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Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students

      Abstract

      Purpose

      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.

      Methods

      Data came from 289,024 students from 223 U.S. universities participating in the American College Health Association–National College Health Assessment II (median age, 20 years). 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.

      Results

      Rates of past-year SR-ED diagnosis and past-month use of diet pills and vomiting or laxatives were highest among transgender students and lowest among cisgender heterosexual men. Compared to cisgender heterosexual women, transgender students had greater odds of past-year SR-ED diagnosis (odds ratio [OR], 4.62; 95% confidence interval [CI], 3.41–6.26) and past-month use of diet pills (OR, 2.05; 95% CI, 1.48–2.83) and vomiting or laxatives (OR, 2.46; 95% CI, 1.83–3.30). Although cisgender SM men and unsure men and women also had elevated rates of SR-ED diagnosis than heterosexual women, the magnitudes of these associations were lower than those for transgender individuals (ORs; 1.40–1.54).

      Conclusions

      Transgender and cisgender SM young adults have elevated rates of compensatory behavior and SR-ED diagnosis. Appropriate interventions for these populations are urgently needed.

      Keywords

      Implications and Contribution
      To date, few studies have examined the impact of gender identity on the prevalence of clinical eating disorders and compensatory behaviors. We found that transgender and cisgender nonheterosexual college students were at increased risk of eating disorder diagnosis and compensatory behaviors. Findings highlight the need for targeted prevention and intervention efforts in these vulnerable groups.
      See Related Editorial p. 133
      Most research on eating-related pathology has focused on cisgender individuals, whose current gender identity matches the sex they were assigned at birth. Although several case studies and case series have described transgender individuals with eating disorders (EDs; e.g., [
      • Hepp U.
      • Milos G.
      Gender identity disorder and eating disorders.
      ,
      • Surgenor L.J.
      • Fear J.L.
      Eating disorder in a transgendered patient: A case report.
      ]), few studies have compared rates of eating-related pathology between transgender and cisgender individuals. Transgender individuals experience high rates of discrimination [
      • Bradford J.
      • Reisner S.L.
      • Honnold J.A.
      • et al.
      Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study.
      ,
      • Grant J.M.
      • Mottet L.S.
      • Tanis J.
      • et al.
      Injustice at every turn: A report of the national transgender discrimination survey.
      ], which have been significantly associated with poor mental health outcomes in sexual minority (SM) populations [
      • Frisell T.
      • Lichtenstein P.
      • Rahman Q.
      • et al.
      Psychiatric morbidity associated with same-sex sexual behaviour: Influence of minority stress and familial factors.
      ,
      • Waldo C.R.
      Working in a majority context: A structural model of heterosexism as minority stress in the workplace.
      ]. Qualitative research suggests transgender persons may be at increased risk of body dissatisfaction, which may predispose them to disordered eating [
      • Hepp U.
      • Milos G.
      Gender identity disorder and eating disorders.
      ,
      • Surgenor L.J.
      • Fear J.L.
      Eating disorder in a transgendered patient: A case report.
      ]; however, results of empirical studies of associations between transgender and EDs have been inconsistent [
      • Cella S.
      • Iannaccone M.
      • Cotrufo P.
      Influence of gender role orientation (masculinity versus femininity) on body satisfaction and eating attitudes in homosexuals, heterosexuals and transsexuals.
      ,
      • Vocks S.
      • Stahn C.
      • Loenser K.
      • et al.
      Eating and body image disturbances in male-to-female and female-to-male transsexuals.
      ,
      • Algars M.
      • Santtila P.
      • Sandnabba N.K.
      Conflicted gender identity, body dissatisfaction and disordered eating in adult men and women.
      ,
      • Khoosal D.
      • Langham C.
      • Palmer B.
      • et al.
      Features of eating disorder among male-to-female transsexuals.
      ]. This inconsistency may result from variation in the size and composition of the transgender groups, as well as the choice of comparison group. In particular, several previous studies selected transgender and comparison participants from different source populations [
      • Cella S.
      • Iannaccone M.
      • Cotrufo P.
      Influence of gender role orientation (masculinity versus femininity) on body satisfaction and eating attitudes in homosexuals, heterosexuals and transsexuals.
      ,
      • Vocks S.
      • Stahn C.
      • Loenser K.
      • et al.
      Eating and body image disturbances in male-to-female and female-to-male transsexuals.
      ,
      • Khoosal D.
      • Langham C.
      • Palmer B.
      • et al.
      Features of eating disorder among male-to-female transsexuals.
      ], a practice that may introduce selection bias [
      • Rothman K.J.
      • Greenland S.
      • Lash T.L.
      Case-control studies.
