Abstract
Purpose:
Disordered weight management behaviors are prevalent among youth; recent case reports suggested these behaviors might also be common in transgender youth. We studied associations of gender identity with disordered weight management behaviors, non-prescription steroid use, and weight perception among transgender and cisgender (non-transgender) high school students in Massachusetts.
Methods:
Data were analyzed from the 2013 Massachusetts Youth Health Survey, an anonymous survey in a random sample of Massachusetts public high schools. Respondents were divided into three groups: transgender (n=67), cisgender male (n=1117), and cisgender female (n=1289). Fisher’s exact tests and multivariable logistic regression models were used to examine unhealthy weight management behaviors in the past 30 days: fasting >24 hours, vomiting, diet pill use, and laxative use; non-prescription steroid use; and self-perceived weight status. Analyses controlled for age, race/ethnicity, and body mass index.
Results:
Compared to cisgender males, transgender adolescents had higher odds of fasting >24 hours (adjusted odds ratio [AOR]=2.9, confidence interval [CI]=1.1–7.8), using diet pills (AOR=8.9, 95% CI=2.3–35.2), and taking laxatives (AOR=7.2, 95% CI=1.4–38.4). Transgender youth had higher odds of lifetime use of steroids without a prescription than male cisgender respondents (AOR=26.6, 95% CI=3.5–200.1). Compared to cisgender females, transgender respondents had higher odds of perceiving themselves as healthy weight/underweight when they were overweight/obese (AOR=2.4, 95% CI=1.5–4.1).
Conclusions:
Transgender youth disproportionately self-reported unsafe weight management behaviors and non-prescription steroid use compared to cisgender youth. Clinicians should be aware of this increased risk among transgender youth. Research is needed to further understand these disparities and to inform future interventions.
Keywords: adolescent, transgender, eating disorder, steroid
Disordered weight management behaviors, defined as vomiting after meals, fasting greater than 24 hours to control weight, and diet pill and laxative use, are alarmingly prevalent among high school students.[1–3] In the United States, more than 26% of female students and 10% of male students endorse engaging in these behaviors over the past month. [1] These methods used to try to control weight have significant health risks, such as electrolyte abnormalities and adverse gastrointestinal consequences.[4,5] Moreover, individuals who engage in disordered weight management behaviors may eventually develop a clinically significant eating disorder (such as anorexia nervosa) or other psychiatric morbidities (such as depression).[1,3] In addition to behaviors leading to weight loss, body dissatisfaction can result in techniques aimed at body modification, such as anabolic steroid use. Male adolescents who are dissatisfied with their body may use anabolic steroids to increase their lean body mass.[6] Prevalence of lifetime use of steroids without a prescription in high school students nationally in the United States is 3.6%. [7]
Cisgender individuals identify with a gender that is concordant with their sex assigned at birth (non-transgender), in contrast to transgender individuals who identify with a different gender from their sex assigned at birth. Cisgender may be further broken down into cisgender male (natal male sex, identifies as a boy/man) and cisgender female (natal female sex, identifies as a girl/woman). Transgender individuals may identify as female (natal male, male-to-female, transgender girl/woman), male (natal female, female-to-male, transgender boy/man), nonbinary (as a gender identity that does not conform to binary male and female gender categories) or elsewhere on the gender spectrum. There can be significant psychological distress that develops for individuals who have a body that does not match their intrinsic sense of gender;[8] however, little is known regarding how this may translate, if at all, to disordered weight management behaviors and eating disorders in transgender people.
