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Published in final edited form as: Curr Pediatr Rep. 2025 Jan 24;13(1):10.1007/s40124-025-00341-1. doi: 10.1007/s40124-025-00341-1

Body Image, Disordered Eating, and Eating Disorders in Gender Diverse Youth

Alexandra Allam 1, Samuel B Seidman 1, Blair Uniacke 2
PMCID: PMC12494176  NIHMSID: NIHMS2061254  PMID: 41049793

Abstract

Purpose of Review

We examine the prevalence of body image disturbance, disordered eating, and eating disorders (EDs) among gender diverse youth, and discuss implications and recommendations for providers encountering these intersecting issues in their practice.

Recent Findings

Increasing evidence demonstrates that transgender and non-binary youth experience greater rates of body image issues, as well as disordered eating and EDs. Gender dysphoria in combination with these body, shape, weight, and food concerns are associated with elevated rates of other comorbid psychiatric problems, each of which place gender diverse youth at risk for adverse outcomes. Routine assessment of gender dysphoria and EDs is necessary for earlier and therefore more successful interventions. Likewise, targeting symptoms of both gender dysphoria and EDs concurrently is critical for optimal results.

Summary

Body dissatisfaction, disordered eating and EDs are often related to and comorbid with gender dysphoria, all of which are prevalent among gender diverse youth. Such symptoms are associated with additional psychiatric issues, including depression, anxiety, and suicidal ideation in this population. For earlier intervention and better outcomes, routine screening in primary care settings is necessary, as are referrals to providers who are equipped to treat both gender- and eating-related problems simultaneously.

Keywords: Transgender, Gender diverse, Eating disorders, Body image, Disordered eating, Youth

Introduction

Recent data indicate that approximately 1.4% of youth (~ 300,000 teens ages 13 to 17) in the United States identify as transgender or gender non-binary [1]. Accumulating evidence indicates that individuals who identify as transgender (i.e., gender identity differs from the gender assigned at birth) or gender non-binary (i.e., individual does not identify exclusively with one gender) are at increased risk for body image disturbance [2], as well as the development of disordered eating [3] and eating disorders (EDs; [4]). Adolescence, itself, marks a period of uniquely elevated risk for the development of EDs, with the peak window for the emergence of anorexia nervosa (AN) occurring between the years of 14–18 [5] and bulimia nervosa (BN) slightly later between ages 18 and 19 years [6]. For gender diverse youth, the development of secondary sex characteristics and other changes associated with puberty can contribute to a greater sense of incongruence between their external appearance and internal identified gender [7]. This discrepancy often contributes to worsening body image and, in turn, efforts to change one’s appearance (e.g., altering one’s weight and shape, attempting to minimize secondary sex characteristics) via disordered eating behaviors, which partly accounts for the elevated rates of such symptoms and of EDs seen in this population [8–10].

Youth who identify as transgender or non-binary (or who are questioning their gender identity) are also more likely to experience minority stress, defined as the additional stress experienced by individuals who belong to marginalized groups due to discrimination and stigma [2]. For gender diverse individuals, this can include both external stigma-related discrimination and harassment due to their gender identity and/or expression as well as internalized stigma-related stress, such as internalized transphobia and stigma consciousness [2]. Minority stress has been implicated in eating-related psychopathology in gender-diverse youth and adults, as well as in the disproportionately high rates of other mental health issues, including depression, anxiety, suicidality, and substance abuse in this population [2, 11].

Given the long-term medical and psychiatric risks associated with the development of EDs [12, 13], early detection and treatment of EDs and of associated eating and body image issues for gender diverse youth is a prominent concern for healthcare providers who treat children and adolescence, including pediatricians. In this review, we present the literature to date examining the prevalence, risk, and treatment for body image disturbances, disordered eating, and EDs in gender diverse youth. Finally, we present several clinical recommendations and reflections for practitioners to improve patient care.

Body Image Concerns amongst Gender Diverse Youth

Emerging research has found that gender diverse youth report greater body image dissatisfaction when compared to their cisgender peers [2]. Various factors have been linked to worsening body image in this population. One study found that age and poor peer relations predicts greater body image dissatisfaction in transgender youth [2]. Other studies have shown that body image dissatisfaction in gender diverse youth is exacerbated by gender appearance dissatisfaction, gender dysphoria, and a motivation to alter one’s body to align appearance with gender identity [14, 15]. Notably, due to the influence of gender-related issues on body image in this population, body image disturbance is likely to involve issues related to weight and shape, as well as gender presentation [16]. Greater body image dissatisfaction has been associated with secondary psychological issues for gender diverse youth, including increased self-criticism and social distress [15], higher levels of depression and suicidality [17–19], greater rates of non-suicidal self-injury (NSSI) and suicide attempts [19], and an increased risk of disordered eating and EDs [20].