      ]. Only one study to date has investigated associations between gender identity and disordered eating using transgender and cisgender groups derived from the same source population. That study, which examined “conflicted gender identity” rather than self-identified transgender status in a cross-sectional study of Finnish twins and their siblings, found that women with conflicted gender identity had higher Eating Attitudes Test disordered eating scale scores than their non-gender identity conflicted counterparts, with no significant difference among men [
      • Algars M.
      • Santtila P.
      • Sandnabba N.K.
      Conflicted gender identity, body dissatisfaction and disordered eating in adult men and women.
      ]. Of note, only one study has compared disordered eating in transgender and cisgender SM individuals [
      • Cella S.
      • Iannaccone M.
      • Cotrufo P.
      Influence of gender role orientation (masculinity versus femininity) on body satisfaction and eating attitudes in homosexuals, heterosexuals and transsexuals.
      ]; to our knowledge, no studies have examined differences in disordered eating in transgender people relative to other gender and sexual minorities and cisgender heterosexual men and women.
      Additional studies have shown that cisgender SM men are at significantly higher risk of disordered eating than heterosexual men (e.g., [
      • Frisell T.
      • Lichtenstein P.
      • Rahman Q.
      • et al.
      Psychiatric morbidity associated with same-sex sexual behaviour: Influence of minority stress and familial factors.
      ,
      • French S.A.
      • Story M.
      • Remafedi G.
      • et al.
      Sexual orientation and prevalence of body dissatisfaction and eating disordered behaviors: A population-based study of adolescents.
      ,
      • Austin S.B.
      • Nelson L.A.
      • Birkett M.A.
      • et al.
      Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students.
      ]). Findings comparing cisgender SM and heterosexual women have been more mixed, with some studies reporting increased levels of disordered eating and others showing no significant differences (e.g., [
      • French S.A.
      • Story M.
      • Remafedi G.
      • et al.
      Sexual orientation and prevalence of body dissatisfaction and eating disordered behaviors: A population-based study of adolescents.
      ,
      • Austin S.B.
      • Nelson L.A.
      • Birkett M.A.
      • et al.
      Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students.
      ]). Surprisingly few studies have compared rates of disordered eating in heterosexual and SM men to those in heterosexual and SM women [
      • Conner M.
      • Johnson C.
      • Grogan S.
      Gender, sexuality, body image and eating behaviours.
      ,
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
      ,
      • Siever M.D.
      Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders.
      ]. These studies have yielded comparable findings, where heterosexual women had higher total scores on the Eating Attitudes Test [
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
      ,
      • Siever M.D.
      Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders.
      ] and restrained eating scale scores on the Dutch Eating Behavior Questionnaire [
      • Conner M.
      • Johnson C.
      • Grogan S.
      Gender, sexuality, body image and eating behaviours.
      ] than heterosexual men and lesbian women; however, there were no significant differences in scores between heterosexual women and gay men.
      None of the previously mentioned studies comparing heterosexual and gay men to heterosexual women included other cisgender sexual minorities, such as those identifying as bisexual or people who were unsure of their sexual orientation. Several studies have found elevated rates of disordered eating among individuals unsure of their sexual orientation relative to their same-gender heterosexual counterparts (e.g., [
      • Austin S.B.
      • Nelson L.A.
      • Birkett M.A.
      • et al.
      Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students.
      ,
      • Hadland S.E.
      • Austin S.B.
      • Goodenow C.S.
      • et al.
      Weight misperception and unhealthy weight control behaviors among sexual minorities in the general adolescent population.
      ]). A recent study examining differences in disordered eating by sexual orientation using data from the American College Health Association's National College Health Assessment (ACHA-NCHA) found that men who identified as gay, bisexual, and unsure of their sexual orientation were all significantly more likely than heterosexual men to have an ED diagnosis and to engage in compensatory behaviors (CBs), whereas associations among women were inconsistent and less robust [
      • Matthews-Ewald M.R.
      • Zullig K.J.
      • Ward R.M.
      Sexual orientation and disordered eating behaviors among self-identified male and female college students.
      ]. The authors stratified their analyses by gender, which prevented comparisons of heterosexual and SM males to heterosexual women, the most well-studied group in the ED literature. In addition, transgender participants were omitted from the analyses because of low numbers. As the ACHA-NCHA is conducted every semester with an increasing number of colleges and universities participating in it, more data have been collected and released since the analyses for the previous study were completed, and the number of transgender participants has increased substantially.
      A closer investigation of how disordered eating differs across gender and sexual orientation may provide a greater understanding of its underlying mechanisms. We sought to expand on prior research by examining differences in eating-related pathology by gender identity and sexual orientation in a large, diverse sample of college students participating in the ACHA-NCHA.

