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Examining body image satisfaction among transfeminine and cisgender female youth in Thailand: a community-based survey

BMC Psychology volume 13, Article number: 238 (2025) Cite this article

Abstract

Background

Higher levels of body image dissatisfaction play a crucial role in the development and maintenance of eating disorders. Among different age groups, adolescents tend to focus more on their body image. However, there is limited data available on body image satisfaction in transfeminine youth. This study aimed to investigate body image satisfaction among transfeminine youth compared to cisgender female youth and to identify factors associated with body image satisfaction in transfeminine youth. Factors such as exercise and hormone intake were examined for their potential influence on body image satisfaction.

Methods

We developed a self-administered questionnaire to survey a sample of 600 youth (212 transfeminine and 388 cisgender female), aged 12–25 years, between 2021 and 2022. Body image satisfaction was assessed using the Body Image Concern Inventory Score (BICI), with a higher BICI score indicating greater body image dissatisfaction.

Results

A total of 209 transfeminine youth and 378 cisgender female youth participated in the study. The results showed that transfeminine youth reported higher levels of body image dissatisfaction than cisgender female youth, with mean ± SD scores of 59.3 ± 15.8 and 50.2 ± 15.9, respectively. Notably, regular exercise was associated with greater body image satisfaction (adjusted b = -7.53 [95% CI -14.78 to -0.27]; p-value = 0.04), while gender-affirming hormone intake did not show a significant association with body image satisfaction.

Conclusions

These findings emphasize the importance of evaluating body image among transfeminine youth and suggest that promoting regular exercise may be an effective strategy to reduce body image dissatisfaction in this population.

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Background

Body image encompasses an individual’s perception of their body’s size, shape, and form, along with the emotional responses associated with these physical characteristics and specific body parts [1]. It transcends mere physical perception by incorporating attitudes, experiences, and perceptions influenced by self-observation and the reactions of others [2]. Understanding body image is crucial, as it varies across developmental stages and is influenced by sociocultural factors.

Transfeminine individuals are those assigned male at birth who identify with a feminine gender identity to a greater extent than with a masculine one [3]. Cisgender individuals are those whose gender identity aligns with their sex assigned at birth [4].

Body image perceptions vary across developmental stages. Early adolescents (10–13 years) often grapple with body image due to rapid physical changes during puberty, uncertainties about appearance, peer comparisons, and a growing interest in sexual anatomy [5, 6]. Middle adolescents (14–17 years) continue to experience pubertal changes, which can heighten body dissatisfaction and concerns about physical appearance [6, 7]. This period is associated with increased preoccupation with body image and a higher risk of developing eating disorders [8, 9]. Late adolescents (18–21 years) begin to achieve physical maturation, but body image concerns may persist due to societal and peer influences, with ongoing risks of eating disorders [10, 11]. Young adults (22–25 years) typically exhibit more stable body images; however, issues from adolescence, including body dissatisfaction and eating disorders, often persist into early adulthood [12, 13].

Different cultures and environments have varying standards of ideal body image, influenced by cultural norms, media representations, and societal expectations [14]. In some cultures, a thinner body is idealized, while others may value a fuller figure [15]. These differing standards impact individuals’ body satisfaction and can contribute to body image disturbances when personal appearance does not align with cultural ideals [16]. Understanding these cultural nuances is essential for effectively addressing body image issues in diverse populations.

Adolescents are more focused on body image than other age groups, with eating disorders commonly beginning during this period [8, 9]. High levels of body image dissatisfaction, frequent body-checking behaviors, and significant body image disturbances are notably associated with the development and persistence of eating disorders [17,18,19]. These factors are particularly impactful among transgender youth, where they also contribute significantly to the prevalence of gender dysphoria [20, 21]. A study reported that 70% of transgender individuals experienced some level of body dissatisfaction [20].

The importance of studying body image dissatisfaction among transfeminine youth is underscored by findings from various studies across Germany, Austria, Switzerland, the United Kingdom, and Iran. These studies have consistently reported heightened body image concerns, increased dissatisfaction, and more frequent body-checking behaviors in transfeminine adults compared to cisgender females [17, 22,23,24]. Furthermore, research investigating the connection between gender roles and attitudes towards body satisfaction reveals that femininity is positively correlated with increased susceptibility to body dissatisfaction and eating disorder risks. Conversely, masculinity often acts as a protective factor against such dissatisfaction, irrespective of an individual’s biological gender [22, 25, 26].

However, most research on body image dissatisfaction among individuals assigned male at birth who experience gender identity incongruence focuses on adults, leaving a notable lack of data on transgender youth—especially in Thailand and other Asian countries [27]. This gap hinders understanding the influence of cultural and environmental factors on body image standards and impedes the development of appropriate interventions for this vulnerable group.

