Some girls really, really want out

On my pet subject: the intricate, obvious relationship between anorexia and gender dysphoria

Street art I spotted in Baltimore, 2019

I wanted to share a newish research article out of Germany,* which is a remarkably sensitive exploration of the ways female adolescent development can go awry—a subject that’s particularly close to my heart, as anybody who’s read anything I’ve ever written knows.

Taking female adolescence as the context in which both disorders must be understood, Alexander Korte and Gisela Gille explore the serious developmental challenges every girl must confront on the way to adulthood. Girls are often sexualized and objectified at early ages, before they have the emotional maturity to make sense of these experiences and often before they themselves have begun to explore their own sexuality. As Korte and Gille put it, “Sexuality is discovered in a girl before it unfolds within her… girls experience an external sexualization of their bodies that still bears little connection to their own feelings.” As a result, girls may suffer embarrassment and confusion and may blame themselves for attracting unwanted attention. These feelings may be triggered or exacerbated by exposure to violent and degrading pornography, sometimes shared by male schoolmates in an effort to induce “shock or shame.” Girls who have experienced sexual abuse are at particular risk. Trans identification and other disorders rooted in the desire to control or reject the body may arise as “trauma-compensatory reactions” or extreme forms of adaptive dissociation. 

Girls must also confront the ubiquitous objectification of the female body, depictions of sexuality that “shows little or no respect for girls’ age- and gender-specific feelings,” the media’s promotion and celebration of trans narratives, the relentless promotion of “self-optimization and the possibilities of body modification” more broadly (for example, in the desire for cosmetic surgeries to alter the appearance of the genitals to conform to new aesthetic norms); and the “very conspicuous, sometimes voyeuristic fascination in our society for self-harming behaviors, especially among young women who submit to trends.” 

So it’s really no wonder that adolescent girls tend to struggle with a “split” between their changing bodies and their evolving sense of self. Reconciling body and self is an arduous process and many girls and young women take detours along the way. These detours may include efforts to “stop time” by refusing to eat in the case of anorexics or by seeking puberty suppression in the case of trans-identified girls. Anorexia and gender dysphoria arise when an adolescent girl fails to maintain a sense of coherence between body and self and must employ desperate measures in order to cope. 

In both disorders, “the body becomes the venue for inner conflicts.” The anorexic girl perceives her body as being “out of control” during puberty and seeks a way to put the body “in its place, to create order.” The intense discipline that restriction requires and the “bizarre ritualization” anorexia entails “replac[e] control over one’s own life,” transforming “paralyzing feelings of powerlessness” into “feelings of power.” Along the way, the anorexic girl acquires “the aura of the extraordinary,” a form of distinction that exerts a particular appeal for “ambitious-perfectionist girls.” Anorexia serves as an “exit strategy” employed when a girl cannot find a way to accept her developing female body.  

The trans-identified girl’s psychological conflicts are similarly “projected onto the body”: “Similar to anorexia, pubescent girls are offered another, albeit particularly drastic opportunity to avoid dealing with maturity-related changes and developmental tasks and to express their individual suffering in a form that is accepted in our time and culture.” Korte and Gille remark upon the “pronounced rejection of the female body” that their young patients exhibit, noting that—in the majority of cases—there is “no pronounced desire for the physical characteristics of the opposite sex.” This suggests that, for many girls, trans is an escape hatch first, then an identity.

Compared to anorexia, gender dysphoria and trans identification offer “decisive advantages,” such as the ability to cross boundaries in a “very concrete, not just symbolic, way”—particularly compelling to young people who have built their identities around transgressive politics—as well as the “strong external validation and positive reinforcement of their disorder” that greets trans-identified adolescents, but not their anorexic peers. 

Korte and Gille illustrate how trans identification and anorexia can be understood as interconnected manifestations of deeper psychological struggles. They contrast the more sensitive psychodynamic approach to anorexia to the incurious affirmative approach that trans-identified girls meet with in many gender clinics. Korte and Gille caution that trans-affirmative approaches risk causing iatrogenic harms and urge clinicians to “be wary and question any universal idea of salvation that seeks to alleviate psychological suffering” through altering the body and to avoid pathologizing temporary crises. The role of the clinician is to compassionately challenge a patient’s fixed ideas, rather than collude with her self-rejection. 

The article is unusual in its scope, which takes into account the psyche of the individual adolescent girl with great insight and sensitivity, without neglecting the broader social, cultural, and political context in which anorexia and trans identification emerge as possible solutions to adolescent crises. The authors also draw attention to the susceptibility of the medical profession to psychic contagions and raise concerns about the implications for assessment and treatment when a form of distress is reconceptualized as a human-rights movement—that is, the point at which medical providers lose the ability to see disorder as such. 

I have to say, it also reminds me of one of my favorite essays, Hilary Mantel’s Some Girls Want Out:

Not every young woman wants to take the world up on this offer. It is possible that there is a certain personality structure which has always been problematical for women, and which is as difficult to live with today as it ever was – a type which is withdrawn, thoughtful, reserved, self-contained and judgmental, naturally more cerebral than emotional. Adolescence is difficult for such people; peer-pressure and hormonal disruption whips them into forced emotion, sends them spinning like that Victorian toy called a whipping-top. Suddenly self-containment becomes difficult. Emotions become labile. Why do some children cut themselves, stud themselves and arrange for bodily modifications that turn passers-by sick in the streets, while others merely dwindle quietly? Is it a class issue? Is it to do with educational level? The subject is complex and intractable. The cutters have chosen a form of display that even the great secular hysterics of the 19th century would have found unsubtle, while the starvers defy all the ingenuities of modern medicine; the bulimics borrow the tricks of both, and are perhaps the true heirs of those spider-swallowers. Anorexia itself seems like mad behaviour, but I don’t think it is madness. It is a way of shrinking back, of reserving, preserving the self, fighting free of sexual and emotional entanglements. It says, like Christ, ‘noli me tangere.’ Touch me not and take yourself off. For a year or two, it may be a valid strategy; to be greensick, to be out of the game; to die just a little; to nourish the inner being while starving the outer being; to buy time. Most anorexics do recover, after all: somehow, and despite the violence visited on them in the name of therapy, the physical and psychological invasion, they recover, fatten, compromise. Anorexia can be an accommodation, a strategy for survival. In Holy Anorexia, Bell remarks how often, once recovered, notorious starvers became leaders of their communities, serene young mothers superior who were noticeably wise and moderate in setting the rules for their own convents. Such career opportunities are not available these days.

*For those of you whose German is even rustier than mine, the Society for Evidence-Based Gender Medicine has just posted an English-language translation, which you can find here.