The False Analogy Between Anorexia and Gender Dysphoria

An oft-used gotcha from the anti-trans side asks if you’d give an anorexic liposuction. The question misunderstands gender dysphoria, but it misunderstands anorexia and mental illness even more.

by Evan Urquhart

If you read a lot of anti-trans propaganda you come across the same arguments over and over. One popular “gotcha” that many transphobes seem think is a clever ploy: If you think gender affirming care helps trans people, then does that mean you’d recommend liposuction to an anorexic? Well, would you? HMMMMMMM????

If you’ve never seen this line used in the wild, here are a couple of examples. The first is from an essay by an anti-trans detrans woman writing for FOX earlier today:

But just to show it’s not just one detransitioned woman’s clever line, here’s an example from a truly unhinged Washington Examiner op-ed in August:

Before we talk about why gender dysphoria is different from anorexia nervosa, let’s talk about the latter in a little more depth.

Anorexia is one of the most, some sources even say THE most, deadly psychiatric conditions a person can have. While many teens will recover after a single course of treatment, for those who don’t (and no one really understands why some young people do and others don’t), studies show that fewer than half of all adults with anorexia will ever fully recover. It is a devastating and debilitating condition, one that too often results in lifelong disability and premature death. One of my close friends suffers from AN, as she has for all fifteen years I’ve known her, and had done long before, going back to when she was a young teen.

The sneering tone conservatives employ when they bring up anorexia as a gotcha has nothing to do with concern over treatment recommendations for gender dysphoria, or for anorexia, or for any other condition. Anyone who knows the first thing about anorexia knows there’s no good treatment for it. Families go bankrupt putting their adult children through round after round of intensive inpatient care, only to have them relapse after they get out, again and again and again. If there was a surgery that worked for anorexia as well as gender affirming care works for people with gender dysphoria, doctors, parents, and patients would welcome it. It would be a game changer, it would be hailed as miraculous, and it would save a great many lives. Anorexics don’t have that because no one has found such a treatment, not because intensive talk therapy and re-feeding programs work. We know they do not.

There’s a reason that liposuction isn’t used for anorexics, and it’s not because anorexics aren’t really fat and need doctors who will stand up to them and tell them so. Not at all! It’s because, with anorexia, the obsessive focus on weight and weight loss does not improve when the anorexic loses weight. It actually gets worse. An anorexic who feels much better about themselves after losing some weight is called a dieter. We give such people liposuction and gastric bypass surgeries and drugs to help suppress their apetites all the time. It is, in fact, very likely that we do this to an excess. There’s a good amount of research that suggests the many interventions doctors use to help patients lose weight cause more harm than good. It’s even unclear whether being overweight (as opposed to obese) is associated with any negative health outcomes at all, and it is also unclear whether weight loss can improve health outcomes for people who are obese.

Many standard treatments for obesity, ironically, look a lot like what these anti-trans writers say no ethical doctor would ever do. Patients’ mental distress about their overweight appearance is routiney treated with medical interventions with few or no health benefits. Even dieting alone may be a health risk, in fact.

What does any of this have to do with trans people, or trans medical care? Well, I’m glad you asked, but it’s the transphobes who seem to think there’s any kind of connection here. Anorexia is a very serious, difficult to treat disorder that carries a high risk of death. Gender dysphoria can also be very serious if left untreated, but a robust and growing body of evidence supports an individualized treatment plan that, most typically, includes some form of medical transition based on the transgender patient’s goals. That’s what works.

We don’t necessarily know why transition greatly improves outcomes for people suffering with gender dysphoria, but we do know that it does. It can seem a little counter-intuitive for people who are used to thinking of gender dysphoria as a mental illness, but ultimately it doesn’t really matter if gender dysphoria is a mental or physical illness at all. In psychiatry, as in all medicine, all that matters is improving patients health, wellbeing, and safety, not changing their minds. Conservatives falsely think that the reason anorexics arent given liposuction is because they’re not really fat, but the truth is that, if liposuction really did improve things for anorexics the same way gender affirming care improves the picture for trans people, then doctors would recommend it in a heartbeat. And well they should.