A Dialectical Behavior Therapy-Oriented Approach to Gender-Affirming Eating Disorder Care for Youth With Gender Dysphoria.

Sam is a 15-year-old, transmasculine teen who reports gender dysphoria since early elementary school. He was referred for psychotherapy following hospitalization for a suicide attempt secondary to bullying. Clinical history revealed long-standing major depressive disorder, social anxiety, gender dysphoria, and anorexia nervosa-restricting type (AN-R). His family exhibits gender-affirming beliefs and language publicly but has struggled significantly with accepting that their assigned female at birth (AFAB) child does not perceive himself as female; they worry about social repercussions for their family. Sam's mother expressed grief at losing opportunities to do traditionally female activities with her child. Sam disclosed disordered eating behaviors (DEBs) during his clinical assessment for therapy. DEBs included periods of fasting, limiting meals to low-calorie foods, refusing to consume food or water prior to physical activity, and exercising with weights and kettlebells for 2 hours daily. He is frequently late for school because choosing his clothing takes a significant amount of time. He expressed discomfort with clothing that has waistbands or components that he can feel pressing on him because they accentuate the curves of his body. Sam is on the wrestling team and wants to be more muscular like his teammates. Although his menstrual cycles have become more irregular in the past year, Sam notes significant distress with menstrual bleeding. This is a fictional vignette based on the combined clinical experience of the authors.