Table 1 Youth articles retained for review

Avila et al. [26]

n = 106

Eating disorders

64 youth transmasculine, 30 youth transfeminine, and 12 nonbinary participants. Adolescents

Cross-sectional

Eating Disorders Examination Questionnaire, two questions developed about frequency of intentional weight manipulation behaviors for gender-affirming purposes

N/A

A majority (63%) of participants reported intentional weight manipulation with the goal of altering their body type to match their gender identity

United States

Beaty et al. [55]

n = 1

Eating disorder

27-year-old trans woman patient

Case study

weight, kcal intake, phosphorous level, and phosphorus supplementation on days 1, 4, 6, 9, 10, 11, 12, 13, 71, and 92 of hospitalization

N/A

High-dose estrogen can negatively impact phosphorus levels by increasing urinary extortion of phosphorus, and thus the hypophosphatemia described in this patient was a result of increased renal losses as a result of supraphysiologic oral estrogen state

United States

Becerra-Culqui et al. [47]

n = 27,633

Eating disorder

588 transfeminine and 745 transmasculine children/youth, with cisgender referent matched controls for each TGNC individual. Racial diversity present

Cross-sectional

Age and demographics; EHR analysis that assessed the presence of various mental health diagnoses and transgender status

N/A

Eating disorder diagnoses were found to be more prevalent among transmasculine and transfeminine children compared to the reference cisgender children

United States

Becker et al. [81]

n = 202

Body image

62 adolescent trans women, 20 adolescent trans women, 50 adult trans men, and 70 adult trans women

Cross-sectional

Body Image Assessment Questionnaire: “attractiveness/self-confidence” scale, “accentuation of body appearance” scale, “insecurity/concern” scale, and “sexual-physical discomfort” scale

N/A

Adolescents had a less favorable body image compared to adults on all four scales. Transgender participants who already received medical interventions reported a less impaired body image

Germany

Becker et al. [82]

n = 864

Body image

135 trans men adults, 115 trans women adults, 235 cisgender female adult controls, and 379 cisgender male controls

Cross-sectional

Age, Hamburg Body Drawing Scale

N/A

The transgender participants reported lower satisfaction with their overall appearance. Trans men presented more extreme dissatisfaction with body features typically associated with the female sex, while trans women presented extreme dissatisfaction with features including body hair and genitalia

Netherlands, Germany, and Norway

Burke et al. [39]

n = 145,379

Eating disorder

2,983 gender minority participants and 142,396 cisgender participants. Racial diversity present

Cross-sectional

Five-item SCOFF eating disorder questionnaire

N/A

Multiracial Indigenous and Hispanic/Latinx persons (and other doubly marginalized groups) had the greatest prevalence estimates of increased ED pathology. ED prevalence was greater than expected based on the observed prevalence estimates in their respective monoracial groups

United States

Cibich and Wade [56]

N = 1

Eating Disorder

One adolescent trans man patient

Case report

BMI, number of objective binges, subjective binges, and purges per week, Eating Disorder Examination Questionnaire, Depression Anxiety and Stress Scales-21, Clinical Impairment Assessment

None

Patient viewed restrictive eating as a way to de-emphasize the feminine fat distribution and obtain a masculine physique. Client reduced ED behaviors and reduced the frequency in which he compared himself to masculine males, and reduced his global eating disorder score though cognitive behavioral therapy

Australia

Coleman and Cesnik [50]

N = 2

Body Image

Case 1: 23-year old man

Case 2: 23-year-old male

Case study

Tennessee Self-Concept Scale, Minnesota Multiphasic Personality Inventory, Beck Depression Inventory, Hamilton Depression Scale, Hamilton Anxiety Scale, Brief Psychiatric Rating Scale

N/A

Lithium carbonate therapy may alleviate the intense obsessional thinking in some cases of gender dysphoria. There may be a biomedical correlate and associated psychopathology to the obsessional drive toward body alteration through hormonal and surgical means

United States

Cooney et al. [57]

N = 1

Eating Disorder

13-year-old trans man

Case study

BMI, hormone levels

N/A

The patient became motivated to lose weight after initial weight loss resulted in decrease in pre-op chest size. Gender identity may be an important variable to assess when working with adolescents as gender dysphoria may contribute to psychosocial struggles that impact weight loss

