Disordered Eating in the LGBT Community: Unique Causes and Consequences
Eating disorders (ED) are harmful and potentially lethal conditions which affect tens millions of people in the United States. The exact cause of EDs remains unknown, but they have “the highest rates of related medical complications, hospitalizations, and mortality of all psychiatric disorders” (Duffy, Henkel, & Earnshaw, 2016, p. 136). EDs exist along a spectrum, and there are various sub-categories which include Anorexia Nervosa (AN-marked by severe limitations of food intake), Bulimia Nervosa (BN-marked by cycles of binging and purging), and Binge Eating Disorder (BED-marked by binge eating with feelings of loss of control but not purging) (Herpertz-Dahlmann, 2015). Although it is estimated that AN and BN affect around 1% and 3% of adolescents and young adults respectively, the prevalence of generalized eating disorder symptoms is much higher. For example, among high school-aged adolescents, estimates of disordered eating are as high as 25% for girls and 11% for boys (McClain & Peebles, 2016). EDs and disordered eating symptoms among adolescents are increasing and are particularly concerning because they are associated with future development of psychiatric conditions such as depression, drug use, and self-harm (Herpertz-Dahlmann, 2015).
Traditionally, eating disorders were perceived to chiefly afflict white, affluent, heterosexual, cisgender (individuals whose gender identity matches their sex assigned at birth) females, but there has been a growing movement to include individuals who do not fit into this category in ED interventions (Gordon, Perez, & Joiner, 2002; McClain & Peebles, 2016). Despite a growing recognition that members of other genders and sexualities are impacted by EDs, “most research on eating disorders and body image has focused on heterosexual, cisgender individuals” (McClain & Peebles, 2016, p. 1080). The lack of research into the causes and impact of EDs among members of the LGBT community represents an example of epistemological ignorance, in which epistemology (the production of knowledge) is impacted by the biases of those producing this knowledge. Epistemological ignorance describes the way that social ignorance (for example, heterosexism- the belief that being straight is ‘normal’ and identifying as anything else is abnormal or inferior) influences research priorities, which, in turn, reinforce social exclusion. In this case, heterosexism results in the exclusion of the LGBT community from ED research. The lack of knowledge of the causes and impacts of ED in the LGBT community, in turn, reinforce social exclusion of the community and ignore the problems that it is facing (Bowleg et al., 2017).
Because adolescence is a critical period for both EDs and sexual orientation and gender identity, ED interventions for LGBT adolescents are particularly critical (McClain & Peebles, 2016). However, the causes of body dissatisfaction (negative feelings and evaluation of one’s own physical appearance) and eating disorders among the LGBT community are vastly different from those in heterosexual, cisgender females. Although these interventions are crucial, it is also important to further develop the unique causes and consequences of ED and disordered eating among individuals of different identities within the LGBT label.
Body dissatisfaction is central to the distress experienced by those with ED, but it plays a particularly unique role in transgender populations because it also manifests in gender dysphoria, which is defined as “the incongruence that trans individuals experience between their assigned sex at birth (and the associated gender role and/or primary and secondary sex characteristics) and gender identity” (Jones, Haycraft, Murjan, & Arcelus, 2016, p. 81). Although body dissatisfaction, which can be measured in relation to one’s body as a whole or to specific body parts, is extremely common among ED patients, it is important to note the unique ways in which it impacts transgender individuals who are affected by ED. While medical intervention has been found to reduce gender dysphoria and body dissatisfaction, not all transgender individuals have access to this option, and not all body parts which cause gender dysphoria can be changed with surgery or hormones (ex: hip shape) (Jones et al., 2016). Because of this, body dissatisfaction, which has been described as “the main contributor towards the onset and manifestation of an eating disorder” among transgender individuals may persist even after gender-affirming hormone treatment or surgery (Jones et al., 2016, p. 92).
Studies have shown transgender populations do not report higher levels of clinical eating disorders, but that “a majority of [transgender] individuals reported current or past disordered eating in an attempt to suppress features of their biological gender or to accentuate features of their gender identity” (Jones et al., 2016, p. 90). For example, transgender women may internalize Western ideas of thinness as the feminine standard of beauty, but may have difficulty achieving this ideal due to bodily features which cannot be changed by either surgery or exercise (ex: broad shoulders or large hands). In this case, even if the woman had completed sexual reassignment surgery and increased her body satisfaction specific to, for example, her genitals, she could still suffer from body dissatisfaction in relation to other body parts which were not changed by the surgery. Conversely, a drive for masculinity has been reported among transgender men as the equivalent of the drive for thinness among transgender women. In the face of body dissatisfaction towards non sex-specific body parts, such as hip shape, transgender men may be at risk of unhealthy eating/exercise habits in order to achieve a body that is more traditionally ‘masculine’. These findings concerning the manifestations of gender dysphoria and body dissatisfaction emphasize the importance of holistic body satisfaction interventions for transgender individuals which examine both the psychosocial and social aspects of body image (Jones et al., 2016).