Alternatively, factors associated with body image satisfaction in gender diverse youth have been evaluated. Research examining the relationships between gender-affirming hormone treatment, body image satisfaction, and associated psychological issues has found that gender-affirming hormone therapy is associated with reduced body image dissatisfaction [17, 18, 21]. This improvement in body image has been associated with lower levels of depression and suicidality in transgender adolescents compared to transgender adolescents that remain untreated [17, 18]. Research has also found support for surgical interventions amongst transgender and gender non-binary adolescents and young adults with chest dysphoria as a means of improving body image compared to untreated peers [22]. Moreover, Becker et al. [14] found that adolescents and adults with gender dysphoria who received a combination of hormone therapy and surgical intervention reported better body image on two of four measures assessing body image satisfaction compared to those who had received hormone therapy alone or who had received no previous gender-affirming interventions.

Disordered Eating

In part due to concerns regarding body image and increased psychological distress amongst gender diverse youth, disordered eating in this population has become a focus of recent research. Disordered eating can be characterized by binge eating, purging, excessive exercise, caloric restriction, muscle building, and/or cognitive restraint, and, if persistent, can be a precipitant of the development of an ED [23]. For many gender minority youth, disordered eating behaviors initially serve as a means of attempting to change weight and shape, controlling one’s body, and/or altering or minimizing secondary sex characteristics, and can be associated with gender dysphoria [8–10]. Research examining differences in disordered eating associated with one’s sex assigned at birth and gender identity revealed that gender diverse youth exhibit higher frequencies of certain disordered eating behaviors compared to their cisgender peers [3, 24–26] and compared to sexual minority adolescents [27]. For example, Guss et al. [24] found transgender adolescents have higher odds of fasting for more than 24 h, using diet pills, taking laxatives, and lifetime use of steroids without a prescription compared to cisgender males. This research also found transgender adolescents have higher odds of perceiving themselves as either being at a healthy weight or underweight when they were overweight or obese compared to cisgender females [24]. Other research has similarly identified elevated rates of weight control behaviors, including vomiting, laxative and diet pill use [25, 28], as well as eating as a means of avoidance or to cope with negative emotions and increased prevalence of binge eating [25], and higher Eating Disorder Examination Questionnaire (EDE-Q) global scores amongst transgender youth when compared to cisgender peers [26]. Another study examining differences within gender diverse adolescents seeking gender-affirming care found that the prevalence of disordered eating behaviors is higher among transgender boys than transgender girls, as well as among adolescents who feel unsure about their gender identity compared to those who identify as transgender or non-binary [29]. Still, other research has found that although many gender diverse youth engage in at least one disordered eating behavior, there are not significant differences between gender diverse youth based on gender identity (e.g., transgender males compared to transgender females and gender non-binary youth, etc. [10, 30, 31]). Therefore, findings have been mixed as to whether differences exist within subgroups of gender diverse youth.

When examining risk factors for disordered eating among gender diverse youth, results are inconsistent regarding whether the type of gender-affirming treatment and/or duration of treatment decreases disordered eating behaviors [10, 30, 31]. While qualitative research suggests that some gender diverse youth report improvements in disordered eating following gender transition [10], quantitative research has not consistently identified significant differences in the prevalence of disordered eating based on engagement in gender-affirming treatment, treatment type, or duration of treatment [30, 31] For example, one study found that transgender females receiving gender-affirming hormone therapy reported a greater proportion of objective binge-eating episodes in the last 28 days compared to those not receiving hormone therapy [30]. Quantitative data are necessary to identify objective, measurable trends and statistically significant differences between groups on variables. The relatively narrow structure of quantitative research can limit the breadth of information obtained by populations. Qualitative research, on the other hand, can fill gaps via its more open-ended format that focuses on why and how trends may develop. It is possible that although quantitative measures of disordered eating symptom severity do indicate that these symptoms do not remit and may potentially worsen in the context of gender-affirming treatment, gender diverse youth may also experience subtle differences in their patterns of disordered eating that are perceived as improvements and are captured in qualitative data.

Additional risk factors for disordered eating in gender diverse youth which have emerged in recent studies include depression and increased stress related to coming out [27]. Age has also been shown to be positively associated with prevalence of disordered eating behaviors and eating to cope for gender diverse youth, such that the older the adolescents are, the more likely they are to endorse past-year weight-loss efforts of fasting, restricting their intake, using laxatives, using diuretics, using food substitutes, skipping meals, and smoking cigarettes, as well as eating as a means of avoidance or to cope with negative emotions [25] and to have higher abbreviated EDE-Q scores [31]. Among transgender youth, reported harassment and discrimination are also associated with higher odds of reported past-year binge eating and fasting or vomiting to lose weight, and these odds are intensified in the absence of protective factors of family connectedness, school connectedness, caring friends, and social support (all of which are linked to lower odds of past-year disordered eating [32]).