      Methods

      The present study uses data collected from students enrolled in 223 U.S. colleges and universities (median age, 20 years) between Fall 2008 and Fall 2011 as part of the ACHA-NCHA [
      American College Health Association
      American College Health Association—National College Health Assessment Spring 2008 Reference Group Data Report (Abridged): The American College Health Association.
      ,
      American College Health Association
      American College Health Association—National College Health Assessment, Fall 2008–Fall 2011.
      ], a nationally recognized survey of a broad range of health behaviors, outcomes, and perceptions among college students. Participating institutions sampled students and collected data in one of the following two ways: (1) students in randomly selected classrooms were asked to complete the survey on paper or (2) a link to the Web-based survey was sent to a random sample of enrolled students. Data were collected anonymously. The mean response rate ranged from 19.0% to 36.0% over the eight semesters of data collection [
      American College Health Association
      American College Health Association—National College Health Assessment Spring 2008 Reference Group Data Report (Abridged): The American College Health Association.
      ,
      American College Health Association
      American College Health Association National College Health Assessment (ACHA-NCHA) Spring 2005 Reference Group Data Report (Abridged).
      ,
      American College Health Association
      American College Health Association—National College Health Assessment II: Reference Group Data Report Spring 2010.
      ,
      American College Health Association
      American College Health Association—National College Health Assessment II: Reference Group Data Report Spring 2011.
      ]. The individual campuses participating in the ACHA-NCHA provided documentation of institutional approval of the survey research. Although the questionnaire was administered in multiple semesters at some institutions, the present study only uses data from the first semester that each institution participated in the survey to ensure that all responses came from unique individuals. To best represent the American college population, the current analyses were limited to participants aged 26 years and older.
      The ACHA-NCHA questionnaire included items regarding mental health, substance use, sexual behavior, and nutrition and has established reliability and validity [
      American College Health Association
      American College Health Association—National College Health Assessment Spring 2008 Reference Group Data Report (Abridged): The American College Health Association.
      ,
      American College Health Association
      American College Health Association National College Health Assessment (ACHA-NCHA) Spring 2005 Reference Group Data Report (Abridged).
      ]. Sexual orientation and gender identity were queried in the demographics section of the interview. Response options for the question, “What is your gender?” were “female,” “male,” and “transgender.” Sexual orientation was assessed by the question, “What is your sexual orientation?” (response options: “heterosexual,” “gay/lesbian,” “bisexual,” or “unsure”). For the current analyses, information on gender identity and sexual orientation was combined into a seven-level variable: transgender, cisgender SM men, cisgender unsure men, cisgender heterosexual men, cisgender SM women, cisgender unsure women, and cisgender heterosexual women (referent). Cisgender heterosexual women were designated as the reference category because the ED literature largely focuses on cisgender women, most of whom are heterosexual. Individuals were categorized as SM if they identified as gay/lesbian or bisexual. Transgender individuals were collapsed into a single group regardless of sexual orientation because of the relatively low number of transgender respondents (n = 479).
      Past-year ED diagnosis was assessed through two questions: “Within the past 12 months, have you been diagnosed or treated by a professional for anorexia?” and “Within the past 12 months, have you been diagnosed or treated by a professional for bulimia?” each with the response options: “No,” “Yes, diagnosed but not treated,” “Yes, treated with medication,” “Yes, treated with psychotherapy,” “Yes, treated with medication and psychotherapy,” or “Yes, other treatment.” For the current analyses, we constructed a single dichotomous variable to reflect whether the respondent had been diagnosed or treated by a professional for anorexia or bulimia within the past year. Participants were also asked whether they had vomited or taken laxatives within the past 30 days and whether they had used diet pills within the past 30 days.
      Variables available in the data set that had been shown to be associated with eating-related pathology and/or gender or SM status were included in the analysis as covariates [