Body dissatisfaction and gender dysphoria are not the only unique risk factors that transgender populations face. Tabaac et al. examined the role of discrimination and harassment in the development of ED in transgender populations and found that 90% of the study participants had experienced discrimination at work and 47% had experienced economic discrimination. Such harassment and unjust treatment is commonly referred to as transphobia. Related to transphobia is the concept of cis-sexism, which is the social structure claiming that transgender identity is abnormal. Taken together, these manifestations of discrimination represent a potent stressor for transgender individuals and may put them at greater risk for adverse mental health outcomes. Tabaac et al.’s study found that “harassment/rejection was inversely associated with body appreciation” and that “the effect of harassment/rejection on body appreciation was fully mediated by self-esteem and satisfaction with life, resulting in multiple mediation” (Tabaac, Perrin, & Benotsch, 2018, p. 1). These results point to the interdisciplinary nature of EDs and the need for holistic treatment options which are specific to the population that they intend to serve (Tabaac et al., 2018).
Body dissatisfaction also plays a role in disordered eating among cisgender, gay and bisexual men. McClain and Peebles found that this group has “greater body dissatisfaction, and more frequently [reported] unhealthy weight control practices, disordered eating behaviors, and classic eating disorders” (McClain & Peebles, 2016, p. 1087). Although a majority of ED cases are heterosexual women, 42% of men who have ED identify as gay or bisexual. The underlying causes of this trend are not fully understood, but studies have shown higher instances of body dissatisfaction, drives for thinness, efforts to look like those in the media, and body image-related anxiety among gay college men compared to heterosexual male students (McClain & Peebles, 2016). More community-based research is needed in this field in order to fully understand the causes and consequences of media portrayal, body dissatisfaction, and ED among gay and bisexual men.
Similarly, very little is research has been done into the rates and causes of ED and body dissatisfaction among cisgender lesbian and bisexual women. Despite the overwhelming focus on women in ED literature, there are conflicting study results concerning the risk of ED among lesbian and bisexual women. For example, Jones et al. discussed one study which reported that this community was “more likely than their heterosexual counterparts to engage in unhealthy weight control behaviors” (Jones et al., 2016, p. 1085) and another which found that “lesbian and bisexual girls were happier with their bodies, put less effort to look like those in the media, and did less dieting than their heterosexual counterparts” (Jones et al., 2016, p. 1084). Before an effective intervention can be designed and implemented, it is crucial that the field of public health research produces more knowledge on the causes and consequences of disordered eating in lesbian and bisexual women.
EDs are highly complex and do not have any one, simple solution or treatment. Rather, they are ideally treated in a holistic, multidisciplinary way which may include medical, nutritional, and mental health professionals. For example, given the unique challenges presented by transphobia for the transgender community, ED interventions should also target positive influences on satisfaction with life and self-esteem, as well as healthy coping mechanisms with the stressors of cis-sexism (Tabaac et al., 2018). Similarly, the gold standard for treatment among adolescents also involves family-based therapy, but family acceptance may present a unique barrier for some LGBT individuals, including those who are experiencing disordered eating (McClain & Peebles, 2016). Although an increased focus on the role of holistic aspects of health and the social determinants of health in ED has been an important step, more research is needed in order to address the unique causes and consequences of disordered eating and body dissatisfaction in the LGBT community, as well as in sub-communities which fall under this label.
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Duffy, M. E., Henkel, K. E., & Earnshaw, V. A. (2016). Transgender Clients’ Experiences of Eating Disorder Treatment. Journal of LGBT Issues in Counseling, 10(3), 136–149. https://doi.org/10.1080/15538605.2016.1177806
Gordon, K. H., Perez, M., & Joiner, T. E. (2002). The impact of racial stereotypes on eating disorder recognition. International Journal of Eating Disorders, 32(2), 219–224. https://doi.org/10.1002/eat.10070
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Jones, B. A., Haycraft, E., Murjan, S., & Arcelus, J. (2016). Body dissatisfaction and disordered eating in trans people: A systematic review of the literature. International Review of Psychiatry, 28(1), 81–94. https://doi.org/10.3109/09540261.2015.1089217
McClain, Z., & Peebles, R. (2016). Body Image and Eating Disorders Among Lesbian, Gay, Bisexual, and Transgender Youth. Pediatric Clinics of North America, 63(6), 1079–1090. https://doi.org/10.1016/j.pcl.2016.07.008
Tabaac, A., Perrin, P. B., & Benotsch, E. G. (2018). Discrimination, mental health, and body image among transgender and gender-non-binary individuals: Constructing a multiple mediational path model. Journal of Gay and Lesbian Social Services, 30(1), 1–16. https://doi.org/10.1080/10538720.2017.1408514