Factors which appear to be protective against disordered eating in gender diverse youth include increased gender identity congruence [3], higher self-esteem [27], and feeling safer at school [25]. Likewise, Chakkour and colleagues [33] found that gender diverse young adults who achieve their desired transition report the greatest appearance congruence on the Transgender Congruence Scale and have significantly lower gender-related motivations for weight loss compared to those with no plans to transition.

Eating Disorders

Amongst gender diverse youth who engage in disordered eating behaviors, a subset meets clinical threshold for an ED, with a greater percentage of this population both meeting the clinical threshold [4, 26] and receiving an ED diagnosis compared to cisgender peers [28, 34]. Review of research has shown that ED behaviors are often used by gender diverse youth as a way of preventing puberty onset or progression and a means of coping with gender-related distress or gender dysphoria [34, 35, 36]. Consequently, it should come as no surprise that youth with a gender dysphoria diagnosis have been found to have greater odds of having a comorbid ED diagnosis compared to those without a gender dysphoria diagnosis [37]. Specifically, while youth with both an ED diagnosis and a gender dysphoria diagnosis have lower odds of having a diagnosis of AN, they have significantly greater odds of having an unspecified or other specified ED diagnosis compared to those without a gender dysphoria diagnosis [37]. Another study examining adolescents admitted to an inpatient ED unit for medical stabilization found that gender diverse adolescents are significantly younger and are more likely to meet criteria for atypical AN, in which individuals meet all criteria for AN including significant weight loss but remain at or above a normal-range BMI [38], compared to their cisgender peers [39]. Consequently, gender diverse adolescents were found to have a higher percent median BMI compared to cisgender peers, yet demonstrate equally severe vital sign instability, which is consistent with existing literature on atypical AN [39]. Research conducted with college students also found that transgender and genderqueer students along with cisgender females have higher rates of self-reported lifetime AN and BN diagnoses, as well as past-year eating pathology-specific academic impairment, compared to cisgender men [40].

Risk factors for EDs in gender diverse youth include negative urgency [41] and a higher prevalence of sexual abuse, verbal/physical/emotional abuse, and bullying histories [42]. Conversely, protective factors and factors that facilitate ED treatment include body-gender congruence via gender-affirming social and medical interventions [4], clinicians’ education about gender diverse populations and gender affirming care [43, 44], as well as increased access to and resolution of economic barriers to ED treatment [45].

Research has also examined the rates of comorbid psychopathology in gender diverse youth with EDs. Chaphekar et al. [39] found that gender diverse adolescents admitted for inpatient ED treatment have a higher prevalence of reported anxiety symptoms. In addition to increased odds of an anxiety diagnosis, youth with dual diagnoses of an ED and gender dysphoria were also found to have significantly greater odds of experiencing depression, suicidality, and self-harm compared to those with neither an ED nor a gender dysphoria diagnosis [37]. Similarly, a study of children, adolescents, and young adults receiving an enhanced approach to outpatient family-based therapy (FBT) for EDs (FBT+; which incorporates a peer mentor and a family mentor who have lived experience with an ED as part of the treatment team and also aims to increase inclusivity specifically with regards to gender diversity) found that gender diverse youth have significantly higher anxiety and depression symptoms, as well as suicidal ideation at admission compared to cisgender peers [46]. Results from qualitative research have also revealed themes of increased risk for self-harm and suicide in transgender and gender non-binary youth, as well as complex psychiatric and medical implications of delay to treatment for either gender dysphoria or disordered eating [47]. Another theme that has emerged from qualitative research is the importance of collaborative management to maximize care and facilitate healthy development to adulthood among gender nonconforming adolescents with EDs [47].

Of note, despite the increased frequency and severity of comorbid mental health issues observed among gender diverse youth, research has also shown that transgender and gender non-binary youth show equal rates of improvement in ED symptoms with treatment as cisgender individuals [46]. For example, Riddle et al. [48] found no significant differences in ED symptoms between transgender and gender diverse adolescents and cisgender adolescents at admission or discharge from ED treatment, despite increased suicidal ideation and depression at admission and elevated levels of suicidal ideation, depression, and anxiety at discharge among gender diverse youth compared to cisgender participants at discharge. Other studies have found that gender and sexual minority children and adults exhibit more severe ED psychopathology and comorbid psychological symptoms at admission but improve more quickly with treatment [42, 49]. Taken together, while comorbidities are prevalent in this population and delays to treatment can lead to increasingly adverse outcomes, gender diverse youth do respond well to treatment, underscoring the importance of access to care.

