This study examined associations of gender identity and sexual orientation with self-reported eating disorder (SR-ED) diagnosis and compensatory behaviors in transgender and cisgender college students.
Data was derived from 289,024 students from 223 U.S. universities participating in the American College Health Association–National College Health Assessment II.
Rates of past-year SR-ED diagnosis and past-month use of diet pills and vomiting or laxatives were compared among transgender students (n = 479) and cisgender sexual minority (SM) male (n = 5,977) and female (n = 9,445), unsure male (n = 1,662) and female (n = 3,395), and heterosexual male (n = 91,599) and female (n = 176,467) students using chi-square tests. Logistic regression models were used to estimate the odds of eating-related pathology outcomes after adjusting for covariates.
The study was done by members of Washington University in St. Louis.
Transgender students responded that they had been diagnosed with an eating disorder in the past year at an alarming rate of 15.82%. Cisgender students were between .55% (heterosexual men) and 3.66% (unsure men). Cisgender sexual minority and unsure men and women were 2-4 times more likely to have been diagnosed with an eating disorder than heterosexual men and women.
The study also found that transgender students reported much higher diet pill usage (13.5%) than heterosexual men (1.88%) or heterosexual women (4.29%)
Transgender individuals may use disordered eating behaviors to suppress or accentuate particular gendered features. It has been suggested that striving for weight loss may be a way for transgender women to conform to feminine ideals of slimness and attractiveness.
Another reason, the authors point out, is a common trigger of eating disorders is stress, and there is research to suggest the stress levels in these individuals is elevated as a result of belonging to a stigmatized social category.
Among lesbian, gay, and bisexual individuals, a strong link has been found between higher levels of minority stress and poorer mental health outcomes. The same mechanisms are likely at play in transgender individuals, who may be exposed to substantial amounts of discrimination, both on an interpersonal and societal level.
In another part of the journal, S. Bryn Austin, Sc. D. of Boston Children's Hospital pens the editorial, With Transgender Health Inequities so Large and the Need so Great, the Burden Is on All of Us to Find Solutions
What is driving these health inequities? Diemer et al. begin to provide some leads. It is well documented that gender and sexual minorities are more likely than cisgender or heterosexual peers to experience violence victimization, harassment, and discrimination. These types of stressors can provoke psychological, physiological, and behavioral stress responses associated with eating disorders. Gendered appearance norms create pressure to strive for societal ideals of femininity and masculinity, pushing young people to use deleterious weight and shape control behaviors. For transgender youth, the risk of social rejection, discrimination, and violence makes the stakes extremely high to achieve conformity aligned with one's gender identity. In a different line of research, a growing body of work points to the influence of gonadal hormones on eating pathology, including endogenous and exogenous hormones. The effects of clinical pubertal suppression in young adolescents and gender-affirming hormone therapy in transgender people on eating behavior and eating disorder symptomatology have yet to be studied.
Diemer et al. have given us a call to action by revealing the greatly elevated rates of eating disorder symptoms in gender and sexual minorities and consequently the enormous burden these devastating yet preventable conditions mete out on these marginalized communities. With inequities this large and need this great, business as usual in research and clinical care—that is, treating transgender and sexual minority young people simply as “subjects” and “patients”—will not produce solutions with the immediacy needed to save lives and prevent unnecessary suffering. The burden is on us now as researchers and clinicians to approach our work with transgender and sexual minority communities as collaborators from the start, partners in understanding the many colluding forces that create the health inequities and identifying strategies and solutions that will ensure that youth of all genders and sexual orientations can transition into adulthood in healthy relationship with food and their bodies.