (22.7%); stopping spending time with non-transgender friends (25.0%); trying to isolate themselves from their families (49.4%), and only trusting information about gender dysphoria from transgender sources (46.6%). This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, and has been especially noted in cases of coronary heart disease. [She] stated ‘none of it’ (minding what she ate and taking her Rx) ‘mattered anymore.’ This was her cure, in her opinion.”. The perspective of this site might be described as cautious about medical and surgical transition overall—specifically with a cautious or negative view of medical and surgical interventions for children, adolescents, and young adults and an accepting view that mature adults can make their own decisions about transition [2, 9]. [48][49] Studies have found that a high proportion of individuals diagnosed with body dysmorphic disorder also had some type of eating disorder, with 15% of individuals having either anorexia nervosa or bulimia nervosa. [302] The incidence of female cases is low in general medicine or specialized consultation in town, ranging from 4.2 and 8.3/100,000 individuals per year. The requirement of six-month duration of symptoms was not included. Four trials including 511 participants were studied but the review was unable to draw any definitive conclusions as to the superiority of one model over another.[291]. In three months, my daughter announced she is trans, gender dysphoric, wants binders and top surgery, testosterone shots…she started self-harming. In the same way, for the current study, recruitment was targeted primarily to sites where parents had described the phenomenon of a rapid onset of gender dysphoria because those might be communities where such cases could be found. One would expect that if a patient refuses the inclusion of information from parents and physicians (prior and current), that the clinician would explore this with the patient and encourage them to reconsider. One participant said, “Nothing other than gender dysphoria was considered to explain my daughter's desire to transition.” Another participant said, “My daughter saw a child therapist and the therapist was preparing to support transgendering and did not explore the depression and anxiety or previous trauma.”, Another theme was insufficient evaluation where parents described evaluations that were too limited or too superficial to explore mental health, trauma or alternative causes of gender dysphoria. Statement of opinions by the evil cis-gendered population are consider phobic and discriminatory and are generally discounted as unenlightened.”, In addition to targeting specific groups of people for mocking, the AYAs and their friend groups also directed mocking towards individuals in the AYAs’ lives such as parents, grandparents, siblings, peers, allies, and teachers. Several types of scales are currently used – (a) self-report questionnaires –EDI-3, BSQ, TFEQ, MAC, BULIT-R, QEWP-R, EDE-Q, EAT, NEQ – and other; (b) semi-structured interviews – SCID-I, EDE – and other; (c) clinical interviews unstructured or observer-based rating scales- Morgan Russel scale[213] The majority of the scales used were described and used in adult populations. Additionally, behaviors associated with deceiving parents and doctors about eating and weight loss, referred to as the “anorexic tricks,” are shared by patients in a manner akin to deviancy training [39–41]. He was too eager to get us set up with a ‘gender therapist’ to get the legal form he needed to start hormones, all while making sure we set up our next appointment within 6 months to start the hormones…”, Parents describe that the clinicians did not take their concerns seriously. Many AYAs have also: withdrawn from their family (45.0%); told other people or posted on social media that their parent is “transphobic,” “abusive,” or “toxic” because the parent does not agree with child’s self-assessment of being transgender (43.0%); refused to speak to their parent (28.5%), defended the practice of lying to or withholding information from therapists or doctors in order to obtain hormones for transition more quickly (16.5%); tried to run away (6.8%). A client undergoing diagnostic tests 3. Say No to Teasing: another concept is to emphasize that it is wrong to say hurtful things about other people's body sizes. The current “About” section states that requests to join the group “will be denied if you are not the parent (or immediate caregiver or family member) of a transgender, gender-fluid, gender-questioning, agender, or other gender-nonconforming child (of any age); or if you are uncooperative during screening” and that the “group is comprised of parents and parenting figures, as well as a select group of advocates INVITED by the admin[istrative] staff to assist & help us with understanding legal and other concerns” [52]. It is important to note that none of the AYAs described in this study would have met diagnostic criteria for gender dysphoria in childhood (Table 3). Men often struggle with binge eating followed by excessive exercise while focusing on building muscle rather than losing fat, but this goal of gaining muscle is just as much an eating disorder as obsessing over thinness. [145] In part, Westernization fosters eating disorders among Asian populations. [2] Treatment varies by disorder and may involve counselling, dietary advice, reducing excessive exercise and the reduction of efforts to eliminate food. There are, however, obvious limitations to relying solely on parent report. The sample of parents included more women (91.7%) than men (8.3%) and participants were predominantly between the ages of 45 and 60 (66.1%) (Table 1). And two parents described that “coming out” prevented the loss of friends explained by one respondent as “to not be trans one would not have been included in his group.”