Clinical Implications

As described above, existing research has been largely consistent in identifying gender diverse youth as being at greater risk for body image disturbance, disordered eating, and, ultimately, the development of EDs. Gender diverse youth are also at greater risk for bullying, harassment, and discrimination, which further increases their risk of body image and eating-related concerns. In addition to enacted stigma (i.e., the higher rates of harassment and discrimination that sexual and gender minority youth experience [32]), experiences of sexual assault and gender dysphoria further heighten the already-elevated risk of body image dissatisfaction and disordered eating behaviors for gender diverse youth. Additionally, increased issues with body image, disordered eating, and EDs are associated with greater psychological distress in this population, including increased rates of anxiety, depression, and suicidality. However, perceived school safety, social and family supports, and access to gender-affirming care are protective factors which have been shown to mitigate these risks. Together, these findings underscore the importance of universal screening for issues related to body image and eating disturbances across all youth regardless of appearance and identity (acknowledging that many gender diverse youth may not be able or do not feel safe enough to share these identities with providers). Likewise, these results highlight the need for providers to be prepared to refer patients, if indicated, to gender-affirming treatment providers who are able to support both gender- and eating-related concerns.

One simple, fast, and effective screening tool that providers can familiarize themselves with and routinely use in assessment of EDs is the Sick, Control, One Stone, Fat, Food (SCOFF; [50]), which has been validated for use with transgender youth [51]. Likewise, the Adolescent Binge Eating Disorder questionnaire (ADO-BED [52]) is a brief, ten-item measure used to screen for binge-eating disorder and has been validated in transgender youth [53]. Finally, the Body Appreciation Scale-2 (BAS-2 [54]) was validated as a measure of body appreciation for gender-diverse individuals in Brazil, though this still needs replication in a U.S. sample [55].

Few studies to date have examined the relative efficacy of different ED treatments and, specifically, ED treatments tailored to gender diverse populations in gender diverse youth [56]. Some research has suggested that cognitive behavioral therapy (CBT) and enhanced CBT (CBT-E) lend themselves to easy modification for providers and patients to incorporate gender-related and other minority stressors into treatment [16, 56]. Likewise, Phase III of FBT, which focuses on the adolescent’s return to typical life and on addressing other issues that serve as barriers to independence and healthy functioning [57], could target gender and identity issues as a focus of treatment [56]. Although much research is still needed to validate these treatments in this population, the consensus amongst researchers is that gender diverse youth access available treatments until further development in this field is made, and that providers of existing ED treatments adhere to a gender affirmative care model (e.g., valuing patient autonomy, acknowledging and respecting patient identities, using inclusive language, etc. [58, 59]). Moreover, increased provider awareness of the unique gender-related issues surrounding body image and eating in gender diverse youth is needed to adequately support this population and increase the efficacy of treatment. Similarly, providers specializing in gender-affirming care should be knowledgeable about and able to assess for disordered eating and EDs due to the relatively high prevalence of these issues in gender diverse youth. Collaboration between providers and ongoing education will be critical in supporting this population as we continue to investigate and learn more about how to best address these intersecting issues [60].

Conclusions

Accumulating evidence indicates that body image disturbance, disordered eating, and EDs are both prevalent and complex in gender diverse youth. Results from this emerging field of research further indicate that gender diverse youth are indeed at increased risk for all the aforementioned problems and that these issues in the presence of gender dysphoria can often intensify comorbid mental health issues. Likewise, treating EDs without addressing specific gender-related concerns can lead to less effective treatment and potentially worse outcomes for this population, as can efforts to treat gender dysphoria while neglecting to specifically target ED symptoms. Although future research is still needed to identify optimal interventions for gender diverse youth with EDs, existing research emphasizes the necessity of routine screening for gender-related, body image, and eating issues across youth as the first step in assessment and treatment. Increased education regarding signs and symptoms of EDs and a gender affirmative care model is encouraged to improve both providers’ understanding and assessment of these issues, as well as their approachability to and rapport with patients. Collaboration between providers can also help facilitate optimal care for this population and ensure diverse needs are being met and comorbid symptoms are being targeted concurrently throughout treatment.

Funding

No funding was received to assist with the preparation of this manuscript.

Footnotes

Human and Animal Rights This article does not contain any studies with human or animal subjects performed by any of the authors.

Competing Interests The authors declare no competing interests.

Data Availability

No datasets were generated or analysed during the current study.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

No datasets were generated or analysed during the current study.

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