Prior research has begun to explore a link between transgender identity and eating disorder diagnosis in adults. A large nationwide survey of college students found that those young adults with a transgender identity had greater odds of having an eating disorder diagnosis in the past year and having disordered weight behaviors compared to cisgender female students.[9] However, not much is known about these behaviors in transgender adolescents, with the only available evidence emerging from case studies.[10–12] These case studies describe how gender dysphoria, which is clinically significant distress due to having a different gender identity than the sex assigned at birth,[8,13] may intersect with disordered eating by manipulating weight to appear more like an individual’s affirmed gender than their biological sex. Moreover, case studies of two gender fluid adults revealed that eating disorder pathology may change depending on the individual’s current gender identity to be either more feminine or more masculine appearing. [14] Qualitative studies in Finnish adults have found that transgender adults (both male-to-female and female-to-male) often self-report engaging in disordered eating.[15] This may be done to suppress secondary sex characteristics of one’s birth sex.[16] For example, being low weighted may reduce “feminine curves” and lead to amenorrhea, which may be desirable for someone who is female-to-male, if they are seeking a more masculine body to match their male gender identity. In male-to-female individuals, disordered weight management techniques might be employed in order to reduce muscle bulk and appear more feminine, which may help to affirm a female gender identity. While these case studies help to provide some insights, population-level and youth-oriented studies are lacking.
Longitudinal studies have found that body dissatisfaction in adolescence increases over time and through young adulthood for both males and females.[17,18] Transgender youth may find puberty distressing and have worsening gender dysphoria as they begin to develop secondary sex characteristics of their assigned sex. [19–21] In one study of transgender youth, poor body image and gender dysphoria improved following gender affirming hormone and surgical treatment.[22] However, for transgender youth, the intersection of body satisfaction and gender dysphoria may be more complex than only the distress over the development of secondary sex characteristics. Recent research has found transgender adults may have dissatisfaction with other areas of their body, such as posture, hair, and chest.[23] Moreover, satisfaction with body characteristics that affect how one might be perceived by others as consistent with societal norms of maleness and femaleness (such as muscularity in female-to-male individuals or body shape in both male-to-female and female-to-male individuals) were associated with overall satisfaction in transgender adults.[24] Qualitative research from older adolescents and young adults found that body dissatisfaction may be related to gender dissociation and body size compared to social norms.[25] It is possible that the body dissatisfaction transgender adults experience may first develop in adolescence and that some of the behavioral and psychological manifestations of such dissatisfaction (such as disordered weight management behaviors) may also emerge during this developmental period for transgender youth.
The aims of this study were to examine differences between transgender and cisgender students in Massachusetts high schools in disordered weight management behaviors, non-prescription steroid use, and perceived weight status. Given the high prevalence of eating disorder behaviors in the adult transgender population compared to the cisgender population, we hypothesized that these behaviors likely begin in adolescence and therefore transgender adolescents would have a higher prevalence of disordered weight management behaviors and non-prescription steroid use than their cisgender peers. Moreover, because the incongruence of their gender identity with their assigned birth sex’s secondary sex characteristics may result in body dysphoria, we hypothesized that transgender youth will perceive their weight status differently from cisgender youth.
Methods
Sample
The Massachusetts Youth Health Survey (MYHS) is a population-based survey of Massachusetts public high school students in grades 9–12, conducted by the Massachusetts Department of Public Health in collaboration with the Massachusetts Department of Elementary and Secondary Education.[26] It is an anonymous survey administered in odd-numbered years to randomly selected high schools. For the 2013 survey, all public high schools were eligible and 57 high schools participated in January-May 2013.[27] The MYHS survey contained a set of core questions that were common to the Centers for Disease Control (CDC) and Prevention’s Youth Risk Health Surveillance System, but additionally includes questions related to protective factors and in 2013 included a question on gender identity. Surveys were self-administered by paper and pencil. Data were used from the 2013 survey with the permission of the Massachusetts Department of Public Health. This analysis was approved by the Institutional Review Board at Boston Children’s Hospital.
The overall MYHS data set contained 2,801 students. A total of 2,473 respondents met inclusion criteria by answering the question on gender identity.
Data source and measures
Data were collected for age (in years), race/ethnicity (Hispanic yes or no; American Indian or Alaska Native, Black or African American, Native Hawaiian or Other Pacific Islander, White), and self-reported weight (in pounds) and height (in feet/inches). Body mass index (BMI) was calculated and categorized to correspond with age and sex percentiles published by the CDC[28] and subsequently classified according to the American Academy of Pediatrics guidelines as underweight (<5th percentile for age/sex), healthy weight (5th ≤ BMI < 85th percentile), overweight (85th ≤ BMI <95th percentile), and obese (≥95th percentile).[29] Sex was assessed with the question: “What is your sex?” with response options of “female” and “male.”