Several factors may influence body image satisfaction among transfeminine youth. Exercise regularity has been associated with improved body image and psychological well-being in adolescents; regular physical activity can enhance self-esteem and promote a positive perception of one’s body [28, 29]. Hormone intake, used by transgender individuals to align their physical characteristics with their gender identity, can impact body satisfaction by promoting physical changes congruent with their gender identity, potentially reducing gender dysphoria and improving overall well-being [29]. Alcohol consumption and smoking have been linked to negative body image and may serve as maladaptive coping mechanisms for body dissatisfaction, exacerbating health risks and impeding positive body image development [30, 31]. Understanding these factors is crucial for developing interventions to improve body image satisfaction in this population.

Based on the literature, we hypothesize that transfeminine youth will exhibit higher levels of body dissatisfaction compared to cisgender female youth. Additionally, factors such as exercise regularity, hormone intake, alcohol consumption, and smoking will significantly influence body image satisfaction among transfeminine youth.

To address this knowledge gap, the present study was designed with three primary objectives: 1. to investigate body image satisfaction among transfeminine youth, 2. to compare body image satisfaction between transfeminine youth and cisgender female youth, and 3. to identify factors influencing body image satisfaction in transfeminine youth.

Methods

Design

This study employed a cross-sectional design and was conducted from September 2021 to October 2022.

Participants

The survey targeted transfeminine and cisgender female youth aged 12–25 years, recruited both onsite and online. Onsite participants were recruited from pediatric outpatient and gender health clinics at King Chulalongkorn Memorial Hospital and the Tangerine Clinic (a transgender-specific health clinic) in Bangkok, Thailand. Online participants were recruited through social media platforms, including an official LINE account, Facebook, and Twitter. Only authorized personnel had access to the data, and all participants completed the questionnaire independently. To ensure participants could complete the self-administered questionnaire independently, cognitive and/or vision ability was part of the eligibility criteria for this study.

Procedure

Informed consent was obtained from all participants, with a waiver of parental consent for adolescents aged 12–18 years to protect those who had not disclosed, or did not wish to disclose, their LGBTQ identity to their parents, given the minimal risk posed by the study. The study protocol was reviewed and approved by the Institutional Review Board of the Faculty of Medicine at Chulalongkorn University, Bangkok, Thailand (No. 613/64). To ensure confidentiality, no personal identifiers were collected, and all procedures adhered to relevant ethical guidelines and regulations, including the Declaration of Helsinki, the Belmont Report, and the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) guidelines. These guidelines were followed to protect participants’ rights, privacy, and well-being throughout the study.

Measures

Questionnaire

The questionnaire included four sections:

  1. 1.

    Confirmation of Sex Assigned at Birth and Gender – Participants’ gender identity was determined using a binary question asking whether they identified as transfeminine or cisgender female. For transfeminine participants, this question was repeated in the sociodemographic section with additional clarification. Participants were asked: “Some people describe themselves as transfeminine when their sex at birth was male, but they think or feel their gender is female. Are you transfeminine (in Thai: kathoey, phuying kham phet, and sao praphet song)?” Response options were: (A) No, I am not transfeminine; (B) Yes, I am transfeminine; (C) I am unsure if I am transfeminine; or (D) I do not understand this question [32]. As there is no single term in Thai that directly translates to ‘transfeminine individuals,’ the questionnaire included a two-step process to confirm participants’ understanding of this term.

  2. 2.

    Sociodemographic Data – Information collected included gender, age, underlying health conditions, school/university characteristics (region, community type, and type of institution by sex), religion, smoking, alcohol consumption, exercise frequency, and gender-affirming hormone use. Regular exercise was defined as exercising more than three times per week, and irregular exercise as less than three times per week [33,34,35]. Gender-affirming hormone use was categorized as “ever used” or “never used.”

  3. 3.

    Anthropometric Data – Body weight, height, BMI, and waist circumference were collected. BMI was calculated as weight (kg) divided by height squared (m²) and classified into four categories based on the Thai growth chart by age and sex: severely underweight (< 16.5 kg/m²), underweight (below − 2SD for age or 16.5–18.5 kg/m²), normal (-2SD to + 1SD for age or 18.5–23 kg/m²), overweight (+ 1SD to + 2SD for age or 23–24.9 kg/m²), and obese (above + 2SD for age or ≥ 25 kg/m²) [36]. Transfeminine participants were categorized using the male growth chart. High waist circumference was defined as > 90 cm for transfeminine participants and > 80 cm for cisgender female participants, according to the Clinical Practice Guideline for obesity in children and adolescents by The Royal College of Pediatricians of Thailand [33].