      • Basow S.A.
      • Foran K.A.
      • Bookwala J.
      Body objectification, social pressure, and disordered eating behavior in college women: The role of sorority membership.
      ,
      • Blosnich J.R.
      • Jarrett T.
      • Horn K.
      Disparities in smoking and acute respiratory illnesses among sexual minority young adults.
      ,
      • Holm-Denoma J.
      • Scaringi V.
      • Gordon K.H.
      • et al.
      Eating disorder symptoms among undergraduate varsity athletes, club athletes, independent exercisers, and nonexercisers.
      ]. Race/ethnicity was ascertained through the question “How do you usually describe yourself? (Mark all that apply),”which had the response options: “non-Hispanic White” (referent); “non-Hispanic Black;” “Hispanic or Latino/a;” “Asian or Pacific Islander;” “American Indian,” “Alaskan Native or Native Hawaiian;” “Biracial or Multiracial;” and “Other.” Participants who selected multiple categories were combined with those who identified as multiracial. Responses to the question “Within the past 30 days, on how many days did you use cigarettes?” were combined into a three-level cigarette use variable: (1) no (referent); (2) yes, but not in the past month; and (3) yes. Participants were coded positive for binge drinking if they reported consumption of ≥5 drinks of alcohol at a sitting at least once during the past 2 weeks in response to the question “During the past two weeks, how many times have you had five or more drinks of alcohol at a sitting?” Stress was assessed with the question “Within the past 12 months, how would you rate the overall level of stress you have experienced?” and the responses were: “No stress” (referent);“Less than average stress;” “Average stress;” “More than average stress;” and “Tremendous stress.” We constructed a four-level variable for athletic participation (referent category: no organized athletics participation) based on responses to the question, “Within the last 12 months, have you participated in organized college athletics at any of the following levels?”: “Varsity,” “Club Sports,” and “Intramurals.” Fraternity/sorority membership (yes vs. no) was determined through responses to the question “Are you a member of a social fraternity or sorority?”
      Analyses were performed using Stata 9.2 (StataCorp, College Station, TX). Multivariable logistic regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for associations of eating-related pathology outcomes with gender and sexual orientation, before and after adjusting for covariates. All multicategory variables were modeled as sets of indicator variables, with an additional category for missing data included in the set of indicator variables for those variables with missing data (see Table 1). Because data from students attending the same institutions may not be independent, ORs and CIs were adjusted for clustering within institutions using Huber–White robust standard errors. Post hoc pairwise Wald tests evaluated whether there were significant differences in ORs between levels of the gender identity/sexual orientation variable. Because of the low number of transgender participants and subsequent collapsing of the transgender group in logistic regression models, additional chi-square analyses examined risk of CBs and ED diagnosis by sexual orientation among members of the transgender subgroup (see Table 3).
      Table 1Characteristics of participants in the American College Health Association–National College Health Assessment
      Student characteristicsN%
      Gender and sexual orientation
       Transgender479.17
       Cisgender sexual minority men5,9772.07
       Cisgender unsure men1,662.58
       Cisgender heterosexual men91,59931.69
       Cisgender sexual minority women9,4453.27
       Cisgender unsure women3,3951.17
       Cisgender heterosexual women176,46761.06
      Race/ethnicity
       European American201,10969.58
       African-American13,0024.50
       Hispanic17,2215.96
       Asian/Pacific Islander29,26610.13
       American Indian/Alaska Native1,256.43
       Multiracial20,6107.13
       Other4,1111.42
       Missing2,449.85
      Past 2-week binge drinking
       Yes104,59536.19
       No183,35563.44
       Missing1,074.37
      Past-month cigarette use
       Yes44,52415.40
       Yes, but not in past month47,15716.32
       No196,15067.87
       Missing1,193.41
      Past-year stress levels
       Tremendous25,7018.89
       More than average118,16640.88
       Average114,48139.61
       Less than average24,1568.36
       None4,9201.70
       Missing1,600.55
      Athletic participation
       Varsity25,2418.73
       Club27,5249.52
       Intramural42,25614.62
       None192,01266.43
       Missing1,991.69
      Fraternity or sorority member
       Yes28,5359.87
       No256,92188.89
       Missing3,5681.23