Gender identity was assessed with a single item, which was included in the “sexual behaviors” section of the survey: “When a person’s sex and gender do not match, they might think of themselves as transgender. Sex is what a person is born. Gender is how a person feels. Are you transgender?” Response options were: “no”; “yes and I identify as a boy or a man”; “yes and I identify as a girl or woman”; “yes and I identify in some other way”; “I do not know what this question is asking”; and “I do not know if I am transgender.”
To assess weight management behaviors, the MYHS asked: “During the past 30 days, have you done any of the following things at least once to lose or maintain your weight?” A list of behaviors was provided; the following behaviors were included for analysis: “Fast (that is going 24 hours or more without eating)”; “vomit or throw up on purpose after eating”; take diet pills without a doctor’s permission”; and “take laxatives.” Response options were “yes” or “no.” Steroid use was assessed with the following question: “In your lifetime, which of the following prescription drugs have you taken that weren’t your own?” The prompt further listed several substances, including “steroids (body building hormones in form of pills or shots)” with answer options of “yes” or “no.” Youths’ self-perceived weight status was assessed on the MYHS with the following question: “How would you describe your weight?” Response options were: “very underweight”; “slightly underweight”; “about the right weight”; “slightly overweight”; and “very overweight.”
Analyses
Statistical analyses were conducted using SAS 9.2. Fisher’s exact tests and multivariate logistic regression analyses were used to examine outcomes and were considered statistically significant at p<0.05. Analyses controlled for age, race/ethnicity, and BMI. Respondents were stratified by gender identity as follows: respondents who responded “no” to the gender identity question were further subdivided by responses to a separate survey question asking about “sex” as cisgender male (sex=male) or cisgender female (sex=female), respectively. Given the low prevalence of transgender youth in the sample, transgender respondents were not further stratified by sex. Participants who responded that they did not know if they were transgender (n=28) or did not understand the question (n=164) were excluded from analyses.
The three gender identity groups (transgender [n=67], cisgender male [n=1,117], and cisgender female [n=1,289]) were compared by unhealthy weight modification behaviors (fasting greater than 24 hours, vomiting after meals, diet pill use, and laxative use) in the past 30 days, lifetime use of non-prescribed body-building steroid use, BMI classification, self-perceived weight status, and accuracy of weight classification (concordance and discordance between weight perception and weight status based on BMI). Respondents were concordant in their weight perception if they had a healthy weight and perceived themselves as having a healthy weight, were overweight/obese and perceived themselves as slightly or very overweight or were underweight and perceived themselves as slightly or very underweight. Respondents were discordant in their weight perception if they had a healthy weight or were underweight but perceived themselves as slightly or very overweight, or were overweight or obese but perceived themselves as having a healthy weight or underweight. Concordance and discordance between weight perception and weight status based on BMI classification has been studied previously using this operationalization for analyses.[30]
Results
Most participants self-identified as white/non-Hispanic, had an average age of 16 years, and had a (BMI) in the healthy range (>5th-<85th percentile). The socio-demographic data stratified by gender identity are presented in Table 1. Frequencies of outcomes stratified by gender identity are presented in Table 2. Cisgender females had the highest prevalence of fasting greater than 24 hours (10.5%) and vomiting after meals (5.9%) in the past 30 days. Prevalence of all weight management behaviors was lowest among cisgender males. Transgender participants had the highest prevalence of diet pill use and laxative use (both 4.8%). Use of steroids not prescribed to the respondent was overall very low in absolute numbers (transgender n=7, cisgender male n=6, and cisgender female n=1).