  4. 4.

    Body Image Concern Inventory (BICI) – The BICI is a reliable and valid self-report instrument designed to assess dysmorphic concerns, demonstrating high internal consistency (Cronbach’s alpha of 0.93 and item-total correlations ranging from 0.32 to 0.73) [37]. The inventory includes 19 questions covering six domains: [1] checking and camouflage behavior [2], reassurance seeking [3], social concern [4], appearance-related avoidance [5], dissatisfaction and concern about appearance, and [6] consultation with medical experts about appearance.

The BICI overall score is calculated by summing the responses to each of the 19 items. Each item is rated on a Likert scale from 1 (never) to 5 (always), indicating the frequency of body image concerns or behaviors. The total possible score ranges from 19 to 95, with higher scores reflecting greater body image dissatisfaction. A score above 72 suggests clinical concern for body dysmorphic or eating disorders.

Permission to use the BICI was obtained from Heather Littleton (Copyright February 2021). The questionnaire was translated into Thai and back-translated by The Chalermprakiet Center of Translation and Interpretation, Faculty of Arts, Chulalongkorn University, Bangkok, Thailand (Supplement 1).

Data analysis

Sociodemographic, anthropometric data, and BICI scores were presented as mean with SD or median with interquartile range for continuous variables, while categorical variables were displayed as frequencies and percentages. Differences in continuous data between the two groups were analyzed using independent sample t-tests, and differences in categorical data were assessed with Chi-square tests. Predictors of BICI scores were evaluated using univariable (unadjusted) and multivariable (adjusted) linear regression analyses. The multivariable model was developed using covariates with a p-value < 0.15 from the univariable model [38]. All p-values reported are two-sided, with statistical significance defined as p < 0.05. Data analysis was conducted using STATA version 15.1.

Results

A total of 212 transfeminine youth and 388 cisgender female youth participated in this study. Three transfeminine and 10 cisgender female participants were excluded due to unconfirmed gender, leaving 209 transfeminine and 378 cisgender female youth for analysis.

Demographic data

The transfeminine youth had a slightly higher median age (19 years, IQR 17–21) than cisgender females (18 years, IQR 16–19) (p < 0.001) (Table 1). A larger proportion of transfeminine youth were in the young adult age group (22–25 years) at 23.4% compared to 9.3% in cisgender females (p < 0.001). Most participants were from Bangkok (33.7%) or Northern Thailand (25%), with significant differences in regional distribution between the groups (p < 0.001). Nearly all attended coeducational (mixed gender) schools, with 7.7% of transfeminine youth in boys’ schools and 6.1% of cisgender females in girls’ schools. Differences in school type (public, private, or international) were also observed, with transfeminine youth more likely to attend private schools (p < 0.001). Community type showed a slight difference, with a higher proportion of transfeminine youth from urban areas compared to cisgender females (p = 0.02). Religion differed between groups, with a higher percentage of transfeminine youth identifying as Buddhist (p < 0.001). Irregular exercise was common across both groups (p = 0.53), while 90% of transfeminine youth reported using gender-affirming hormones.

Table 1 Demographic characteristics of study participants
Full size table

Anthropometric data

As shown in Table 2, transfeminine youth had a significantly higher median weight (56 kg, IQR 52–65) and height (171 cm, IQR 167–175) compared to cisgender females, who had a median weight of 50 kg (IQR 45–59) and height of 160 cm (IQR 155–164) (p < 0.001 for both weight and height). Despite these differences, the median BMI was similar between the two groups (19.7 kg/m² for transfeminine youth vs. 19.6 kg/m² for cisgender female participants; p = 0.97). Both groups had a similar distribution across BMI categories, with most participants falling within the “normal” range (42.4%). A slightly higher percentage of cisgender females had a high waist circumference (15.3%) compared to transfeminine youth (11.5%), although the majority of both groups maintained a normal waist circumference (p = 0.20).

Table 2 Anthropometric data of the study participants
Full size table

Body image satisfaction

Table 3 shows that, out of a possible 95 points on the BICI scale, transfeminine youth demonstrated significantly higher body image dissatisfaction than cisgender female youth, with mean scores of 59.3 (SD 15.8) and 50.2 (SD 15.9), respectively (p < 0.001). A higher BICI score indicates greater body image dissatisfaction, and notably, 23% of transfeminine youth had scores exceeding the clinical concern threshold of 72, compared to only 8.7% of cisgender female youth (p < 0.001). This threshold suggests potential clinical concerns for body dysmorphic or eating disorders [37].