      Results

      Of the 289,024 participants with data on gender identity and sexual orientation, .17% of participants (n = 479) identified as transgender persons, 2.07% (n = 5,977) as cisgender SM men, .58% (n = 1,662) as cisgender unsure men, 31.69% (n = 91,599) as cisgender heterosexual men, 3.27% (n = 9,445) as cisgender SM women, 1.17% (n = 3,395) as cisgender unsure women, and 61.06% (n = 176,467) as cisgender heterosexual women. Most of the participants (69.58%) were European American. Almost all participants were full-time students (95.40%) and attended 4-year colleges and universities (93.31%). Students at public institutions comprised the majority of the sample (64.18%). Additional characteristics of the participants are described in Table 1.
      Approximately one and a half percent (1.52%; n = 4,384) of the sample reported being diagnosed with an ED in the past year. Past-month use of vomiting or laxatives was reported by 2.79% (n = 8,054) of the sample and 3.49% (n = 10,085) reported use of diet pills within the past month.
      Prevalence rates and adjusted ORs for self-reported eating disorder (SR-ED) diagnosis and past-month use of diet pills and vomiting or laxative use by sexual orientation and gender identity are shown in Table 2. The prevalence of all three outcomes was highest among transgender students and lowest among cisgender heterosexual male students. After adjusting for covariates, transgender students had significantly greater odds of past-year ED diagnosis (OR, 4.62; 95% CI, 3.41–6.26), past-month diet pill use (OR, 2.05; 95% CI, 1.48–2.83), and past-month vomiting or laxative use (OR, 2.46; 95% CI, 1.83–3.30) compared to cisgender heterosexual women. Although the magnitudes of the associations were lower than those for transgender persons, cisgender unsure women also had significantly elevated odds of past-year SR-ED diagnosis (OR, 1.40; 95% CI, 1.14–1.73) and using laxatives or self-induced vomiting in the past month (OR, 1.35; 95% CI, 1.14–1.61), but lower odds of diet pill use (OR, .80; 95% CI, .69–.98), relative to cisgender heterosexual women. Cisgender SM men also had significantly elevated odds of past-year ED diagnosis (OR, 1.45; 95% CI, 1.28–1.65) compared to heterosexual women. In contrast, compared with cisgender heterosexual women, cisgender heterosexual men had significantly lower odds of past-year ED diagnosis (OR, .27; 95% CI, .24–.30), past-month diet pill use (OR, .39; 95% CI, .37–.42), and past-month vomiting or laxative use (OR, .15; 95% CI, .14–.17). Cisgender SM women were significantly less likely than heterosexual women to have used diet pills (OR, .74; 95% CI, .65–.85) or vomiting or laxatives (OR, .72; 95% CI, .62–.84) in the past month.
      Table 2Prevalence of self-reported past-year eating disorder diagnosis and past 30-day compensatory behaviors by gender identity and sexual orientation and results from logistic regression models
      Past-year eating disorder diagnosis (N = 4,384)Past-month diet pill use (N = 10,085)Past-month vomiting or laxative use (N = 8,054)
      %OR (95% CI)
      OR with 95% CI adjusted for age, race/ethnicity, binge drinking, cigarette use, stress, college athletic participation, and fraternity/sorority membership.
      %OR (95% CI)%OR (95% CI)
      Transgender15.824.62 (3.41–6.26)A13.502.05 (1.48–2.83)A15.012.46 (1.83–3.30)A
      Cisgender sexual minority men2.061.45 (1.28–1.65)B4.16.92 (.83–1.02)B3.691.04 (.95–1.14)B
      Cisgender unsure men3.661.54 (1.13–2.09)B4.68.91 (.71–1.17)BD3.58.77 (.58–1.02)C
      Cisgender heterosexual men.55.27 (.24-.30)C1.88.39 (.37–.42)C.67.15 (.14–.17)D
      Cisgender sexual minority women3.52.89 (.73–1.08)D5.11.74 (.65–.85)D5.24.72 (.62–.84)C
      Cisgender unsure women2.971.40 (1.14–1.73)B3.86.80 (.69–.98)BD5.411.35 (1.14–1.61)E
      Cisgender heterosexual women1.851.00 (referent)4.291.00 (referent)3.711.00 (referent)
      Values in bold type are statistically significant (p < .05).
      OR (95% CI) with different superscripts within columns differ significantly from one another (p < .05) in pairwise comparisons.
      OR = odds ratio; CI = confidence interval.
      a OR with 95% CI adjusted for age, race/ethnicity, binge drinking, cigarette use, stress, college athletic participation, and fraternity/sorority membership.
      Post hoc tests indicated that the ORs for transgender participants were significantly greater, and those of cisgender heterosexual men were significantly lower, than the ORs of any other group for all three outcomes (p < .001 for all comparisons). The ORs for past-year SR-ED and past-month diet pill use in cisgender SM men did not differ significantly from those for cisgender unsure men but were significantly greater than those for cisgender SM women. In turn, the ORs for past-year ED and past-month vomiting and laxative use were significantly greater among cisgender unsure women than cisgender SM women (p < .05 for all).
      Among transgender students (Table 3), those who were unsure of their sexual orientation had significantly higher rates of past-year ED diagnosis, past-month vomiting or laxative use, and past-month use of diet pills than those who identified as heterosexual or SM. It should be noted, however, that rates of these outcomes for all transgender subgroups were higher than those among cisgender participants.
      Table 3Prevalence of self-reported past-year eating disorder diagnosis and past 30-day compensatory behaviors by sexual orientation among transgender participants in the American College Health Association's National College Health Assessment
      Heterosexual % (N)Sexual minority % (N)Unsure % (N)Chi-square, omnibus p value
      Past-year eating disorder diagnosis7.63 (9)A11.74 (25)A27.42 (34)B.0001
      Past-month vomiting or laxative use6.03 (7)A12.56 (27)A26.40 (33)B<.0001
      Past-month diet pill use7.76 (9)A9.81 (21)A25.81 (32)B<.0001
      Percentages with different superscripts are significantly within rows different from one another in pairwise comparisons (p < .05).

