According to the National Eating Disorders Association (NEDA), the idea that eating disorders are restricted to women who are young, white, and straight is one of many damaging myths that continue to persist. Eating disorders have neither a “look” nor do they discriminate by race, ethnicity, age, size, or sexuality. And one population that NEDA says is disproportionately impacted by eating disorders is the LGBTQ+ community, whose members often experience unique stressors that can contribute to developing an eating disorder. These unique stressors, NEDA explains, include:
Being rejected or fearing rejection from loved ones and work colleaguesBeing bullied or discriminated against due to their sexuality or gender identityExperiencing violence and post-traumatic stress disorder, which are known to raise the risk of developing an eating disorderFeeling that one’s biological sex and gender identity don’t alignFeeling unable to meet certain body image aspirations or “ideals”
The LGBTQ+ community also faces barriers to accessing treatment for eating disorders, says NEDA, including a lack of options that address gender identity and sexuality issues or a lack of support from loved ones. Stereotypes about who can develop an eating disorder (such as the young, thin, straight, white woman stereotype) can also stand in the way of treatment, according to the Columbia University Global Mental Health Programs. Everyday Health asked Whitney Linsenmeyer, PhD, RD, (pronouns: she, her, hers), to address the special issues that heighten the risk of eating disorders in the LGBTQ+ community. Dr. Linsenmeyer is a spokesperson for the Academy of Nutrition and Dietetics, as well as an assistant professor and director of the Didactic Program in Dietetics at the Saint Louis University Doisy College of Health Sciences in Missouri. Her areas of expertise include transgender nutrition and eating disorders, among others. Everyday Health: How did eating disorders in the LGBTQ+ community come onto your radar? What got you interested and involved in this field? Whitney Linsenmeyer: I am an ally to the LGBTQ+ community and work primarily with the transgender community. My interest in transgender health was first sparked by patients I was working with through the Saint Louis University Student Health Center on campus. I began looking into any research or resources from my profession in nutrition and dietetics on providing gender-affirming nutrition care, but found very little at the time, despite pressing and somewhat obvious questions, including:
What is the best way to approach eating disorder management in a transgender client, given the unique relationship between body size, shape, and gender expression?Can nutrition therapy mitigate any of the known effects of gender-affirming hormone therapy, such as elevated cholesterol levels in the blood?
It’s a privilege to work with transgender folks one-on-one, and I have also been able to work with the Transgender Center at Children’s Hospital in St. Louis to develop a nutrition screening protocol for eating disorders. We now have a protocol in place to screen for anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant-restrictive food intake disorder, as well as food insecurity. This protocol was published in June 2020 in the journal Current Developments in Nutrition. EH: Is the LGBTQ+ community more prone to eating disorders, and if so, why? WL: Rates of eating disorders have been found to be significantly higher among transgender youth compared with cisgender youth (cisgender refers to a person whose gender identity aligns with their birth sex), according to a review published in October 2019 in the journal Current Psychiatry Reports. Among high school students in Massachusetts, transgender teens were more than twice as likely to report fasting for longer than 24 hours, more than 8 times more likely to use diet pills, and more than 7 times more likely to use laxatives when compared with cisgender male students, a study published in October 2016 in the Journal of Adolescent Health showed. Among college students in the United States, transgender students were over 4 times more likely to report having been diagnosed with an eating disorder in the past year, and more than twice as likely to have used diet pills, vomiting, or laxatives in the past month when compared with cisgender, heterosexual women, according to a study published in August 2015 in the Journal of Adolescent Health. Disordered eating may be elevated among transgender youth and adults for a variety of reasons, such as:
The desire to achieve attributes of body size and shape associated with one’s gender identityWanting to suppress certain changes during puberty, such as beginning menstruation, that are not consistent with one’s gender identityThe desire to mask the presence of features common to a larger body size, such as breasts or wider hips, that are not aligned with one’s gender identityAs a coping mechanism for gender-related stigma and distressTransgender men, in particular, seeking a larger body size that is distinguished by visible muscles or that is simply perceived as more masculine due to a larger size alone