Table 1:
Demographics: Age in years, race/ethnicity, and weight status by gender identity and sexb among public high school students in Massachusetts, n=2,473
| Transgender | Cisgender | |||
|---|---|---|---|---|
| Characteristic | Sex = male n=41 n(%) | Sex = female n=26 n(%) | Sex = male n=1,117 n(%) | Sex = female n=1,289 n(%) |
| Age, in years | ||||
| ≤14 | 5 (12.2%) | 5 (19.2%) | 103 (9.2%) | 123 (9.5%) |
| 15 | 9 (22.0%) | 6 (23.1%) | 278 (24.9%) | 352 (27.3%) |
| 16 | 15 (36.6%) | 7 (26.9%) | 295 (26.4%) | 338 (26.2%) |
| 17 | 8 (19.5%) | 6 (23.1%) | 270 (24.2%) | 306 (23.8%) |
| ≥18 | 4 (9.8%) | 2 (7.7%) | 170 (15.2%) | 169 (13.1%) |
| Race/ethnicity | ||||
| White, non-Hispanic | 28 (68.3%) | 9 (36.0%) | 764 (69.4%) | 885 (69.8%) |
| Black, non-Hispanic | 5 (12.2%) | 2 (8.0%) | 7 (10.6%) | 97 (7.6%) |
| Hispanic | 4 (9.8%) | 9 (36%) | 138 (12.5%) | 146 (11.5%) |
| Other/multiracial | 4 (9.8%) | 5 (20.0%) | 106 (9.6%) | 140 (11.0%) |
| BMIa | ||||
| ≤ 5th percentile, underweight | 3 (7.3%) | 9 (34.6%) | 121 (10.8%) | 146 (11.3%) |
| 5th < BMI < 85th percentile, healthy weight | 28 (68.3%) | 15 (57.7%) | 733 (65.6%) | 914 (70.9%) |
| 85th ≤ BMI < 95th percentile, overweight | 9 (21.9%) | 1 (3.9%) | 141 (12.6%) | 142 (11.0%) |
| ≥95th percentile, obese | 1 (2.4%) | 1 (3.9%) | 122 (10.9%) | 87 (6.8%) |
BMI= Body mass index
According to age/sex percentiles published by the Centers for Disease Control and Prevention[28] and classified according to the American Academy of Pediatrics guidelines[29]
Wording of question on sex: “What is your sex?” Wording of question on gender identity: “Please choose the one best fitting response. When a person’s sex and gender do not match, they may think of themselves as transgender. Sex is what a person is born. Are you transgender?”
Table 2:
Prevalence of unhealthy weight management behaviors in the past 30 days, lifetime non-prescribed steroid use, and weight perception among transgender (n=67), cisgender male (n=1117), and cisgender female (n=1298) youth in Massachusetts public high schools
| Characteristic | Transgender n (%) |
Cisgender Male n (%) |
Cisgender Female n (%) |
|---|---|---|---|
| Weight behaviors past 30 days | |||
| Fasting > 24 hours | 6 (9.5) | 40 (3.8) | 131 (10.5) |
| Vomiting after meals | 2 (3.3) | 10 (1) | 73 (5.9) |
| Diet pill use | 3 (4.8) | 11 (1) | 38 (3.1) |
| Laxative use | 3 (4.8) | 11 (1) | 38 (3.1) |
| Lifetime use | |||
| Non-prescription steroid use | 7 (38.9) | 6 (5.2) | 1 (0.7) |
| Weight perception | n=66 | n=1111 | n=1287 |
| Concordant weight perceptiona | 28 (43.4) | 595 (53.6) | 730 (56.7) |
| Feels overweight, but is not | 16 (24.2) | 195 (17.6) | 310 (24.1) |
| Feels healthy/underweight, but is not | 22 (33.3) | 321 (28.9) | 247 (19.2) |
Concordant weight perception: was healthy weight and perceives self as healthy weight, was overweight/obese and perceived self as slightly/very overweight, or was underweight and perceived self as slightly/very overweight
Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) of behaviors are in Table 3. Compared to cisgender males, transgender adolescents had higher odds of fasting longer than 24 hours (AOR=2.9, 95% CI 1.1–7.8), using diet pills (AOR=8.9, 95% CI=2.3–35.2), and taking laxatives (AOR=7.2, 95% CI=1.4–38.4). There were no statistically significant differences between transgender youth and cisgender females for fasting, diet pills, and laxative use or between transgender youth and cisgender males and females for vomiting after meals. Transgender youth had a 26.6 higher odds (95% CI=3.5–200.1, p=0.0014) of lifetime use of steroids without a prescription than male cisgender respondents. Due to low use of steroids among cisgender females, analyses were not conducted to compare cisgender females with transgender youth.