Canada

Couturier et al. [58]

N = 2

Eating disorder

16-year-old Caucasian trans woman and 13-year-old Caucasian trans man

Case study

None noted

N/A

As eating disorder symptoms lessened, the desire to change secondary sex characteristics became evident. The increased expression of gender dysphoria was associated with a reduction in eating disorder behaviors, possibly driven by the accentuation of secondary sex characteristics as weight restoration progressed

Canada

Cusack and Galupo [27]

N = 194

Body image and eating disorder

Total 194 nonbinary adults. 122 assigned female, 61 assigned male, 4 assigned intersex, and 7 who did not respond. Racial diversity present

Cross sectional

Body Checking Questionnaire (BCQ); Body Appreciation Scale (BAS) is a positive measure of body image; Eating Disorder Examination-Questionnaire (EDE-Q)

Open-ended question about other body checking behaviors that were not reflected in the BCQ

Body checking predicted eating disorder pathology, and body image significantly improved the model. Gender congruence did not additional variance in predicting eating pathology

United States

Diemer et al. [45]

N = 289,024

Eating Disorder

479 (.17%) transgender students, 5977 (2.07%) cisgender, sexual minority male students, 1662 (.58%) cisgender unsure men, 91,599 (31.69%) cisgender heterosexual men, 9445 (3.27%) cisgender sexual minority women, 3395 (1.17%) cisgender unsure women, and 176,467 (61.06%) cisgender heterosexual women

Age and racial diversity present

Cross-sectional

Questionnaire asking about sexual orientation and gender identity, past-year ED diagnosis and behaviors including vomiting, laxative pill use, and diet pill use were assessed by questions with yes/no answers. As well as race, cigarette use, binge drinking, stress levels, athletic participation, and fraternity/ sorority membership

N/A

Transgender students had treated odds of past-year eating disorder diagnosis, past-month diet pill use, and past-month vomiting or laxative use compared to cisgender, heterosexual women. Compared to heterosexual or sexual minority transgender students, transgender students who were unsure of their sexual orientation had significantly higher rates of past-year ED diagnosis, past-month vomiting or laxative use, and past-month use of diet pills

United States

Donaldson et al. [30]

N = 5

Eating Disorder

Participant 1: 15-year-old transgender female

Participant 2: 22-year-old who presented to ED clinic at age 17 and identified as a cisgender female and then asserted gender queer

Participant 3: 19-year-old transgender man

Participant 4: 13-year-old who first identified as a transgender male at age 10 and then asserted gender nonconformity at age 13

Participant 5: 14-year-old transgender male who asserted gender identity at age 5

Case Series

BMI

Screening questions developed by the eating disorder and gender clinics

Findings suggest that gender nonconforming youth may turn to maladaptive behaviors to change their bodies as a result of the absence of timely gender dysphoria management. This study highlights several barriers to timely care, including parental refusal to support gender identity, parental rejection of gender-affirming treatment, and lack of timely referral to gender or ED clinic

United States

Duffy et al. [38]

N = 71

Eating Disorder

19 transgender women, 22 transgender men, 27 nonbinary people, 3 people with another gender identity. Racial diversity present

Measurement Testing, Cross-sectional

Eating Disorder Examination Questionnaire Short Form (EDE-QS)

N/A

The EDE-QS demonstrated internal consistency and correlated significantly with indices of disordered eating and body image. Mean values for gender identity groups did not significantly differ from one another

United States

Duffy et al. [32]

N = 84

Eating Disorder

6 women, 30 men, and 48 nonbinary participants

Adults, racial diversity present

Qualitative survey data

Demographics

Online qualitative questionnaire addressing psychiatric history, ED and treatment history, and experiences as a transgender person

One identified theme of this study regards the role of the body in eating disorder treatment, including the role of the physical body as the cause of the eating disorder, which was highlighted by about one third of participants. Others explained that the issue of body image is more complex for transgender clients and therefore eating disorder treatment needs to focus on more than a positive body image, and rather include transition in the eating disorder recovery process