Table 3 Comparison of mean BICI scores by groups
Full size table

Subgroup analyses by age, BMI category, waist circumference, and exercise frequency revealed that transfeminine youth had consistently higher BICI scores across nearly all subgroups. Age-specific analyses showed significantly higher BICI scores among transfeminine youth compared to cisgender females across early, middle, and late adolescence (p < 0.001, p = 0.03, and p < 0.001, respectively), but not in young adults (p = 0.07). In BMI categories, transfeminine youth in the underweight, normal, overweight, and obese groups scored significantly higher than cisgender females (p < 0.001, p < 0.001, p = 0.03, and p = 0.005, respectively), though scores were similar among those classified as severely underweight (p = 0.82).

Waist circumference was another factor, with transfeminine youth reporting significantly higher BICI scores in both normal and high waist circumference groups compared to cisgender females (p < 0.001 and p = 0.001, respectively). Exercise frequency also influenced BICI scores, as transfeminine youth scored significantly higher in both the “never” and “irregular” exercise groups compared to cisgender females (p < 0.001 for both), while no significant difference was found among those who engaged in regular exercise (p = 0.12).

These findings underscore a greater level of body image dissatisfaction among transfeminine youth across nearly all subgroups, as well as across the six domains of the BICI (Supplement 2).

In the univariate analysis (Table 4), BMI, waist circumference, and regular exercise were associated with BICI scores in transfeminine youth. Higher BMI (b = 0.83, 95% CI 0.38 to 1.27; p < 0.001) and waist circumference (b = 0.62, 95% CI 0.21 to 1.03; p = 0.003) correlated with higher BICI scores, while regular exercise was linked to lower scores (b = -8.1, 95% CI -15.54 to -0.67; p = 0.03). In the multivariate analysis, regular exercise remained the only significant factor associated with reduced BICI scores (adjusted b = -7.53, 95% CI -14.78 to -0.27; p = 0.04), while other factors such as age, BMI, and waist circumference were not significant.

Table 4 Factor related to BICI score in transfeminine
Full size table

Discussion

The purpose of this study was to investigate body image satisfaction in transfeminine youth compared to cisgender female youth. Results showed that transfeminine youth had lower body image satisfaction than cisgender female youth across early, middle, and late adolescence, consistent with previous adult studies [17, 22,23,24]. Early adolescence is a critical period for self-concept and identity formation, during which individuals become increasingly sensitive to body changes, appearance, and attractiveness. For transfeminine youth, the onset of secondary sex characteristics—such as testicular enlargement, genital growth, facial and body hair, and voice changes—can conflict with their gender identity, leading to heightened body image dissatisfaction. This aligns with findings that early adolescent transfeminine youth report higher body image dissatisfaction compared to other age groups [21].

Body image concerns among transfeminine youth peak in early adolescence and remain relatively stable through middle adolescence, late adolescence, and young adulthood. This pattern may be due to the initial incongruence between gender identity and the development of secondary sex characteristics in early adolescence, a mismatch that persists with minimal change in later stages. Research supports that these concerns are most pronounced in early adolescence and tend to stabilize as development continues [21]. In contrast, body image satisfaction in cisgender female youth tended to decline with age, consistent with previous studies [39]. This may reflect increases in BMI and body fat after puberty, which can contribute to feelings of being overweight or obese among cisgender females [12, 40].

The subgroup analysis by BMI category, waist circumference, and exercise frequency further revealed that transfeminine youth generally had lower body image satisfaction than cisgender female youth, except among those classified as severely underweight. Previous research has shown that low-weight cisgender female youth often report higher body image satisfaction [41, 42], likely due to societal ideals that favor thinness as attractive. Thin-ideal internalization has also been strongly linked to increased body monitoring and body image dissatisfaction among transfeminine youth [19]. Our findings suggest that severely underweight cisgender female and transfeminine youth may perceive themselves as aligning with societal standards of attractiveness, resulting in comparable levels of body image satisfaction.

Regarding factors influencing body image satisfaction among transfeminine youth, regular exercise emerged as the only significant factor associated with greater satisfaction. Engaging in regular physical activity may enhance self-perception and positively alter perceptions of body fatness, thereby improving body image satisfaction [13, 43].

In our study, a higher percentage of transfeminine youth reported using gender-affirming hormones compared to other studies [1, 20, 44]. In Thailand, over-the-counter access to contraceptive pills without a physician’s prescription may contribute to this finding. However, the use of gender-affirming hormones was not significantly associated with body image satisfaction. While such hormones can bring physical appearance closer to that of cisgender females, thereby potentially enhancing self-perception, they may not necessarily change attitudes, experiences, or perceptions of others’ reactions [45].

