Studies have highlighted high prevalence of eating disorders among people with gender dysphoria, particularly transgender boys. This finding is extremely important: it means that transgender youth are exposed to the additional health hazards, which are extremely serious, of eating disorders. This paper highlights a series of conceptual problems inherent in the notion of ‘comorbidity’, and suggests that such notion needs careful examination. A superficial understanding such notion may lead healthcare professionals to assume that many transgender youth suffer additional psychopathology; they may thus become wary of commencing medical treatment for gender dysphoria until those other conditions are controlled. It is therefore essential, both from an ethical and a clinical point of view, that the notion of ‘comorbidity’ be properly understood, in order to avoid the risk that a helpful finding is turned into an additional stigma for transgender people and an obstacle to provision of medical treatment.
In this paper, those assigned female at birth who identify as boys or who identify as non-binary but towards the masculine end of the gender spectrum are described as trans boys and vice versa.
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Terminology is often controversial in this area of study. Gender expansive and gender diverse are sometimes used and may be regarded as more inclusive notions. However, I will use ‘gender nonconforming’ because it is more commonly used.
12.
See note 5.
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A 2015 resolution by the Council of Europe is available at http://tgeu.org/tgeu-media-statement-council-of-europe-adopts-historic-transgender-resolution/. Members of the WHO Working Group on the Classification of Sexual Disorders and Sexual Health have published two papers. In these papers the authors propose the removal of GID from the Mental and Behavioural Disorders and its inclusion in a non-psychiatric category. See Drescher J, Cohen-Kettenis P and Winter S. Minding the body: situating gender identity diagnoses in the ICD-11. Int Rev Psychiatr 2012; 24: 568–577.
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In this paper, I use the notion of ‘sex’ of assignment in inverted commas. This is the terminology typically used in the scholarly literature, and in standard definitions adopted - for example, by the World Professional Association for Transgender Health. ‘Sex’ is usually meant to refer to the set of biological data and it is differentiated from both ‘gender identity’ and ‘gender role’. See for example, World Professional Association for Transgender Health 2011, online p. 2. For the sake of simplicity, I use here the standard terminology: however, it is important to note that talking about ‘sex of assignment’ seems to suggest that an individual’s ‘sex’ is something observable, a set of biological data that can be ‘seen’ at birth or maybe later (presumably by looking initially at the genitalia, or by taking further tests). Instead, the ‘sex’ of an individual is not a simple matter, and not purely a matter of ‘observation’ as is sometimes claimed. As I have argued elsewhere, it is not clear what ‘biological sex’ actually is, and what people look for when they try to determine a person’s ‘sex’. I have argued that ‘sex’ is no less of a construct than gender. For this reason I use ‘sex’ in inverted commas. It would be more precise to talk about ‘gender of assignment’ but to align the paper to common usage I will use ‘sex of assignment’. For more on this point see, Giordano S. The confused stork. Sex, gender, parenting. In: Hens K, Cutas D and Horstkötter D (eds) Parental Responsibility in the Context of Neuroscience and Genetics. Dordrecht: Springer, 2016.
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See note 24, p. 47.
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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-V. US: American Psychiatric Association, 2013, Section 2.10.
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The DSM-V is only a diagnostic instrument, and there is wide and comprehensive psychological literature on eating disorders that provides much more detailed descriptions of eating disorders. Due to its large use, I will rely here on the classification exposed in DSM.
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With the exception perhaps of some isolated cases of body dysmorphia, in which healthy leg amputation has been authorised.
40.
Indeed, the so-called ‘paradoxical method’ has been used in the past for anorexia nervosa. The idea was to ignore completely the thinness of the anorexic, and indeed subtly praise it, so that as a strategy to elicit concern that modality of behaviour would lose its efficacy. The paradoxical method has been abandoned for being highly hazardous. In any case, the ultimate aim of that approach was to get rid of the thinning strategy, and not to help the anorexic to obtain the thinnest body she could.
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