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Anorexia nervosa is a mental illness. It is classified as a mental illness in every major psychiatric diagnostic system, including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5-TR) and the International Classification of Diseases, 11th Revision (ICD-11). Few clinicians hesitate to say so.
Yet when the conversation turns to gender dysphoria, many professionals suddenly become reluctant to ask whether they are looking at another form of mental illness. That question has itself become controversial. Why should that be? Could it be fear of condemnation from trans-identified activists who often speak about mental illness in deeply derogatory terms?
This is troubling because mental health professionals should be leading the effort to destigmatise the term, not buying into the idea that it is something to avoid. Every day psychotherapists like myself sit with people who are suffering. We witness depression, obsessive compulsive disorder, anorexia, gender dysphoria, addiction, anxiety disorders and countless other forms of mental illness. If clinicians begin behaving as though the phrase itself is too uncomfortable to say, they send a message that there is something shameful about belonging to that group. But there isn’t.
Somewhere along the way, the phrase mental illness has itself become contentious. Many people recoil from it. Psychologists, psychotherapists and psychiatrists are increasingly reluctant to use it. They prefer softer language. They reach for phrases that feel less confronting. Mental illness is beginning to sound like a slur, as though it were an accusation rather than a clinical description. Yet if we recognise one pattern of self-destructive thinking as a mental illness, why should we hesitate to explore whether similar psychological processes may be operating elsewhere?
Mental illness is part of the human condition. Life can overwhelm people. Trauma can ruin people’s lives. Loneliness can undo us. Some people appear to be born more sensitive to pain than others, while others reach a breaking point after years of carrying too much. Kind and sensitive people often struggle more often because they feel their emotions so deeply. None of this deserves embarrassment. Nobody should be encouraged to believe they must avoid the term mental illness as though it were a shameful phrase that makes them less than others.
Nobody knows what life will bring. A serious illness, a bereavement, a divorce, years spent caring for someone else, financial collapse or childhood trauma that suddenly resurfaces can alter the course of a person’s life. The boundary between mental health and mental illness is far more fragile than most people imagine and there is no clear line separating healthy people from mentally ill people. Almost every one of us will love someone who develops, or has developed, a mental illness. Many of us will experience one ourselves. Clinicians should be part of the solution by helping to remove the shame that has gathered around those words, not part of the problem by encouraging people to believe they need a different label.
If we, as psychologists, psychotherapists and psychiatrists, begin treating the phrase mental illness as something to tiptoe around, we strengthen the stigma we are trying to dismantle. We do a disservice to the very people we hope to help. Our patients deserve better than that.
These thoughts were very much on my mind as myself and Mia sat down with psychologist Deanne Jade for this week’s episode of Beyond Gender. Deanne founded Britain’s National Centre for Eating Disorders and has spent over forty years treating people with anorexia and other eating disorders.
The similarities between patients who have developed rapid-onset gender dysphoria and those with anorexia are impossible to ignore. Relentless self-criticism, compulsive body checking, perfectionism, rigidity, the conviction that altering a healthy body will finally bring relief, and the desperate search for certainty all appear in both groups. Eating disorder clinicians are literally decades ahead of us. They have spent decades developing ways to understand and work with this psychological pattern. If we want to understand rapid-onset gender dysphoria, we have much to learn from them - the very last thing we should do is shy away from these similarities as if the sufferer has something to be ashamed about.
It is helpful for loved ones of people with anorexia, as well as those with ROGD, to know that a harsh internal voice constantly reinforcing the central belief is almost always present. They then gravitate towards communities that celebrate self-destructive behaviour and reward commitment to the identity.
Deanne, Mia and I discuss how anorexia can become a monomania, which functions as a protective mechanism, where a person’s thinking becomes organised around a single consuming fixation. The fixation is protective, offering certainty and, over time, crowding out everything else. The specific object of the fixation - whether it is becoming thinner or medically transitioning - matters less than the psychological process itself.