Table 3:
Adjusteda odds ratios unhealthy weight management behaviors in the past 30 days, lifetime non-prescribed steroid use, and perceptions among transgender, cisgender male, and cisgender female youth in public high schools in Massachusetts.
| Characteristic | Transgender vs Cisgender Male | Transgender vs Cisgender Female |
|---|---|---|
| Weight behaviors past 30 days | ||
| Fasting > 24 hours | 2.9 (1.1–1.78) | 0.9 (0.3–2.3) |
| Vomiting after meals | 3.3 (0.4–28.0) | 0.3 (0.1–2.5) |
| Diet pill use | 8.9 (2.3–35.2) | 2.8 (0.8–10.0) |
| Laxative use | 7.2 (1.4–38.4) | 1.3 (0.3–5.5) |
| Lifetime use | ||
| Non-prescription steroid use | 26.6 (3.5–200.1) | b |
| Accuracy of weight perception | ||
| Feels overweight, but is not | 1.3 (0.7–2.5) | 0.9 (0.5–1.6) |
| Feels healthy/underweight, but is not | 1.4 (0.9–2.4) | 2.4 (1.5–4.1) |
Bolded text indicates statistical significance at p <0.05
Adjusted for age in years, race/ethnicity, and body mass index
Did not calculate due to small n
Compared to cisgender females, transgender respondents had higher odds of perceiving themselves as healthy weight or underweight when they were overweight or obese by BMI (AOR=2.4, 95% CI=1.5–4.1). There were no other significant discordant views on weight perception between transgender respondents and cisgender females or males (Table 3).
Discussion
In a large sample of Massachusetts public high school students, this study found that transgender youth were more likely than cisgender males to engage in unsafe weight management behaviors and use non-prescribed body building steroids. Specifically, compared to cisgender male youth, transgender youth had significantly higher odds of fasting greater than 24 hours, and using diet pills and laxatives in the past 30 days to lose or maintain their weight. Transgender youth may be using disordered weight management behaviors to gain control over their bodies during puberty to align their physical appearance with their gender identity. Disordered weight management behaviors may put transgender youth at risk for medical complications, such as electrolyte disturbances and gastrointestinal side effects.[5] Moreover, disordered weight loss behaviors may be early indicators for an eating disorder.[2] In the context of prior research among young adults showing that transgender college students have higher rates of self-reported eating disorder diagnosis and disordered weight management behaviors than cisgender students, [9] our findings suggest that the higher prevalence of disordered weight management behaviors for transgender compared to cisgender people may begin as early as high school. Further research is needed to resolve why these differences exist. Additionally, as it has been previously found that treatment of gender dysphoria in adolescence with gender affirming hormones and surgery improves psychological outcomes,[22] another area for further study is to determine if there are fewer disordered weight management behaviors in transgender youth who have access to gender management clinics. Early interventions to address disordered weight management behaviors are needed for transgender youth, including screening for these health behaviors in clinical settings.
