Featured Article
Article Title
Eating Disorders in Sexual and Gender Minority Adolescents
Authors
Jason M. Nagata; Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
Elena Stuart; Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
Jacqueline O. Hur; Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
Smriti Panchal; Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
Patrick Low; Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
Anita V. Chaphekar; Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
Kyle T. Ganson; Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
Jason M. Lavender; Military Cardiovascular Outcomes Research Program (MiCOR), Department of Medicine, Uniformed Services University, Bethesda, MD; Department of Medicine, Uniformed Services University, Bethesda, MD; The Metis Foundation, San Antonio, TX
Abstract
Purpose of Review: To consolidate recent literature addressing eating disorders and disordered eating behaviors among sexual and gender minority (SGM) adolescents, including but not limited to lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents.
Recent Findings: Sexual and gender minority adolescents are at heightened vulnerability to eating disorders and disordered eating behaviors compared to their cisgender and heterosexual peers, potentially due to minority stress, gender norms, objectification, and the influence of the media, peers, and parents. We report findings from recent literature on the epidemiology and prevalence, assessment, mental health comorbidity, quality of life and psychosocial functioning, risk and protective factors, and treatment and interventions for eating disorders in sexual and gender minority adolescents.
Summary: Addressing eating disorders in sexual and gender minority adolescents requires an integrated approach consisting of screening, tailored treatment, and comprehensive support to address intersectional challenges. Gender-affirming and trauma-informed care approaches may be considered.
Keywords
Eating disorders; LGBT; LGBTQ+; transgender; gay lesbian; bisexual
Summary of Research
“Millions of adolescents worldwide suffer from eating disorders, which are serious mental health conditions characterized by persistent disturbances in eating or related weight control behaviors that significantly impair health and/or functioning… Notably, adolescence into young adulthood has been identified as a period of peak risk for eating disorder onset, highlighting the importance of understanding eating disorders and disordered eating behaviors in adolescents, particularly among adolescent populations that may be at heightened risk” (p. 1-2).
"An ever-growing body of literature suggests that sexual and gender minorities (SGM) exhibit elevated vulnerability for body dissatisfaction, disordered eating behaviors, and eating disorders, likely due to an interplay between stigma and societal bias, minority stress, and other social pressures. Sexual and gender minority populations include individuals who identify as lesbian, gay, bisexual, queer, or questioning (sexual minority), as well as those who identify as transgender, gender-diverse, gender-fluid, or gender-expansive (gender minority)" (p. 2).
“The most widely used eating disorder measures were typically developed based on traditional conceptualizations of eating disorder symptomatology that centered on the experiences of predominantly white and socioeconomically advantaged young women and has focused nearly exclusively on the thin body ideal and drive for thinness. More recently, research has begun to address the applicability, utility, and limitations of existing measures for use among more diverse populations, including sexual and gender minority individuals. Specifically, topics of consideration have included the extent to which existing measures accurately and comprehensively capture the potentially unique experience and manifestation of eating disorder symptoms in sexual and gender minority populations, and the need for culturally sensitive questionnaires, screening tools, and diagnostic measures that incorporate non-stigmatizing language and mirror the diverse experiences of sexual and gender minority individuals” (p. 4).
“Co-occurring mental health concerns are common among those with eating disorders, and recent findings suggest that compared to their cisgender and heterosexual peers, sexual and gender minority individuals with eating disorders in particular demonstrate higher rates of mental health comorbidities”(p. 5). Additionally,“among sexual and gender minority adolescents, the complex interplay between minority status and the psychosocial impacts of eating disorder symptoms may impede the formation of a positive self-image and social connections, which are cornerstones of healthy adolescent development and are crucial for the transition into young/emerging adulthood” (p. 5).
“Concealment pressures and minority stressors, such as low income, ethnic minority status, and non-conforming identities, contribute to increased eating disorder prevalence and severity among sexual and gender minority individuals. While societal stigma impacts all sexual and gender minorities, sexual minorities face orientation-linked challenges unique to their sexual minority subgroups. For example, adolescent lesbians are more likely to report higher BMIs while gay male adolescents are more likely to report being influenced by appearances portrayed in media. Meanwhile, gender minorities experience identity-related issues including distress around undesired traits associated with their assigned sex. Lack of self-acceptance and adherence to perceived societal appearance standards in these instances result in higher rates of disordered eating behaviors” (p. 6).