United States, Europe, and Canada

Duffy et al. [46]

N = 365,749

Eating Disorder

237,844 cisgender females, 127,227 cisgender males, and 678 transgender participants

Adults, racial diversity present

Cross-sectional

Survey questions covered topics including gender identity, past-year eating disorder status, history of non-suicidal self-injury, and history of suicidal ideation and attempts

N/A

About 1.5% of the overall sample reported past-year eating disorder diagnosis or treatment, with rates higher for transgender participants than for cisgender participants. Rates of past-year NSSI, suicidal ideation, and suicide attempts were highest among transgender individuals with eating disorders (EDs)

United States

Ewan et al. [48]

N = 1

Eating Disorder

19-year-old Hispanic trans woman patient

Case report

BMI, medical labs including hormone levels

Medical history, eating disorder behaviors, motivations for weight loss, and course of treatment

The patient’s desire to lose weight and onset of disordered eating behaviors coincided with her decision to transition socially. She began testosterone suppressants for medical gender transition to aid in eating disorder recovery as her desire to appear more feminine was inextricably linked to her disordered eating behaviors

United States

Feder et al. [5]

N = 97

Eating Disorders

60 patients who were assigned female at birth (61.9%) and 37 patients who were assigned male at birth (38.1%). 58 participants identified as male and 2 identified as gender fluid

Youths

Retrospective chart review

Patient demographics including sex, gender identity, sexuality, age, height, weight, body mass index at assessment and over the course of treatment; assessment for DSM-5 criteria for Gender dysphoria and eating disorders; presence of co-morbid psychiatric diagnoses, pre-existing medical conditions, medications, medical and psychiatric admissions, diagnostic evaluations, and ED and GD-relevant treatments

N/A

95% of the sample studied endorsed body dysmorphia and gender dysphoria. Transgender men were found to have a 19 × increased risk of having a restrictive ED compared to cisgender females in the population, while transgender women were found to have a 10 × increased risk compared to cisgender females

Canada

Ferrucci et al. [83]

N = 10,415

Eating Disorder

10,415 transgender people

Cross-sectional

ICD 10 codes for eating disorders. Covariates included age, region of medical service within the United States, relationship to plan-holder, sex reported on claims, and type of insurance coverage

N/A

Unspecified feeding and eating disorders were the most diagnosed eating disorders, followed by anorexia nervosa, other specified feeding and eating disorders, bulimia nervosa, binge eating disorder, and avoidant restrictive feeding and intake disorder. Those diagnosed with any eating disorder were more likely to be young, reported as female on claims

United States

Gordon et al. [29]

N = 21

Body image and eating disorder

11 participants who identified as female, 7 as transgender, 1 as transsexual, 1 as genderqueer, and 1 as demi-girl

Adults, racial diversity present

Qualitative

N/A

Interviews covered body satisfaction, needs for gender affirming body change, stress and coping, social influences on feelings about appearance, and past or current experiences with weight and shape control behaviors, demographic characteristics, body image, and weight and shape control information

Four main themes: (1) Gender socialization processes and the development of femininity ideals; (2) Experiences of stigma and discrimination; (3) Biological processes; and (4) Resilience processes. Narratives suggest that some parents or peers might manage their anxieties or prejudices about gender identity by channeling them into more socially acceptable narratives about weight gain and fitness

United States

Grammer et al. [37]

N = 8,531

Eating disorder

230 transgender students, 8,301 cisgender students. Racial diversity present

Cross-sectional

the self-report Stanford-Washington University ED Screen (SWED) (Graham et al., 2019)

N/A

Cisgender female students and GD students reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to cisgender male students. Some SD students and GD students who met criteria for probable EDs were also more likely to report chronic ED symptoms and probable comorbid psychiatric diagnoses compared to heterosexual students and cisgender males, respectively

United States

Guss et al. [65]

N = 2,473

Eating disorder

67 transgender participants, 1,117 cisgender males, and 1,289 cisgender females

Age and racial diversity present

Cross-sectional

age, self-reported weight, height, weight management behaviors

N/A

Transgender participants had the highest prevalence of diet pill use and laxative use