This study did not demonstrate statistically significant differences in unsafe weight management behaviors between transgender youth and cisgender females. The lack of significant differences for unsafe weight management behaviors between transgender youth and cisgender females is consistent with prior work that has hypothesized that transgender females may internalize a “thin female ideal,” similarly to cisgender females, although in our study transgender combined both transgender girls and boys in the sample.[31] A matched control study found that body dissatisfaction was associated with being assigned female at birth, regardless of gender identity.[31]
The increased risk of non-prescribed steroid use (termed as body building hormones) in transgender youth compared to cisgender males is concerning. In qualitative research, young adult males identified insecurities, body dissatisfaction, and societal pressure regarding the ideal male body as reasons for use of androgenic-anabolic.[32] Prior quantitative studies have found that 25% of transgender adults currently on hormones (such as estrogen/testosterone) had ever received them from a non-medical source both in the United States and Canada.[33,34] The motivations behind steroid use in the transgender population are not clear from this analysis, although it may be related to difficulty engaging in medical care to have hormones prescribed and further study is needed in this area.
Transgender youth were significantly more likely than cisgender females to perceive themselves as normal/underweight when they were overweight. It is unclear why this may be the case for transgender youth. Previous research has determined that girls perceive their weight status more accurately than boys and that perceiving oneself as overweight is associated with weight loss behaviors.[35,36] Although transgender youth in this study were more likely than cisgender males to engage in unsafe weight management behaviors, they were not more likely than cisgender males to perceive themselves as overweight. The findings additionally highlight the similarities between cisgender females and transgender adolescents, although all transgender youth were combined as a single group and differences between male-to-female and female-to-male youth were not able to be detected. A prior analysis of data from the MYHS found that all youth who perceived themselves as overweight or underweight had higher odds of disordered weight management behaviors.[2]
There were several limitations to this study. The wording of the question on gender identity included the response “I do not know what this question means,” which highlights that how best to ask about gender identity is not known in this age group. Youth who selected this response option (n=164) were excluded from the analysis; we also excluded participants who responded that they did not know whether or not they were transgender (n=28). Moreover, due to small sample size, we combined all transgender-identified students into a single group. It is likely that subgroups of transgender individuals (e.g., female-to-male and male-to-female) have different experiences of weight management behaviors, non-prescription steroid use, and weight perceptions. Unfortunately, we were unable to study subgroup differences among transgender youth due to small sample size. Future research should include purposeful recruitment to yield a larger sample of transgender individuals to allow for examination of diverse gender identity subgroups, including transgender girls/women, transgender boys/men, and non-binary youth who do not conform to binary gender categorizations. Responses, including height and weight, were self-report, which may be subject to recall biases.[35,37] Additionally, the highest risk students may have been absent from school on the day of the survey and are thus not included in this study. Lastly, results from a single state may not be generalizable to other states. Despite these limitations, inclusion of a gender identity question in the 2013 MYHS provided a unique opportunity to evaluate associations of gender identity in the sample. It is essential to include questions assessing gender identity in national surveillance surveys in order to evaluate how gender identity is associated with health behaviors and experiences on a larger scale to monitor health disparities facing transgender youth.
In conclusion, this study highlights the increased odds of transgender youth to engage in unsafe weight management behavior and non-prescription steroid use compared to their cisgender peers. These findings add evidence from a population-level survey to the findings from numerous case studies and adult literature that describe disordered weight management and restrictive eating in individuals with gender dysphoria.[11,12,15,16] There are several key clinical implications of these results. First, it is important for clinicians to assess gender identity and gender dysphoria in patients who present with an eating disorder given the increased risks of fasting, diet pill and laxative use in transgender youth compared to their cisgender peers. It has been suggested that addressing gender dysphoria may improve disordered eating.[11,12] Similarly, it is important for providers to assess for disordered weight management behaviors and potential eating disorders in transgender patients, particularly adolescents. Clinicians need to be aware of these risks when working with transgender youth in order to identify potential referral services that may be required, although specific guidelines that reflect the intersection of gender identity and body dysphoria are yet to be developed. Further research is necessary to inform and develop potential interventions.
Implications and Contribution:
This study explored differences in weight management behaviors and weight perceptions between transgender and cisgender high school students. In this representative sample, transgender youth had significantly higher odds of unsafe weight management behaviors and non-prescription steroid use compared to cisgender males. Interventions are urgently needed to address these health disparities.
