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Kant et al. Plast Aesthet Res. 2026;13:4 Page 7 of 20

Table 3. Eating disorder behaviors and related concerns
Behavior Concern Assessment/Counseling need

Identify “ready to drink” supplemental nutrition that is acceptable to
Calorie restriction Surgical recovery requires calories and proper the patient and can be used post-surgery. May also be useful for
nutrition [42]
patients with ARFID
Purging/Vomiting Stress on surgical sites
Prepare the patient that nausea induced by anesthesia may be a
Oral health/dental problems that may affect trigger and make a plan in advance to address it
anesthesia [43]
Laxative use Concern that bowel prep may reactivate Used shared decision making to balance the potential risks of bowel
symptoms preparation for eating disorder recurrence with the benefits for
Increased risk of gastroparesis surgical safety [44-47]
Vaginal packing putting pressure on the colon may Prepare patient in advance to address cognitions related to previous
partially obstruct the movement of solid waste laxative use and disordered eating behaviors
(vulvovaginoplasty only)
Will the patient be able to restrict activity for long enough to
Compulsive exercise Need for activity restriction can cause depression successfully recover?
both indirectly and directly from loss of the coping
skill and the exercise-related endorphins Work on developing new coping skills that the patient can use during
the postoperative period
ARFID: Avoidant/restrictive food intake disorder.

Eating disorders
Research has repeatedly demonstrated that disordered eating is more prevalent among transgender patients
relative to their cisgender peers, with the highest occurrence among transgender men, and the lowest
occurrence associated with active gender-affirming hormone and surgical treatment [36,37] . The latter suggests
that gender-affirming care may serve a protective function in this regard, highlighting the need for access .
[38]
It also emphasizes that, in addition to the multitude of well-known reasons that people of all genders may
engage in disordered eating, there may be unique reasons that transgender patients may restrict their food
intake related to managing their gender dysphoria . Specifically, significant weight loss can affect the body
[39]
in ways that impact dysphoria such as stopping menstruation or affecting the distribution of body fat [36,39] .

Some literature also suggests that a history of anorexia and/or bulimia may add risk to the use of anesthesia
via undetected damage to the cardiovascular system . This speaks to a well-documented sequelae of acute
[40]
calorie restriction caused by malnutrition and electrolyte imbalance . While the common picture of
[41]
disordered eating is calorie restriction, purging behaviors are equally common. These can take many forms
from self-induced vomiting to the use of laxatives. Behavioral health providers should routinely assess for a
range of disordered eating behaviors, both current and historical. Patients with a history of an eating
disorder should be stable and in well-maintained recovery before they are appropriate candidates for surgery.
However, it is important for providers to assess specific concerns and challenges patients may face during
recovery to help them develop appropriate coping strategies [Table 3].

Body dysmorphic disorder
While individuals with gender dysphoria accurately perceive a disconnect between the appearance of their
gendered body and their internal identity, those with body dysmorphic disorder (BDD) inaccurately perceive
or appraise some aspect of their appearance [48,49] . In other words, people with BDD focus on perceived
problems with their appearance, while those with gender dysphoria focus on the incongruence between their
body and gender identity. They also may be distinct in their temporal focus - with those with BDD
concerned about their current appearance and people with gender dysphoria concerned about both their

current and future congruence [Table 4].
[50]