. ‘Oh, no,’ she laughed. These types of presentations have not been described in the research literature for gender dysphoria [1–10] and raise the question of whether social influences may be contributing to or even driving these occurrences of gender dysphoria in some populations of adolescents and young adults. Although this question cannot elicit specific details about a persons’ beliefs about medical interventions, beliefs about transgender identification, or their beliefs about their own child, it can be used to assess if the participants in this study are similar in their basic beliefs about the rights of transgender people to the participants in the US national poll. Other psychological problems that could possibly create an eating disorder such as Anorexia Nervosa are depression, and low self-esteem. This research sample of AYAs also differs from the general population in that it is predominantly natal female, white, and has an over-representation of individuals who are academically gifted, non-heterosexual, and are offspring of parents with high educational attainment [59–61]. [142] Further, exposure to Western values through private Caucasian schools or caretakers is another possible factor related to acculturation which may be associated with the onset of eating disorders. Funding: The author received no specific funding for this work. ", "What Psychedelics Could Mean for Eating Disorders", "Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders", "Randomized controlled trial of a treatment for anorexia and bulimia nervosa", "Stressful life events predict eating disorder relapse following remission: six-year prospective outcomes", 10.1002/(SICI)1099-0968(200003)8:2<181::AID-ERV336>3.0.CO;2-#, "Health Consequences of Eating Disorders", "Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010", "Mortality rates in patients with anorexia nervosa and other eating disorders. However, maintaining confidentiality of the patient does not prevent the clinician from listening to the medical and social history of the patient provided by the parent. Although not all research studies on gender dysphoric adolescents exclude those with adolescent-onset gender dysphoria [10], it is important to note that most of the studies on adolescents, particularly those about gender dysphoria persistence and desistance rates and outcomes for the use of puberty suppression, cross-sex hormones, and surgery only included subjects whose gender dysphoria began in childhood and subjects with adolescent-onset gender dysphoria would not have met inclusion criteria for these studies [16–24]. Representative quotes for each theme were selected by LL, reviewed by MM, and agreement was reached. The AYAs who were the focus of this study had many comorbidities and vulnerabilities predating the onset of their gender dysphoria, including psychiatric disorders, neurodevelopmental disabilities, trauma, non-suicidal self-injury (NSSI), and difficulties coping with strong or negative emotions (Table 4). here. Gelder, Mayou, Geddes (2005). [40] These websites are often interactive and have discussion boards where individuals can share strategies, ideas, and experiences, such as diet and exercise plans that achieve extremely low weights. What do you say to that? Thinning of the hair as well as dry hair and skin are also very common. It is possible that some of the participating parents may not have noticed symptoms of gender dysphoria before their AYA’s disclosure of a transgender identity; could have been experiencing shock, grief, or difficulty coping from the disclosure; or even could have chosen to deny or obscure knowledge of long term gender dysphoria. The adolescent and young adult children were, on average, 14.4 years old when their first friend became transgender-identified (Table 6). Website moderators and potential participants were encouraged to share the recruitment information and link to the survey with any individuals or communities that they thought might include eligible participants to expand the reach of the project through snowball sampling techniques. Traditional African cultural ideals are reflected in the practice of some health professionals; in Ghana, pharmacists sell appetite stimulants to women who desire to, as Ghanaians stated, “grow fat”. “Her current therapist seems to accept her self diagnosis