Exploring the roles of gender identity and neurodivergence in the development of eating disorders among neurodivergent trans and gender diverse people – a large-scale qualitative study

Background Trans and gender diverse (TGD) people experience disproportionately high rates of eating disorders and are more likely to be autistic and/or have attention deficit hyperactivity disorder (ADHD) than their cisgender peers. Qualitative research shedding light on the mechanisms underlying these intersections remains limited. This study explored how gender identity, autism, and ADHD intersect to shape the development and lived experience of eating disorders in neurodivergent TGD people. Methods We conducted an online survey with 260 neurodivergent TGD adults (75.4% assigned female at birth; M age = 28.0 years) in the UK, all with current and/or past experience of an eating disorder. Participants responded to two open-ended questions about factors contributing to their eating disorder. Responses were analysed using reflexive thematic analysis. Results Participants’ accounts are represented in one theme: ‘Eating disorders function as a way of managing both internal experiences and external challenges’. Within this theme, we discuss four subthemes that represent unique and intersecting contributors to distress for neurodivergent TGD adults with lived experiences of eating disorders: (1) Gaining control in an overwhelming world (2), Living in a body that does not reflect your gender (3), Negotiating identity and belonging in a cisnormative and neuronormative society, and (4) Managing bodily presentation for safety. Conclusions Findings highlight the heterogeneity of eating disorder experiences in neurodivergent TGD people and the roles of autism and ADHD. They situate eating disorders within a complex interplay of sociocultural and interpersonal environments that all impact on experiences of distress and capacity to cope with this distress. Plain english summary Trans and gender diverse people, whose gender identity does not align with their sex assigned at birth, are more likely than cisgender people to experience eating disorders. They are also more likely to be autistic or have attention deficit hyperactivity disorder (ADHD). However, we do not fully understand how gender identity, autism, and ADHD affect people’s experiences of eating disorders. We analysed written responses from 260 trans and gender diverse adults in the UK who were also autistic or had ADHD and a current or past experience of an eating disorder. Participants answered open-ended questions about the factors they thought contributed to their eating disorder via an online survey. Participants described their eating disorder as a way of coping with challenges they faced. Some of these challenges were linked to their gender diversity, autism, and/or ADHD. These challenges included feeling overwhelmed by sensory experiences, feeling uncomfortable in their body, struggling to fit into others’ expectations, feeling isolated and different to others, as well as worries about being judged or targeted, or feeling unsafe. These findings show that there is no single reason why trans and gender diverse people develop eating disorders. Support and treatment need to take into account people’s identities, life experiences, and neurodivergent characteristics.