CASE 1 (fig. 1)
Case 1 was a 35-year Japanese MtF transsexual patient with bulimia nervosa. Fourteen years had passed since she had undergone GRS and hormonal treatment when she visited our department to seek treatment for her eating disorder. During her early childhood, she already felt that she belonged to the other sex. When she was 12 years, she noticed that her breasts were growing. She was suspected of having a sex development disorder by a pediatrician, but she refused to undergo further examinations. With regard to the fluctuation of her body weight before the GRS, we confirmed that the onset of her eating disorder was not before the GRS. She used to like eating when she was under 10 years old. However, the gradual decrease of her weight was due to the decrease of the amount of her food intake. She said that she had not dieted and she had not cared care much about her body shape and image before the GRS. Therefore, the onset of her eating disorder was after the GRS.
During her adolescence, she had an ongoing gender identity problem. She started taking hormonal treatment using estrogen at the age of 19 years, and several months later she underwent GRS. In addition, she legally changed her first name to a female one at the age of 20 years. At that time, her weight was 80 kg and height 1.71 m (body mass index, BMI, 27.4 kg/m2), and binge eating or self-induced vomiting had never occurred to that point in time.
By undergoing GRS, her primary goal should have been achieved. However, she realized that she was not capable of pregnancy and abandoned herself to despair, which led her to binge eating and self-induced vomiting. One of the reasons she was not able to stop these pathological eating behaviors was that she could never disclose her sexual dysphoria, even to her partner, friends, or colleagues. Although her parents knew her situation, she did not want to bother them. When she was not able to stop binge eating, her weight became 100 kg (BMI, 30.9 kg/m2), at 27 years. On the other hand, when her self-induced vomiting was dominant, her minimum weight was 57 kg (BMI: 19.5 kg/m2), at 30 years. At 30 years, she had a male partner. However, she broke up with him because she was not able to disclose her gender problem and the fact that she was infertile. After she broke up with her partner, she was not able to control binge eating.
She worked as a secretary from 20 to 33 years. However, she had resigned from the job six months before she visited our department for the first time, because she had to spend a lot of time binge eating and she was emotionally unstable due to her fear of becoming fat.
At her first visit to our department at 33 years, her weight was 90 kg (BMI, 30.9 kg/m2). Her chief complaint was binge eating and self-induced vomiting once or twice every day. Her symptoms included fear of becoming fat and distorted body image. There was no significant past medical history, psychiatric history, or family history at the time of diagnosis.
She was admitted to the hospital to improve her eating behavior on two different occasions for two weeks each time. Then, she continued to receive outpatient treatment for bulimia nervosa in our department and hormonal treatment by a gynecologist. She said that hormonal treatment was one of the most important things in her life. Although she lives as a woman now receiving GRS and hormonal treatment, she still has episodes of binge eating, self-induced vomiting, and food restriction due to the psychological stress about gender identity.
Overall, there were three turning points about her eating disorder symptoms (Fig. 1). The first point was after GRS. She realized new gender problems and she started binge eating and self-induced vomiting. The second point was when she broke up with her partner. Then, her binge eating worsened because she could not disclose her gender problem to her partner. The third point was when she resigned from her job due to psychological stress from misunderstandings about gender dysphoria by her colleagues and to exacerbation of binge eating. She was disappointed with the lack of understanding about gender dysphoria in Japan. Although she desired to lower her body weight, she could not help binge eating due to the stress. Therefore, her weight has been fluctuating between 50 and 130 kg.
CASE 2 (fig. 2)
Case 2 was a 35-year-old Japanese FtM transsexual patient with anorexia nervosa binge eating/purging type. He began hormonal treatment at 24 years and underwent GCS at 27 years; therefore, eight years had passed since he had undergone GCS, when he visited our department to seek treatment for eating disorders.
During his early childhood, he already identified himself with the other sex. When he was 15 years, he desired to stop the development of secondary sexual characteristics. He thought that a lower body weight could prevent breast growth and menstruation. Therefore, he started food restriction, and his body weight decreased to 30 kg, with a height of 1.53 m (BMI, 12.8 kg/m2).
He began self-induced vomiting after he entered university to lose weight, but he was able to control his self-induced vomiting until 23 years. Then, he was not able to control his binge eating and his weight increased to 56 kg (BMI, 23.9 kg/m2). At 24 years, he disclosed his gender dysphoria and started undergoing hormonal treatment using testosterone. Testosterone prevented the female physical characteristics, and he experienced improvement in his body dissatisfaction, negative feelings, and binge eating. He was also able to increase his body weight. However, three years after starting the hormonal treatment, he restarted self-induced vomiting and his weight decreased. The reason was unclear even after we asked him repeatedly. His doctor suggested that he should discontinue the hormonal treatment due to his low body weight. When he did so, he became emotionally unstable and increased the frequency of self-induced vomiting and binge eating.
Around this time, his body weight decreased to 29 kg (BMI, 12.4 kg/m2). He underwent bilateral mastectomy at 27 years, and he legally changed his first name to a male one. Then, he improved his eating behavior and gained weight to 34 kg for one year. When he restarted self-induced vomiting, he had started attending lesbian, gay, bisexual, and transgender (LGBT) community gatherings. He had been distressed about the lack of understanding about gender dysphoria in Japan, but he found LGBT friends with same problems at that time. Therefore, he was able to improve his psychological status and to stop his pathological eating behaviors again, at 30 years. However, he lost weight again due to eating schedule disturbances because his part time job was so busy that he could not have time for lunch, as is often the case for Japanese workers. Then, he visited our department to seek a specialized treatment because he felt muscle weakness.
At his first visit to our department at 31 years, his weight was 29 kg (BMI, 12.4 kg/m2). We started self-monitoring of his eating behavior as an outpatient treatment. Then, he was admitted to our inpatient unit because he could not gain weight. During his admission, he was able to increase his weight to 33.4 kg. However, his eating behavior was related to a desire to get rid of his feminine features, and he reported engaging in excessive exercises to increase his muscularity. Therefore, his weight was maintained at approximately 34 kg, and he could not gain any more weight.
His doctor decided to restart hormonal treatment. Subsequently, he achieved improved satisfaction with his appearance, and he became more motivated to gain weight. Finally, he reached a weight of more than 40 kg (BMI, 16.9 kg/m2) for the first time in 10 years.
In summary, there were four turning points in his eating disorder symptoms. The first was related to secondary sexual characteristics. He lost weight to 30 kg to prevent breast growth and menstruation. The second was when he disclosed his gender dysphoria and started undergoing hormonal treatment; the treatment improved his dissatisfaction and he was able to gain weight. However, he began binge eating at that time. The third point was when he legally changed his name and started attending LGBT community gatherings. He was relieved and his eating habits improved. Finally, he restarted hormonal treatment and reached 40 kg (fig. 2).