of gender dysphoria and follows what she says without seeming too much interested in exploring the sexual trauma in her past.” Another parent wrote, “The Asperger psychiatrist did not seem to care whether our daughter's gender dysphoria stemmed from Asperger's. As to the more subtle aspects of parental influence, it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. The APA Task Force on the Treatment of Gender Identity Disorder notes that adolescents with gender dysphoria “should be screened carefully to detect the emergence of the desire for sex reassignment in the context of trauma as well as for any disorder (such as schizophrenia, mania, psychotic depression) that may produce gender confusion. [58] Other candidate genes for epigenetic studies in eating disorders include leptin, pro-opiomelanocortin (POMC) and brain-derived neurotrophic factor (BDNF). This study did not specifically explore parental approaches to gender dysphoria or parental views on medical or surgical interventions. [140] Girls are told that if they wish to find a partner and birth children they must gain weight. Statistically significant differences were revealed for AYAs with exposure to social influences having worse outcomes for mental well-being and parent-child relationships, and greater numbers exhibiting distrust, isolating and anti-social behaviors including: narrowed range of interests and hobbies, expressing that they only trusted information from transgender sources, trying to isolate themselves from their family, losing interest in activities that weren’t predominantly with transgender or LGBTIA participants, and telling people or posting on social media that their parent is “transphobic,” “abusive,” or “toxic” because the parent doesn’t agree with the child’s assessment of being transgender. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. According to Life Works an article about eating disorders "People of any age can be affected by pressure from their peers, the media and even their families but it is worse when you're a teenager at school." This study cannot speak to those details about the participants. [2] Rates of other eating disorders are not clear. The following are three quotes by three different parents describing insufficient evaluations. Methodology, Findings that may support a maladaptive coping mechanism hypothesis include that the most likely description of AYA ability to use negative emotions productively was poor/extremely poor and the majority of AYAs were described as “overwhelmed by strong emotions and tries to/goes to great lengths to avoid experiencing them.” Although these are not validated questions, the findings suggest, at least, that there is a history of difficulty dealing with emotions. It has been documented that some people with celiac disease, irritable bowel syndrome or inflammatory bowel disease who are not conscious about the importance of strictly following their diet, choose to consume their trigger foods to promote weight loss. The following quotes describe individuals targeted. Evidence from a prospective birth cohort study", "Eating Disorders in Children and Adolescents. Almost a third (31.2%) of AYAs brought up the issue of suicides in transgender teens as a reason that their parent should agree to treatment. [145] In particular, risk factors for eating disorders include higher socioeconomic status, preference for a thin body ideal, history of child abuse, high anxiety levels, hostile parental relationships, jealousy towards media idols, and above-average scores on the body dissatisfaction and interoceptive awareness sections of the Eating Disorder Inventory. Quantitative findings are presented as frequencies, percentages, ranges, means and/or medians. The higher than expected rate of non-heterosexual orientations of the AYAs (prior to announcement of a transgender-identity) may suggest that the desire to be the opposite sex could stem from experiencing homophobia as a recent study showed that being the recipient of homophobic name calling from one’s peers was associated with a change in gender identity for adolescents [63]. Inclusion criteria were (1) completion of a survey with parental response that the child had a sudden or rapid onset of gender dysphoria; and (2) parental indication that the child’s gender dysphoria began during or after puberty. On the one hand, an increase in visibility has given a voice to individuals who would have been under-diagnosed and undertreated in the past [45]. Her friends egg her on when she does this.” Another parent offered, “If they aren't mocking ‘cis’ people, they are playing pronoun police and mocking people who can't get the pronouns correct.” Another participant said, “New vocabulary includes ‘cis-stupid’ and ‘cis-stupidity.’” And a fourth participant described, “They assume anyone that is critical about being transgender (even just asking questions) is either ignorant or filled with hate.”, Participants described that their children and friend group seemed to focus on feeling as though they were victims.
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