Gender Identity and Eating Disorders

Most research about eating disorders is conducted with cisgender women. Cisgender is used to indicate when one’s current gender identity matches the sex they were assigned at birth. In contrast, transgender is used to indicate when one’s current gender identity does not match the sex they were assigned at birth. Gender identity describes one’s innermost concept of self as male, female, or a blend of both or neither. In contrast, sexual orientation describes one’s sexual attraction. We often think of eating disorders as being most common in cisgender heterosexual women, especially those from middle or upper class backgrounds. However, new research indicates that transgendered individuals may represent an often overlooked at-risk population.

In a study recently published in Journal of Adolescent Health, Diemer et al (2015), used data from the American College Health Association’s National College Health Assessment (ACHA-NCHA) which included 289,024 participants from students in 223 U.S. colleges and universities between 2008-2011. Students anonymously completed a survey that assessed for gender identity, sexual orientation, past year eating disorder (ED) diagnosis, compensatory behaviors (vomiting/laxative use) in past 30 days, and use of diet pills in past 30 days. Based on responses to the questions about gender identity and sexual orientation, the researchers grouped participants into the following 7 categories: transgender (n=479, 0.17%), cisgender sexual minority (SM) (gay/bisexual) men, cisgender unsure men (n=1,662, 2.07%), cisgender heterosexual men (n=91,599, 31.69%), cisgender SM (lesbian/bisexual) women (n=9,445, 3.27%), cisgender unsure women (n=3,395, 1.17%), cisgender heterosexual women (n=176,467, 61.06%). Due to the relatively low number of transgender respondents, the authors were unable to divide this group by sexual orientation.

Results indicate that the prevalence of ED diagnosis, compensatory behaviors, and use of diet pills were highest among transgender students and lowest among cisgender heterosexual male students. Specifically, transgender students had significantly greater odds of ED diagnosis (4.62 times greater than cisgender heterosexual women who were the reference group), compensatory behaviors (2.46 times greater), and diet pill use (2.05 times greater). Transgender students were at the highest risk compared to any of the other groups. At a lesser magnitude than transgender students, cisgender women who were unsure about their sexual orientation were at a significantly higher risk of ED diagnosis and compensatory behaviors but lower risk of diet pill use. Cisgender SM men also had significantly higher risk of ED diagnosis but no significant differences in the other two outcomes. In contrast, cisgender heterosexual men had significantly lower risk of all 3 outcomes. Cisgender SM women were also at significantly lower risk of compensatory behaviors and diet pill use but no significant differences in ED diagnosis from the reference group. Among transgender students, those who were unsure of their sexual orientation were at the highest risk of all 3 outcomes when compared to transgender students who identified as heterosexual or SM.

This study highlights the risk of eating disorder diagnoses and behaviors in transgender students, particularly those who are unsure about their sexual orientation. Transgender individuals experience strong feelings that their physical appearance does not match with their gender identity. Some may use disordered eating behaviors to manipulate their body to more closely approximate the ideals of their gender identity. For example, weight loss may suppress male and female secondary sex characteristics and help transgendered women conform to feminine ideals of thinness. In contrast, weight gain may help transgendered men conform to a more masculine body type and hide female characteristics. Transgender individuals also experience high rates of minority stress, defined as the excess stress experienced by individuals in stigmatized social categories, which has been linked to poor mental health outcomes including disordered eating. Transgender students who are unsure about their sexual orientation may experience the greatest levels of minority stress among the transgender community because they are unable to seek the social support of SM communities which is appear to be protective against the effects of minority stress. The authors of this study do note that transgendered students are more likely to come into contact with mental health professionals as a result of the counseling requirement for anyone pursuing gender affirming treatments and therefore may be more likely to receive an eating disorder diagnosis; however this does not explain the increased rates of compensatory behaviors or use of diet pills.

One limitation of this study is that the survey asked about ED diagnoses made by a mental health professional. Since most eating disorders are untreated and undiagnosed, the prevalence of EDs in this study is likely underestimated. This study also did not assess for a full range of eating disordered behaviors and neglected binge eating disorder. Since the transgender group of participants was relatively small, the researchers were unable to divide the group into subgroups so we don’t have any specific information about female-to-male vs male-to-female vs genderqueer transgender individuals. In addition, they were unable to distinguish between different sexual orientations among the transgender group in most statistical analyses. The transgender community is diverse and it is likely that these subgroups could have important differences in their eating disorder behaviors. Despite these limitations, this study highlights the important relationship between gender identity, sexual orientation, and eating disorder pathology.

Reference: Diemer E, Grant J, Munn-Chernoff M, Patterson D, Duncan A (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57, 144-149.

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