We explain how this maps closely onto the psychiatric concept of the extreme overvalued belief. In this context, the individual’s belief that they must medically transition becomes fused with their identity. They are utterly uninterested in any evidence that challenges this belief, dismissing it as coming from people who simply do not understand. The individual searches only for information that confirms the belief, while anything that creates doubt produces extreme anxiety.
Of course, parents of trans-identified children are very familiar with this mindset. They know all too well the tendency to walk on eggshells around their child because they fear a meltdown if the child becomes agitated. Over time, this can feel extremely controlling because, just like the frogs in boiling water, parents and other family members learn to speak and behave in ways that are less likely to agitate the ROGD individual. Meanwhile, their online world becomes dominated by transition-related content. Their friendship group narrows. They become fixated on language, and every conversation circles back to being trans.
Deanne argues that anorexia does not arise from a single cause. Certain people may be born with traits such as rigidity, perfectionism and difficulty expressing emotion. Those traits do not determine the outcome, but they do create a susceptibility. When those vulnerabilities collide with a compelling idea during adolescence, the fixation can take hold.
The same framework may help explain rapid-onset gender dysphoria. Certain young people are especially susceptible to particular contagions. Eating disorders have always existed, but their prevalence exploded once they entered popular culture. Magazines, television and, later, online communities spread the idea far beyond the small number of original cases.
“I've always thought there's a kind of golden thread between anorexia, bulimia, as I now call it, forevermore, self-harming, and gender dysphoria…And those contagions have got bigger and better. Karen Carpenter, obviously, for anorexia, and then, bulimia for those Beverly Hills 90210, all those all those teenage TV shows, were a big vector, as well as the magazines. Then self harm seemed to kind of accelerate through, from the 80s to the 90s to the noughties….They always existed, but they were vanishingly rare. And now gender dysphoria has taken the baton as the new way, and it's a social contagion spread among teenage girls and then out to the wider society, to the boys and to the adults.”
One of the strongest parallels is the belief itself. Anorexia is maintained by thoughts such as “thinner is better” or “food is dangerous.” Those beliefs are experienced as truth rather than symptoms. They organise behaviour, justify suffering and become almost impossible to question.
Gender dysphoria often operates in much the same way. The belief becomes “I cannot live unless I medically transition.” If that belief functions as an extreme overvalued belief, then immediately affirming it will reinforce the very process that has trapped the person.
Eating disorder specialists know that we cannot argue someone out of anorexia - and direct confrontation usually strengthens the illness. Recovery begins when the person reaches a turning point, when they become able to imagine another life. That turning point cannot be forced, but therapy can help create the conditions in which it becomes possible.
They think it's a noble quest. They start just completely narrowly focusing on all trans-related material. Hadley Freeman wrote about it in her book Good Girls. She was writing about anorexia, and she talked about the saints who were starving themselves back in centuries past and I realized there's a puritanical zeal that actually is very recognisable in the disposition of the act of anorexic and the active gender dysphoric (for want of a better phrase) that they are overcome by something. It almost feels religious or spooky or something… they've got these crazed eyes.
Eating disorder treatment therefore works around the illness rather than attacking it head on. Therapists help patients develop flexibility, recognise rigid thinking, reduce compulsive body checking and reconnect with values outside the disorder. Gradually the fixation loses its grip. This may be one of the most important lessons for clinicians working with gender distress. Instead of exploring gender, debating identity or rushing towards medical intervention, therapy can strengthen psychological flexibility, widen the person’s world and help them reconnect with relationships, interests and hopes that have nothing to do with gender.
The goal of treatment for anorexia is to help the individual understand their own mind, loosen the grip of the fixation and gradually reclaim their life. That task becomes much more difficult when clinicians working with gender dysphoria are determined to avoid any mention of mental illness and are constrained by policies and legislation that fail to recognise psychological defence mechanisms.
People who are suffering deserve compassion, curiosity and good care. They also deserve clinicians who are prepared to call mental illness by its proper name without flinching or behaving as though there is something shameful about doing so.
I’d love to hear your thoughts. Please leave any insights, comments, or questions in the comments section below.