United States

Hartman-Munick et al. [36]

N = 32

Eating disorder

8 transgender women, 13 transgender men, 9 nonbinary adults, and 2 who identified as another gender. Racial diversity present

Qualitative, Inductive

N/A

online forum and focus group questions about experiences with ED

Three major themes emerged from the analysis: (1) Barriers to ED screening/treatment; (2) Complexity of the relationship between EDs and gender dysphoria; (3) Need for provider education in gender affirming care practices for ED screening and treatment

United States

Hepp et al. [54]

N = 2

Eating disorder

2 identical twins with eating disorders. One had GID and one did not

Case study

Demographics, BMI

Relevant medical history

Hypotheses offered about the origins of transgender identity and dysphoria

Switzerland

Himmelstein et al. [41]

N = 9,679

Eating disorder

9,679 LGBTQ teens

Racial diversity present

Cross-sectional

Demographic data including BMI, weight-based victimization frequency, frequency of dieting, binge eating, and strategies for weight control on a 4-point scale, Godin Leisure Time Exercise Questionnaire, frequency of difficulty falling asleep, Motivations to Eat Scale

N/A

Weight based victimization associated with adverse eating, dieting, and weight-related health behaviors for sexual and gender minority adolescents

United States

Idrus and Hymans [84]

N = 30

Body image

30 transgender waria adults

Qualitative

N/A

Semi-structured interviews covering body image, shape, and efforts to change their body

Many took contraceptive hormones meant for women as a means of reshaping bodies. They also used various whitening agents to change skin color

India

Kuper et al. [72]

N = 148

Body image

148 youth receiving gender-affirming hormone therapy

Gender identity. Male, boy, or guy: 81 (55%), Male spectrum: 9 (8%), Female, girl, or woman: 52 (35%), Female spectrum: 2 (1%), Something else: 3 (2%)

Racial diversity present

Cross-sectional

Body Image Scale, Screen for Child Anxiety Related Emotional Disorders, Quick Inventory of Depressive Symptoms; Gender identity, sexual orientation

N/A

Significant decrease in body dissatisfaction, self-reported depressive symptoms, and total anxiety symptoms was observed during the follow-up period. Decreases in generalized, separation, and school-related anxiety symptoms were significant. No change in clinician report of depressive symptoms was found

United States

Lemma [51]

N = 1

Body image

1 trans woman

Case study

N/A

N/A

Transgender people are looking for identity congruence

Not known

Lin et al. [70]

N = 46

body image

13 trans men, 10 trans women, 11 cisgender males, and 12 cisgender females. Adults

Cross-sectional

Beck Depression Index, Defense Style Questionnaire, Klein Sexual Orientation Grid, FMRI

None

Transgender individuals more concerned with body image as a central feature of their identity

Taiwan

Linsenmeyer et al. [67]

N = 164

Eating disorder

128 transgender men, 28 transgender women, and 8 nonbinary people

Cross-sectional

Sick, Control, One Stone, Fat, Food Questionnaire (SCOFF), Adolescent Binge Eating Disorder Questionnaire (ADO-BED), Nine-Item Avoidant/Restrictive Food Intake Disorder

Screen (NIAS), and Hunger Vital Sign

Questionnaire about previous ED diagnosis, demographic information

A majority of participants were a healthy weight, while 17.1% were overweight, and 28.0% were obese. An estimated 8.7% reported a previous eating disorder diagnosis. 28.0% screened positive on the SCOFF, 9.1% on the ADO-BED, 75.0% on the NIAS, and 21.2% on the Hunger Vital Sign. Transgender males scored higher on the NIAS than transgender females. Those with a previous eating disorder diagnosis scored significantly higher on the Hunger Vital Sign

Lipson et al. [66]

N = 65,231

Eating disorder

1,237 gender minority students and 63,994 cisgender students

Racial diversity present

Cross-sectional

2 questions to identify gender identity, Patient Health Questionnaire, Generalized anxiety disorder scale, SCOFF screen

N/A

Demonstrated 2 to 4 times higher prevalence of depression, anxiety, eating disorders, self-injury, and suicidality in gender minority sample as compared to cisgender