“Presentation variations of eating disorders and increased risk of psychiatric comorbidity in sexual and gender minority adolescents present a need for targeted interventions. Gender minority adolescents present with even higher weights and degrees of vital sign instability and are hospitalized at younger ages than their cisgender peers. Despite a significant prevalence of eating disorders in sexual and gender minorities, there are currently no treatments specifically targeted toward sexual and gender minority adolescents” (p. 6).
Translating Research into Practice
“Sexual and gender minority individuals encounter a range of identity-based traumas that influence disordered eating behavior, yet the support from current systemic healthcare structures is limited. Medical treatments, such as gender reconstructive surgery, fertility preservation, and continued health screening for sexual and gender minority individuals, are incredibly complex, which can potentially result in more stress and fear regarding receiving treatment. During these treatments, sexual and gender minority individuals have expressed perceiving a lack of understanding and compassion from healthcare providers, primarily due to a lack of education and perpetuation of cis-heteronormative treatment models. The confluence of identity-based trauma, societal pressures, and specific medical challenges faced by sexual and gender minority adolescents underscores the need to develop a knowledgeable and empathetic healthcare workforce capable of navigating sexual and gender minority individuals’ specific challenges and enhancing their health outcomes.
Policy reform within social and healthcare institutions may improve access to and outcomes of eating disorder treatment for sexual and gender minority adolescents. Gender-affirming and trauma-informed interventions have yielded positive health outcomes, such as less emotional internalization, better psychological functioning, and a greater sense of belonging in sexual and gender minority adolescents with eating disorders. Integration of sexual and gender minority health and eating disorder care into standard medical curricula may better enable healthcare providers to provide sensitive care and improve health outcomes in sexual and gender minority adolescents” (p. 7).
Other Interesting Tidbits for Researchers and Clinicians
“Our review describes significant gaps in the research on eating disorders and disordered eating behaviors among sexual and gender minority adolescents. These areas focus primarily on diversifying study populations, tracking the prevalence of eating disorders and disordered eating behaviors among sexual and gender minorities over time, improving assessment tools, and developing inclusive treatment protocols.
There is a need to diversify study populations to ensure that the experiences of a wide breadth of sexual and gender minority adolescents are being documented. This will ensure that future research, theory, assessment, and treatment are tailored to the needs of the population. Tracking the prevalence of eating disorders and disordered eating behaviors among sexual and gender minority adolescents over time is critical to understanding how these disorders and behaviors evolve as one goes through crucial developmental milestones. Tracking trends over time will also provide valuable insights into additional risk and protective factors (e.g., relationships, careers, hormone stabilization post-puberty) that arise as one progresses through life. Additionally, tracking trends over time will offer insights into treatment outcomes and inform care optimization, including identifying how gender-affirming treatment may be a critical intervention.
Assessments of eating disorders and disordered eating behaviors that are specific to the sexual and gender minority experience need to be developed. These should be validated among a diverse group of adolescents to ensure sensitivity and specificity. The inclusion of gender incongruence and minority stress experiences into assessment tools may also be particularly relevant and can assist with conceptualizing treatment needs, including developing inclusive treatment protocols that consider recent insights into sex differences. Improving care for this vulnerable group requires addressing these existing gaps in our understanding.
Further exploration of the implications of hormone treatment or pubertal suppression on eating disorders within transgender adolescents is another crucial research avenue. Recent advancements in understanding sex differences in eating disorder treatment inform personalized care, and future research should continue prioritizing compassionate and inclusive interventions attuned to sex differences and gender diversity. Indeed, highlighting the need for providers to be knowledgeable, empathetic, and inclusive is key to improving sexual and gender minority healthcare. Involving sexual and gender minority adolescents in the development and refinement of interventions to their specific experiences and needs and assessing how these efforts reduce societal stigma and minority stress may be one route to enhancing treatment outcomes for this group. This endeavor will require collaborative efforts across healthcare disciplines, integrating clinical insights with empirical research to pave the way for a more inclusive and effective healthcare paradigm for sexual and gender minority adolescents” (p. 7).