Additionally, we found no significant impact of school characteristics (region, community type, type grouped by sex) or religious affiliation on body image satisfaction among transfeminine youth.

This study has several strengths, including its focus on body image satisfaction among transfeminine youth, an under-researched area, and the inclusion of a diverse age range spanning early, middle, and late adolescence, allowing for a more comprehensive view of body image concerns at various developmental stages. Conducting the study in Thailand also adds contextual relevance by providing insights into body image concerns within a Southeast Asian cultural setting, which is often underrepresented in existing literature. Additionally, identifying regular exercise as a factor associated with improved body image satisfaction highlights a modifiable aspect that could inform intervention strategies. However, the study has limitations. The cross-sectional design restricts the ability to draw causal conclusions, and findings may have limited generalizability outside the Thai context. Moreover, the reliance on self-reported data introduces a risk of social desirability bias, especially among early and middle adolescents, potentially impacting the accuracy of responses. Finally, while a pilot version of the Thai BICI was used to ensure understanding, this tool has not been formally validated for reliability and consistency within the Thai population. Future research should explore these aspects further and investigate comorbidities such as gender dysphoria, depression and eating disorders to expand understanding of body image satisfaction in this population.

Conclusion

In conclusion, this study highlights significant body image dissatisfaction among transfeminine youth compared to cisgender female youth, with early adolescence identified as a critical period for heightened concern. Regular exercise emerged as the only factor significantly associated with improved body image satisfaction, underscoring its potential role in supportive interventions. Despite the high usage of gender-affirming hormones among transfeminine youth, hormone use was not linked to body image satisfaction, suggesting that physical alignment alone may not fully address body image concerns.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to thank the Tangerine clinic and the Buddy CU clinic for their assistance. We would also like to thank Dr. Michael Ullman, research affair, Faculty of Medicine, Chulalongkorn University, for kindly reviewing and editing our English article.

Funding

This study was supported by a grant from Ratchadapiseksompotch Fund, Faculty of Medicine, Chulalongkorn University, Grant No. GA65/03.

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Authors and Affiliations

  1. Division of Ambulatory Pediatrics, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand

    Thitaporn Prownpuntu, Nadvadee Aungkawattanapong, Jarujan Subchartanan, Orapa Suteerojntrakool, Therdpong Tempark & Chansuda Bongsebandhu-phubhakdi

  2. Center of Excellence in Pediatric Nutrition, Division of Nutrition, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

    Orapa Suteerojntrakool

  3. Center of Excellence in Transgender Health (CETH), Chulalongkorn University, Bangkok, Thailand

    Chansuda Bongsebandhu-phubhakdi

Authors
  1. Thitaporn Prownpuntu
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  2. Nadvadee Aungkawattanapong
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  3. Jarujan Subchartanan
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  4. Orapa Suteerojntrakool
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  5. Therdpong Tempark
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  6. Chansuda Bongsebandhu-phubhakdi
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Contributions

T.P.: Conceptualization, Methodology, acquisition of data, Formal Analysis, Methodology, Writing – Original Draft PreparationN.A & J.S. & O.S. & T.T: Conceptualization, Methodology, ValidationC.B.: Project Administration, Resources, Supervision, Visualization, Funding Acquisition, Writing – Review & Editing conceived and submissionAll authors reviewed the manuscript.

Corresponding author

Correspondence to Chansuda Bongsebandhu-phubhakdi.

Ethics declarations

Ethics approval and consent to participate

Informed consent was obtained from all participants. We obtained a waiver of parental consent for adolescents aged 12–18 years as the research posed a minimal risk and could have presented potential harm for adolescents who had not or did not wish to divulge their LGBTQ identify to their parents. This study protocol was reviewed and approved by the Institutional Review Board of the Faculty of Medicine of Chulalongkorn University in Bangkok, Thailand (No. 613/64). No names or personal details were collected to ensure confidentiality and privacy. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Ethical Standards Disclosure

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Ethics Committee of the faculty of Medicine, Chulalongkorn University.

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linkedin.com/in/chansuda-bongsebandhu-88844748.

Financial support

Our study received financial support from from Ratchadapiseksompotch Fund, Faculty of Medicine, Chulalongkorn University, Grant No. GA65/03.

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Prownpuntu, T., Aungkawattanapong, N., Subchartanan, J. et al. Examining body image satisfaction among transfeminine and cisgender female youth in Thailand: a community-based survey. BMC Psychol 13, 238 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02546-x

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s40359-025-02546-x

Keywords

BMC Psychology

ISSN: 2050-7283

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