United States

Manzouri et al. [71]

N = 96

Body image

28 trans men transexuals, 34 cisgender males, and 34 cisgender females

Adults

Cross-sectional

FMRI, Body perception task

N/A

Possible biological markers in own-body image network for gender dysphoria in transgender individuals

Sweden

McGuire et al. [43]

N = 90

Body image

31% trans men participants, 37% trans women participants, and 32% other gender participants

Adults, racial diversity present

Qualitative

Demographic information, Body Image Scale adapted for transgender individuals

In depth interviews about body satisfaction, eating patterns, and social acceptance

Themes identified how the intersection of gender and body size influenced body image satisfaction. This was also influenced by self and other acceptance

United States, Ireland, and Canada

Murray et al. [52]

N = 2

Eating disorder

1 23-year-old trans woman of Indian origin and 1 24-year-old trans woman of Chinese origin

2 case reports

N/A

Therapy

Masculinity and femininity play a role in eating disorders. For example, ideas of femininity lead to a drive for thinness while masculinity in eating disorders is a drive for more muscle tone

United States

Peterson et al. [85]

N = 96

Body Image

54 trans men participants, 31 trans women participants, and 15 nonbinary/ gender fluid participants

Age diversity present

Cross-sectional

Author developed questionnaire regarding interest in weight changes, past drug or alcohol use, history of bullying, history of suicide attempts, and body image concerns

N/A

A desire for weight change, either weight loss or weight gain, was associated with increased likelihood for history of suicide attempts among this sample

United States

Peterson et al. [68]

N = 249

Eating disorder

249 transgender youth seeking hormone therapy. Age diversity present

Cross-sectional

Eating Disorder Examination Questionnaire

N/A

Eating Disorder Examination Questionnaire may be appropriate for use with transgender youth

United States

Pham et al. [86]

N = 3

Eating disorder

1 transgender man and 2 transgender women

Case series

ASD severity, BMI

clinical interviews; medical records review

Transgender youth with ASD may experience diverse features of disordered eating that may or may not be uniquely related to gender dysphoria. Youth with both gender dysphoria and ASD may be at higher risk of negative clinical outcomes because of the additive effects of gender dysphoria and ASD

United States

Pistella et al. [42]

N = 31,609

Eating disorder

358 transgender individuals, 31,251 cisgender individuals; Racial diversity present

Cross sectional

California Healthy Kids Survey (CHKS) with supplementary Physical Health and Nutrition Module (PHMN)

N/A

Transgender students who felt less safe at school, participated in less exercise at school but exercised more overall, and exhibited both healthy eating habits and unhealthy eating habits

United States

Ristori et al. [49]

N = 2

Body image, eating disorder

One 14-year-old assigned male at birth

One 16-year-old assigned female at birth

Case study

Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults, The Beck Depression Inventory, the Beck Anxiety Inventory, and the Youth Self-Report subscales of Internalizing, Anxiety/ Depression, Social Withdrawal, the Body Uneasiness Test, Multi-Attitude Suicide Tendency Scale, BMI, age

N/A

In both patients, treatment to suppress puberty with gonadotropin-releasing analogues improved psychological functioning and resolved pathological eating behaviors

Italy

Roberts et al. [45]

N = 2,110

Eating disorder

633 transgender men, 63 transgender women, 443 nonbinary adolescents, and 919 cisgender adolescents. Racial diversity present

Cross-sectional

The Eating Pathology Symptoms Inventory (EPSI); Transgender Congruence Scale

N/A

Among gender minority participants, adolescents who experienced greater gender identity congruence reported lower levels of binge eating, cognitive restraint, purging, caloric restriction, and muscle building. Nonbinary/questioning assigned female at birth adolescents endorsed higher caloric restriction than cisgender girls. Transmasculine adolescents engaged in greater caloric restriction than cisgender girls and boys. Transmasculine adolescents engaged in greater muscle building than all other groups

United States

Röder et al. [73]

N = 126

Body image and eating disorder

23 transgender females and 103 transgender males

All adolescents

Cross-sectional

KIDSCREEN-27, KIDSCREEN-10,

Body Image (weight loss behavior) via one question. Hamburg Body Drawing Scale, Youth Self Report