Acknowledgements:
Drs. Austin and Guss are supported in part by the MCHB/HRSA Leadership Education in Adolescent Health (LEAH) Training grant T71-MC00009. Dr. Katz-Wise is supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health & Human Development (NIH K99HD082340). Dr. Austin is additionally supported by NIH R01 HD057368, NIH R01 HD 066963 and MCHB T76-MC00001. The authors would like to acknowledge the participants of the Massachusetts Youth Health Survey, the Massachusetts Department of Public Health, as well as Dr. Joshua Borus and the Sexual Orientation and Gender Identity and Expression Working Group for their feedback and guidance.
References
- [1].Forman-Hoffman V. High prevalence of abnormal eating and weight control practices among U.S. high-school students. Eat Behav 2004;5:325–36. [DOI] [PubMed] [Google Scholar]
- [2].Gonsalves D, Hawk H, Goodenow C. Unhealthy weight control behaviors and related risk factors in Massachusetts middle and high school students. Matern Child Health J 2014;18:1803–13. [DOI] [PubMed] [Google Scholar]
- [3].Neumark-Sztainer D, Wall M, Guo J, et al. Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare 5 years later? J Am Diet Assoc 2006;106:559–68. [DOI] [PubMed] [Google Scholar]
- [4].Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med 2016;129:30–7. [DOI] [PubMed] [Google Scholar]
- [5].Campbell K, Peebles R. Eating disorders in children and adolescents: state of the art review. Pediatrics 2014;134:582–92. [DOI] [PubMed] [Google Scholar]
- [6].Wroblewska AM. Androgenic--anabolic steroids and body dysmorphia in young men. J Psychosom Res 1997;42:225–34. [DOI] [PubMed] [Google Scholar]
- [7].Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance - United States, 2011. MMWR Surveill Summ 2012;61:1–162. [PubMed] [Google Scholar]
- [8].American Psychiatric Association. Diagnostic and statistical manual of mental disorders : DSM-5. Arlington, VA: American Psychiatric Association; 2013. [Google Scholar]
- [9].Diemer EW, Grant JD, Munn-Chernoff MA, et al. Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students. J Adolesc Health 2015;57:144–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [10].Couturier J, Pindiprolu B, Findlay S, et al. Anorexia nervosa and gender dysphoria in two adolescents. Int J Eat Disord 2015;48:151–5. [DOI] [PubMed] [Google Scholar]
- [11].Ewan LA, Middleman AB, Feldmann J. Treatment of anorexia nervosa in the context of transsexuality: a case report. Int J Eat Disord 2014;47:112–5. [DOI] [PubMed] [Google Scholar]
- [12].Strandjord SE, Ng H, Rome ES. Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned. Int J Eat Disord 2015;48:942–5. [DOI] [PubMed] [Google Scholar]
- [13].Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, Decuypere G, Feldman J, Fraser L, Green J, Knudson G, Meyer WJ, Monstrey S, Adler RK, Brown GR, Devor AH, Ehrbar R, Ettner R, Eyler RG E. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgenderism 2012;13:165–232. [Google Scholar]
- [14].Murray SB, Boon E, Touyz SW. Diverging eating psychopathology in transgendered eating disorder patients: a report of two cases. Eat Disord 2013;21:70–4. [DOI] [PubMed] [Google Scholar]
- [15].Ålgars M, Alanko K, Santtila P, et al. Disordered Eating and Gender Identity Disorder: A Qualitative Study. Eat Disord 2012;20:300–11. [DOI] [PubMed] [Google Scholar]
- [16].Hepp U, Milos G. Gender identity disorder and eating disorders. Int J Eat Disord 2002;32:473–8. [DOI] [PubMed] [Google Scholar]
- [17].Bucchianeri MM, Arikian AJ, Hannan PJ, et al. Body dissatisfaction from adolescence to young adulthood: findings from a 10-year longitudinal study. Body Image 2013;10:1–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [18].Rohde P, Stice E, Marti CN. Development and predictive effects of eating disorder risk factors during adolescence: Implications for prevention efforts. Int J Eat Disord 2015;48:187–98. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [19].de Vries ALC, Steensma TD, Doreleijers T a H, et al. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med 2011;8:2276–83. [DOI] [PubMed] [Google Scholar]