      Discussion

      To our knowledge, ACHA-NCHA includes the largest number of transgender participants ever to be surveyed about EDs and CBs, thus enabling us to conduct statistically powerful analyses of the relationship between gender identity, sexual orientation, and eating-related pathology. We found that transgender students had elevated rates of past-month CBs and that both transgender participants and cisgender male SM participants had increased rates of past-year SR-ED diagnosis relative to cisgender heterosexual women. Transgender participants were also significantly more likely than members of any other group, including cisgender sexual minorities, to report past-year ED diagnosis and past-month CBs. Consistent with prior research, we found that eating-related pathology was more prevalent among those with transgender and SM identities (e.g., [
      • Cella S.
      • Iannaccone M.
      • Cotrufo P.
      Influence of gender role orientation (masculinity versus femininity) on body satisfaction and eating attitudes in homosexuals, heterosexuals and transsexuals.
      ,
      • Vocks S.
      • Stahn C.
      • Loenser K.
      • et al.
      Eating and body image disturbances in male-to-female and female-to-male transsexuals.
      ,
      • Algars M.
      • Santtila P.
      • Sandnabba N.K.
      Conflicted gender identity, body dissatisfaction and disordered eating in adult men and women.
      ,
      • Austin S.B.
      • Nelson L.A.
      • Birkett M.A.
      • et al.
      Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students.
      ,
      • Matthews-Ewald M.R.
      • Zullig K.J.
      • Ward R.M.
      Sexual orientation and disordered eating behaviors among self-identified male and female college students.
      ]). As in previous studies, women who were unsure of their sexual orientation were more likely to have engaged in CBs than cisgender heterosexual women [
      • Austin S.B.
      • Nelson L.A.
      • Birkett M.A.
      • et al.
      Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students.
      ,
      • Hadland S.E.
      • Austin S.B.
      • Goodenow C.S.
      • et al.
      Weight misperception and unhealthy weight control behaviors among sexual minorities in the general adolescent population.
      ], cisgender SM women had significantly lower rates of CBs than cisgender heterosexual women, and cisgender heterosexual men had decreased rates of all three outcomes [
      • Austin S.B.
      • Nelson L.A.
      • Birkett M.A.
      • et al.
      Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students.
      ,
      • Hudson J.I.
      • Hiripi E.
      • Pope Jr., H.G.
      • et al.
      The prevalence and correlates of eating disorders in the national comorbidity survey replication.
      ,
      • Swanson S.A.
      • Crow S.J.
      • Le Grange D.
      • et al.
      Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement.
      ].
      There are several potential explanations for our finding that transgender identity is associated with higher risk of SR-ED diagnosis and CBs relative to any cisgender group. First, findings from a small body of qualitative studies have implied that 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 [
      • Surgenor L.J.
      • Fear J.L.
      Eating disorder in a transgendered patient: A case report.
      ,
      • Algars M.
      • Santtila P.
      • Sandnabba N.K.
      Conflicted gender identity, body dissatisfaction and disordered eating in adult men and women.
      ]. Transgender men and women may also use weight loss to suppress secondary sexual characteristics [
      • Hepp U.
      • Milos G.
      Gender identity disorder and eating disorders.
      ,
      • Algars M.
      • Santtila P.
      • Sandnabba N.K.
      Conflicted gender identity, body dissatisfaction and disordered eating in adult men and women.
      ].
      A second possibility is that the high prevalence of eating-related pathology among transgender students in this sample may be a result of minority stress, defined as the excess stress experienced by individuals in stigmatized social categories as a result of their social position, through processes such as discrimination, violence victimization, the pressure of concealing one's identity, social alienation, and internalized social stigma [
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
      ]. Minority stress has been identified as a potential factor in the association between transgender identity and disordered eating [
      • Vocks S.
      • Stahn C.
      • Loenser K.
      • et al.
      Eating and body image disturbances in male-to-female and female-to-male transsexuals.
      ,
      • Algars M.
      • Santtila P.
      • Sandnabba N.K.
      Conflicted gender identity, body dissatisfaction and disordered eating in adult men and women.
      ]. Among lesbian, gay, and bisexual individuals, a strong link has been found between higher levels of minority stress and poorer mental health outcomes (e.g., [
      • Frisell T.
      • Lichtenstein P.
      • Rahman Q.
      • et al.
      Psychiatric morbidity associated with same-sex sexual behaviour: Influence of minority stress and familial factors.
      ,
      • Waldo C.R.
      Working in a majority context: A structural model of heterosexism as minority stress in the workplace.