N/A

Transgender participants had significantly lower Health Related Quality of Life scores compared to norm scores. Transgender males scored significantly lower on poor peer relations than transgender females. 50% of all adolescents in the study reported intention to lose weight or weight-loss behavior,

Germany

Romito et al. [7]

N = 9

Body image and eating disorder

7 adolescents assigned female at birth, 2 assigned male at birth

Case series

demographic survey; questionnaires assessing body image and disordered eating behaviors

Interviewers used open-ended questions to engage participants in a semi-structured discussion about their weight, shape, body, and eating behaviors both before their transition and since their transition

Three themes were described: (1) Disordered eating behaviors aimed to align the body with one’s gender identity; (2) Disordered eating behaviors related to broader mental health concerns (eating behaviors as means of coping with depression etc.); (3) The influence of developmental and social context (parent delayed treatment, romantic partnerships)

United States

Simbar et al. [74]

N = 90

Body Image

31% female participants and 69% male participants

Patients with no hormone therapy or surgery: 30,

Patients with hormone therapy: 30,

Patients with gender reassignment surgery: 30,

Adults

Cross sectional

Quality of Life questionnaire and Fisher's Body Image questionnaire

N/A

Surgery significantly improved the quality of life and body image of individuals with gender dysphoria. Body image, quality of life, and physical health were all positively correlated. Authors highlighted the significant social health on the quality of life scale

Iran

Simone et al. [28]

N = 13,584 students

Eating disorder

4,526 cisgender men, 8,820 cisgender women, and 238 transgender or genderqueer participants

College students/adults, racial diversity present

Cross sectional

Age, BMI, gender identity, sexual orientation, self-reported mental health diagnoses, stressors, substance use, eating disorders impacting academic education

N/A

Compared to cisgender male participants, cisgender women and transgender or genderqueer participants reported greater odds of past year eating pathology that impaired their academic performance and a self-reported lifetime diagnosis of anorexia nervosa

United States

Simone et al. [34]

N = 5,057

Eating disorder

1205 transgender men, 506 transgender women, 2717 gender queer or gender non-conforming, and 629 gender expansive students. Racial diversity present

Cross-sectional

SCOFF questionnaire

Demographic information

Prevalence of clinically relevant ED risk was highest among gender queer/non-conforming (GQ/NC) students (38.8%), followed by trans women (37.1%), gender expansive students (34.0%), and trans men (34.1%). Prevalence of ED risk was higher among trans men who identified as gay (36.7%), bisexual (40.4%), queer (34.6%), or another sexual orientation (44.6%) relative to heterosexual trans men (23.6%)

United States

Strandjord et al. [60]

N = 1

Eating disorder

A 16-year-old white transgender man

Case study

N/A

N/A

Case report describes adolescents with gender dysphoria where disordered eating was the presenting symptom. The patient also shared an association between a desire to appear less feminine and his eating disorder

United States

Surgenor and Fear [62]

N = 1

Eating disorder

One 25-year-old transgender woman patient. Born in New Zealand and of mixed Fijian-Indian and European ethnicity

Case study

N/A

N/A

Patient presented with an eating disorder associated with transgender identity. She used restricting and purging to obtain a more feminine shape, which she viewed as “success” as a transgender person

New Zealand

Wagner and Stevens [59]

N = 1

Eating disorder

23-year-old white transgender man patient

Case report

None

None

Review of patient diagnosed with anorexia nervosa for 6 years and reluctance to engage in treatment. Saw himself as less masculine because of eating disorder

United States

Watson et al. [6]

N = 923

Eating disorder

Adolescent sample, age and racial diversity present

Cross-sectional

Questions regarding school connectedness, family connectedness, perception of friends caring; Medical outcomes study social support survey, Questions regarding binge eating, lose weight by fasting/diet pills/laxatives/and vomiting

N/A

Higher rates of harassment and discrimination was linked to higher odds of disordered eating behavior such as binge eating, fasting, or vomiting to lose weight, while family and school connectedness and social support had a protective effective against odds of disordered eating

Canada