EH: Are any specific types of eating disorders more prevalent in the LGBTQ+ community? WL: There is a sound body of evidence to support a higher prevalence of eating disorders among transgender people compared with cisgender people, but further research is needed to determine the prevalence of specific eating disorders among transgender people. Based on our screening protocol at the Transgender Center at Children’s Hospital in St. Louis, nearly 30 percent of transgender patients screened positive for anorexia nervosa or bulimia nervosa, 15 percent screened positive for binge eating disorder, and 60 percent screened positive for avoidant-restrictive food intake disorder. EH: How have stereotypes about “who gets an eating disorder” affected the LGBTQ+ community? WL: The pervasive stereotype of someone with an eating disorder is a young, extremely thin, white woman. The reality is that eating disorders affect folks of all ages, gender identities, sizes, races, and ethnicities. These stereotypes can be harmful when folks “don’t fit the mold” of what society expects to see in someone with an eating disorder. It can be harder for folks to recognize something is off in themselves, harder for their friends or family members to take notice, and even sometimes harder for healthcare providers to recognize. EH: How might gender-based, societal beauty standards affect people in the LGBTQ+ community, especially people who are transgender, nonbinary (having a gender identity that is not strictly male or female) or gender-nonconforming (having a gender identity that does not conform to the traditional view of two genders)? WL: Our identities have so many layers, including gender expression, or the way in which we express our gender identity through our appearance, dress, and behaviors. For many transgender folks, body size and shape are an important part of their gender expression. Many of the transgender folks I have worked with have indeed talked about their “ideal body,” but what’s interesting is that what is considered “ideal” is very contextual. I’m thinking of one transgender man I worked with who gained about 60 pounds throughout his medical transition and genuinely wanted that larger body size because he felt himself “coming alive” and going from “invisible to visible.” He might have been labeled obese by conventional standards, but his larger body size was an expression of his masculinity. There’s also a lot of critique of the stereotype of a nonbinary person as lean and often white, or the #FtMfitness hashtag on social media that features images of very fit and chiseled transgender men. All stereotypes can be difficult to reckon with when someone doesn’t fit the mold. EH: Are eating disorders more likely to be overlooked in LGBTQ+ populations? WL: Actually, eating disorders could be more likely to be diagnosed in certain LGBTQ+ populations, like the transgender community, given that transgender folks often may complete a mental health assessment prior to medically transitioning. On the other hand, my sense is that healthcare providers who provide gender-affirming care may be most focused on aspects of medically transitioning, such as gender-affirming hormone therapy, and less focused on other mental health considerations. EH: What are some barriers that can stand in the way of getting treatment for an eating disorder among people who are LGBTQ+? WL: General distrust of the medical community is a big issue. Based on the findings of the 2015 U.S. Transgender Survey (PDF), which is a large-scale survey of transgender adults in the United States, 23 percent of respondents did not see a doctor when needed due to fear of being mistreated as a transgender person, 33 percent had a negative experience with a healthcare provider in the past year, such as verbal harassment or being refused treatment, and 25 percent had issues with their health insurance related to being transgender, such as being denied routine care. Eating disorders are an extremely sensitive topic, and any distrust of the medical providers would only increase a person’s likelihood to keep those issues to themselves. EH: How can people who are LGBTQ+ access treatment for an eating disorder? Are there resources specifically for this community? WL: Two good resources are:
Fighting Eating Disorders in Underrepresented Populations, or FEDUP (Formerly Trans Folx Fighting Eating Disorders, or T-FFED) FEDUP is a collective of transgender and gender-diverse folx (“folx” is a word that explicitly signals the inclusion of groups commonly marginalized) and allies. They provide resources for gender-diverse folx, including a closed support group on Facebook, as well as training for healthcare professionals.National Eating Disorders Association (NEDA) NEDA supports individuals and families affected by eating disorders. They offer resources including online screening, a helpline, a treatment locator, and support groups. They also have sections of their website specifically devoted to the LGBTQ+ population.
Also, anyone already connected to a gender clinic or a healthcare provider who provides gender-affirming care can request a referral to a trusted provider who specializes in eating disorder care and is well-versed in transgender health. EH: What are some signs and symptoms of eating disorders, and what should someone do if a loved one shows these signs and symptoms? WL: According to NEDA, the signs and symptoms of an eating disorder can include:
Drastic fluctuations in weight — both weight loss and weight gainHyper-focus on body weight, food, calories, or dietingRestrictions on foods or nutrients that are not for medical, religious, or cultural reasons (such as avoiding carbohydrates)Evidence of binge eating, such as disappearance of large quantities of food in short periods of time or empty wrappersEvidence of purging, such as frequent trips to the bathroom after eating, signs of vomiting, or the presence of laxatives or diureticsStrict food rituals, such as excessive chewingFear of eating in publicHoarding foodMaintaining an excessive and rigid exercise routine
If a friend or family member shows signs or symptoms of an eating disorder, one of the most important things one can do is to continue being a friend or family member to them, and not try to be their doctor or therapist. For example, a parent’s role would include helping their child make an appointment with a therapist, but it shouldn’t include policing their child’s behaviors. Help connect them to a skilled healthcare team as soon as possible, and make sure you maintain a position of unwavering care and support for your loved one.