      ,
      • Diaz R.M.
      • Ayala G.
      • Bein E.
      • et al.
      The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 US cities.
      ]). 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 [
      • Bradford J.
      • Reisner S.L.
      • Honnold J.A.
      • et al.
      Experiences of transgender-related discrimination and implications for health: Results from the Virginia Transgender Health Initiative Study.
      ,
      • Clements-Nolle K.
      • Marx R.
      • Guzman R.
      • et al.
      HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health intervention.
      ]. This discrimination has been linked to an increased risk of several forms of psychopathology [
      • Benotsch E.G.
      • Zimmerman R.
      • Cathers L.
      • et al.
      Non-medical use of prescription drugs, polysubstance use, and mental health in transgender adults.
      ,
      • Clements-Nolle K.
      • Marx R.
      • Katz M.
      Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization.
      ,
      • Nemoto T.
      • Bodeker B.
      • Iwamoto M.
      Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work.
      ,
      • Nuttbrock L.
      • Hwahng S.
      • Bockting W.
      • et al.
      Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons.
      ,
      • Yadegarfard M.
      • Ho R.
      • Bahramabadian F.
      Influences on loneliness, depression, sexual-risk behaviour and suicidal ideation among Thai transgender youth.
      ]. Minority stress may also explain our finding that transgender students who were uncertain of their sexual orientation were significantly more likely to report EDs and CBs than those who identified as heterosexual or sexual minorities. Transgender persons who are unsure of their sexual orientation may face even greater levels of minority stress based on their gender identity in addition to invalidation of their sexual orientation because of their transgender identity. However, it is unclear why transgender individuals who identify as sexual minorities do not exhibit similarly elevated risk relative to their heterosexual peers. It may be that individuals who are unsure of their sexual orientation are less able to access SM communities as a source of social support, which appears to ameliorate minority stress [
      • Meyer I.H.
      Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence.
      ].
      A third possibility is that at least some of the association between transgender identity and past-year SR-ED diagnosis is attributable to a greater likelihood of contact with mental health professionals among transgender individuals. Compared to cisgender individuals, transgender persons have greater rates of many forms of psychopathology (e.g., [
      • Clements-Nolle K.
      • Marx R.
      • Katz M.
      Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization.
      ]), and the presence of co-occurring psychiatric disorders is associated with increased treatment-seeking [
      • Iza M.
      • Olfson M.
      • Vermes D.
      • et al.
      Probability and predictors of first treatment contact for anxiety disorders in the United States: Analysis of data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).
      ]. Moreover, transgender individuals are often required to attend counseling to receive gender affirming treatments, increasing their overall rate of interaction with mental health professionals. A previous study found that 75% of transgender participants had received counseling on their gender identity [
      • Grant J.M.
      • Mottet L.S.
      • Tanis J.
      • et al.
      Injustice at every turn: A report of the national transgender discrimination survey.
      ]. In contrast, only 17.9% of participants in the population-representative National Comorbidity Survey Replication reported mental health services use in the previous 12 months [
      • Wang P.S.
      • Lane M.
      • Olfson M.
      • et al.
      Twelve-month use of mental health services in the United States: Results from the national comorbidity survey replication.
      ]. Although the reduced magnitude of the associations between transgender identity and CBs compared to that with SR-ED diagnosis suggests that increased likelihood of contact with mental health professionals may account for some of the strength of association between transgender identity and ED diagnosis, the fact that associations with CBs were still robust is an indication that the difference in rates of diagnosis cannot be entirely attributed to differences in mental health services use.
      The present study should be interpreted in light of several limitations. First, given that the eating-related pathology assessment was limited to questions regarding diagnosis of anorexia nervosa and bulimia nervosa by a health care provider in the past year, and that studies of general population samples have shown that few individuals with diagnosable EDs ever receive treatment (e.g., [
      • Swanson S.A.
      • Crow S.J.
      • Le Grange D.
      • et al.
      Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement.
