Eating Disorders in Gender-Expansive Individuals

Eating disorder research—and the treatment that it informs—has long been limited by a myopic focus on thin, young, white, cisgendered women. This narrow perspective excludes marginalized groups, such as Black women, from research, leaving us with little to no empirical data on how these groups are impacted by eating disorders and how they respond to treatment interventions.

A recent study by Nagata et al (2020) was one of the first to examine eating disorders in gender-expansive populations. The researchers define gender-expansive as the spectrum of gender identities that do not fit within the binary (man or woman) identity system. This may include people who identify as agender (do not identify as having a gender), genderqueer or non-binary (gender identity is outside the binary), pangender (identification with multiple or all genders), and gender fluid (gender identity that shifts with time). Gender-expansive is distinct from transgender (identify as the gender opposite that assigned at birth, which still falls into the binary system). Previous research suggests that gender-expansive people have higher levels of psychological distress, less social support, experience more bullying, and have poorer mental health outcomes when compared to transgender and cisgender people.

This study sought to establish community norms for one of the most commonly used instruments in eating disorder research, the Eating Disorder Examination Questionnaire (EDE-Q). The researchers assessed 998 gender expansive participants from the Population Research in Identity and Disparities for Equality (PRIDE) study, a longitudinal study of adults living in the US who identify as a sexual and/or gender minority. The average age of participants was 29 years old, 79% identified as white, and 63% had completed a college degree or higher.

Results indicated that, at least once per month, 23% of participants reported dietary restraint, 12.9% reported binge eating, 7.4% reported excessive exercise, 1.4 % reported self-induced vomiting, 1.2% reported laxative misuse, and 13.8% had been diagnosed with an eating disorder by a healthcare professional. There were no significant differences in eating attitudes or disordered eating behaviors between gender-expansive individuals and transgender men. Gender-expansive individuals reported lower Restraint and Shape Concern scores than transgender women; higher Eating, Weight, and Shape Concern scores than presumed cisgender men; and lower restraint but higher Shape Concerns scores than presumed cisgender women.

This study can help clinicians interpret EDE-Q scores in gender-expansive clients. Prior to this study, there were no established community norms for the EDE-Q for gender-expansive people and they are rarely included in eating disorder research. This has made it difficult (if not impossible) for gender-expansive people to get evidence-based care; when treatments are only studied on a very specific subgroup of the eating disorder population, it is impossible to know if those same treatments are effective for people who are outside of the studied group and/or if there are unique considerations or alterations in treatment that need to be made. This bias in research leads to bias in healthcare in which marginalized groups are unable to receive treatment that has been shown to be effective in research.

Gender minority groups face unique stressors that increase the risk of eating disorders, especially in regards to the connection between body image and gender identity. The researchers posit that it is possible that gender-expansive individuals are less impacted by binary gender body ideals than transgender or cisgendered people. Clearly, gender-expansive individuals comprise a distinct group with unique implications for eating disorder symptoms and treatment, and further research is needed to better understand the complex nature of eating disorder symptoms in this population as well as the ways that gender identity intersects with other marginalized identities, such as race, which was not examined in this predominately white sample.