- [20].Rosenthal SM. Approach to the patient: transgender youth: endocrine considerations. J Clin Endocrinol Metab 2014;99:4379–89. [DOI] [PubMed] [Google Scholar]
- [21].Edwards-Leeper L, Spack NP. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary “Gender Management Service” (GeMS) in a major pediatric center. J Homosex 2012;59:321–36. [DOI] [PubMed] [Google Scholar]
- [22].de Vries ALC, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics 2014;134:696–704. [DOI] [PubMed] [Google Scholar]
- [23].van de Grift TC, Cohen-Kettenis PT, Steensma TD, et al. Body Satisfaction and Physical Appearance in Gender Dysphoria. Arch Sex Behav 2016;45:575–85. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [24].van de Grift TC, Cohen-Kettenis PT, Elaut E, et al. A network analysis of body satisfaction of people with gender dysphoria. Body Image 2016;17:184–90. [DOI] [PubMed] [Google Scholar]
- [25].McGuire JK, Doty JL, Catalpa JM, et al. Body image in transgender young people: Findings from a qualitative, community based study. Body Image 2016;18:96–107. [DOI] [PubMed] [Google Scholar]
- [26].Massachusetts Youth Health Survey (MYHS). Available at: http://www.mass.gov/eohhs/gov/departments/dph/programs/admin/dmoa/health-survey/myhs/. AccessedAugust 31, 2015.
- [27].Polanowicz JW, Bartlett C, Cohen B. A Profile of Health Among Massachusetts Middle and High School Students, 2013. 2014. [Google Scholar]
- [28].Prevention C for DC and. Growth Charts - Clinical Growth Charts. Available at: http://www.cdc.gov/growthcharts/clinical_charts.htm. AccessedAugust 31, 2015.
- [29].Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 Suppl :S164–92. [DOI] [PubMed] [Google Scholar]
- [30].Hadland SE, Austin SB, Goodenow CS, et al. Weight misperception and unhealthy weight control behaviors among sexual minorities in the general adolescent population. J Adolesc Health 2014;54:296–303. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [31].Witcomb GL, Bouman WP, Brewin N, et al. Body image dissatisfaction and eating-related psychopathology in trans individuals: a matched control study. Eur Eat Disord Rev 2015;23:287–93. [DOI] [PubMed] [Google Scholar]
- [32].Leone JE, Fetro JV. Perceptions and attitudes toward androgenic-anabolic steroid use among two age categories: a qualitative inquiry. J Strength Cond Res 2007;21:532–7. [DOI] [PubMed] [Google Scholar]
- [33].Rotondi NK, Bauer GR, Scanlon K, et al. Nonprescribed hormone use and self-performed surgeries: “do-it-yourself” transitions in transgender communities in Ontario, Canada. Am J Public Health 2013;103:1830–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [34].Mepham N, Bouman WP, Arcelus J, et al. People with gender dysphoria who self-prescribe cross-sex hormones: prevalence, sources, and side effects knowledge. J Sex Med 2014;11:2995–3001. [DOI] [PubMed] [Google Scholar]
- [35].Chung AE, Perrin EM, Skinner AC. Accuracy of child and adolescent weight perceptions and their relationships to dieting and exercise behaviors: a NHANES study. Acad Pediatr 13:371–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [36].Oellingrath IM, Hestetun I, Svendsen MV. Gender-specific association of weight perception and appearance satisfaction with slimming attempts and eating patterns in a sample of young Norwegian adolescents. Public Health Nutr 2016;19:265–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [37].Sherry B, Jefferds ME, Grummer-Strawn LM. Accuracy of adolescent self-report of height and weight in assessing overweight status: a literature review. Arch Pediatr Adolesc Med 2007;161:1154–61. [DOI] [PubMed] [Google Scholar]