      ]), the true prevalence of EDs in this sample is likely underestimated. We were also unable to examine the full range of disordered eating behaviors, and thus it is unknown whether the prevalence of ED symptoms other than purging and use of diet pills, such as binge eating, differs by gender identity and sexual orientation. Second, we were unable to distinguish between female-to-male, male-to-female, and genderqueer (individuals whose gender identity does not fall within the male–female binary) transgender persons; thus, these results may not generalize to all transgender people. Third, study participants were college students, a population that is on average, younger and of higher socioeconomic status compared with the general population (e.g., [
      • Walpole M.
      Socioeconomic status and college: How SES affects college experiences and outcomes.
      ]); therefore, it is unknown whether these results will generalize to other populations. Fourth, the ACHA-NCHA has a low response rate, which may have introduced sampling bias. However, overall rates of eating-related pathology were broadly comparable to population studies of this age group (e.g., [
      • Hudson J.I.
      • Hiripi E.
      • Pope Jr., H.G.
      • et al.
      The prevalence and correlates of eating disorders in the national comorbidity survey replication.
      ]), suggesting respondents did not greatly differ from nonrespondents with regard to these behaviors. Fifth, because of the relatively small number of transgender respondents, we were unable to distinguish between transgender persons of different sexual orientations in logistic regression models. Although we used chi-square analyses to examine differences in eating-related pathology by sexual orientation among transgender individuals, we were unable to adjust for covariates or to compare rates of SR-ED diagnosis or CBs in transgender individuals of varying sexual orientations to their cisgender counterparts. The relationship between gender identity, sexual orientation, and eating-related pathology may therefore be more nuanced than is represented in this analysis.
      Despite these limitations, given the dearth of research on EDs in transgender individuals, these findings serve as an important starting place for future investigations. Longitudinal studies with more comprehensive assessments of disordered eating are needed to identify factors contributing to relationships among gender identity, sexual orientation, and eating-related pathology. In particular, given that the label transgender encompasses a wide range of gender identities and life experiences, future research should examine potential distinctions in rates of eating-related pathology between subgroups of transgender populations (i.e., male-to-female, female-to-male, and genderqueer transgender persons), and the impact of an individual's coming out on rates of psychopathology. Future studies should also investigate the potential differences in conditions comorbid with eating-related pathology between these subgroups. In particular, previous studies have shown gay men are at high risk of steroid/anabolic-androgenic steroid/appearance and performance enhancing drug abuse [
      • Blashill A.J.
      • Safren S.A.
      Sexual orientation and anabolic-androgenic steroids in US adolescent boys.
      ], which has been tied to increased muscularity concerns in cisgender gay men relative to heterosexual men (e.g., [
      • McCreary D.R.
      • Hildebrandt T.B.
      • Heinberg L.J.
      • et al.
      A review of body image influences on men's fitness goals and supplement use.
      ]). Although androgenic steroids are often part of supervised medical care for transgender men, this population may also experience increased muscularity concerns and elevated risk of steroid/anabolic-androgenic steroid/appearance and performance enhancing drug abuse relative to cisgender heterosexual men. More nuanced examinations of these topics are necessary for the development of targeted ED intervention and prevention efforts for the gender and SM community. Clinicians should also be aware that transgender clients may be at increased risk for eating-related pathology and should adjust screening practices accordingly.

      Acknowledgments

      These data were presented in part at the International Conference on Eating Disorders 2014 in New York in March 2014.

      Funding Sources

      The study was supported by National Institutes of Health grants K23AA017684 , T32AA07580 , R01 AA017915 , R21 AA021235 , and R01 DA023668 .

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      Linked Article

      • With Transgender Health Inequities so Large and the Need so Great, the Burden Is on All of Us to Find Solutions
        Journal of Adolescent HealthVol. 57Issue 2
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          Diemer et al. [1] offer readers nothing short of a breakthrough study on transgender health (and to a lesser extent, sexual minority health), revealing substantially elevated rates of eating disorder symptoms and past-year diagnosis or treatment for an eating disorder in transgender college students relative to their cisgender classmates. Eating disorders are devastating conditions, with the highest rates of medical complications, hospitalization, and mortality compared with all other psychiatric disorders [2].
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