Understanding Eating Disorders in LGBTQ People

By Lauren Anderson, LMSW

Across the country and the world during the month of June, people come together to celebrate Pride Month and support LGBTQ people. This is a time to honor the work that has been done to achieve equal justice and opportunities for those who identify as lesbian, gay, bisexual, transgender, or queer/questioning. While the battle for equal rights is often drawn out in a public and political arena, the more silent threats faced by LGBTQ individuals must not be overlooked. A prime example that is frequently missed is the significant risk for eating disorders within this community.

Eating disorders are serious conditions that can lead to physical problems in the cardiovascular, gastrointestinal, neurological, and endocrine systems. According to the National Eating Disorders Association (NEDA) (2018C), people with anorexia nervosa are six times more likely to die compared with the general population. These deaths are often attributed to starvation, substance misuse, and suicide.

Additionally, people with eating disorders often have co-occurring mental health diagnoses, most commonly mood and anxiety disorders. According to NEDA (2018A), a major depressive disorder is diagnosed in 32% to 39% of people with anorexia nervosa, 36% to 50% of people with bulimia nervosa, and 33% of people with binge eating disorder, and an anxiety disorder is diagnosed in 48% to 51% of people with anorexia nervosa, 54% to 81% of people with bulimia nervosa, and 55% to 65% of people with binge eating disorder.

One common myth about eating disorders is that they mainly affect white teenage girls. The reality is that anyone can experience this illness. Unfortunately, because of this misconception, and a lack of research into eating disorders in minority populations, there is less awareness of the considerable impact on the LGBTQ population than in others. As a result, LGBTQ people often experience the illness in silence given the general public’s lack of education around the signs of eating disorders.

Disordered Eating in LGBTQ People
Research has shown that youth who are sexual minorities often have higher rates of disordered eating behaviors, including the following:

Sexual minority males have worse overall body image compared with heterosexuals (Miller & Luk, 2019).
As many as 1 in 4 LGB youth reported purging, fasting, and/or taking diet pills to lose weight (Institute of Medicine, 2010).
LGB youth may be at an increased risk for binge eating and purging as early as 12 years old (NEDA, 2018B).

Unfortunately, these trends carry over into college-age students. A study examining data from The American College Health Association—National College Health Assessment II found that LGBTQ students had higher rates of eating disorder diagnoses and disordered eating behaviors. Specifically, rates of eating disorder diagnosis in the past year, and use of diet pills, vomiting, and/or laxatives in the past month, were highest among transgender students and were also elevated for cisgender (identifying with the gender that corresponds to birth sex) gay, lesbian, and queer/questioning individuals (Diemer, Grant, Munn-Chernoff, Patterson, & Duncan, 2015).

The Relationship Between Discrimination and Eating Disorders
There are different theories about why eating disorder disparities exist in the LGBTQ people. One of the major explanations is that disordered eating occurs, at least in part, as a result of social stressors such as lack of acceptance, harassment, rejection, and physical victimization, known as minority stress (Meyer, 2003; Watson, Adjei, Saewyc, Homma, & Goodenow, 2017).

A study of 496 lesbian women found that discrimination and minority stress led to social anxiety, which led to body shame; body shame then led to binge eating (Mason & Lewis, 2016).
80.4% of New England LGBTQ college students reported experiencing at least one form of discrimination (Gordon et al., 2019). Of these, 60.9% reported at least one disordered eating behavior.

At the same time that higher rates of individuals affected by eating disorders occur among sexual minority youth, their rate of treatment is lower than their cisgender, heterosexual counterparts (Miller & Luk, 2019). Discrimination, a lack of culturally competent care, lack of support from family and friends, and a lack of education on the signs and symptoms of eating disorders serve as barriers for LGBTQ individuals who are seeking treatment and support (Bowman, 2018; NEDA, 2018B). While there has been an emergence of more safe spaces, such as drop-in centers, gay-straight alliances, community centers, and health care resources for LGBTQ people to access support and mental health care, these spaces have not become widespread, leaving many isolated.

Moving Forward to Better Care
One protective factor that serves LGBTQ people is the influence of social support. Connectedness, community, and support all help to reduce disordered eating behavior among LGBTQ individuals. In one study, transgender participants report that actively including their partners and families in their recovery and gender transitions helped improve their eating disorder symptoms and transition process. They also found that receiving positive reinforcement of their gender presentation by coming out to their community reduced their urge to engage in disordered eating behaviors (Bowman, 2018).

Additionally, respondents noted that negative interactions with doctors prevented them from seeking treatment. They report that establishing a rapport with doctors before disclosing their gender identity was needed for trust and safety and that providers who asked for gender pronouns and used them correctly felt safe and protective (Bowman, 2018).

As social workers who care for LGBTQ people, it is our duty to provide safe, open spaces and advocate for those in need of help. As with any person who has an eating disorder, evidence-based treatment and nutrition education are often a recommended course of treatment in LGBTQ people. Treatment can be inpatient or outpatient, depending on the level of care needed. Individual therapy is always an option but given the complex role of family in their lives, family therapy may also be an essential component of treatment.

In our role, social workers can also advocate for more research and information about those living with eating disorders. In truth, there is not enough current information about eating disorders in general and even less in minority populations. Currently, we do not even have specific numbers of how many LGBTQ individuals have an eating disorder diagnosis nationwide or at the regional level. More information will help us to determine who to reach with prevention and recovery programs and the best way to reach them.

As we continue to move forward, we can help LGBTQ clients connect to other members of their community by helping them find local LGBTQ-friendly organizations or support groups. We can support them in the process of coming out and garnering support from their family and friends by connecting them with mentors and offering therapy sessions that include family members. As we work with our LGBTQ clients, we must encourage self-care, teach how to build coping skills, and help clients develop a positive sense of identity. All of these skills will aid in recovery.

It is important that we offer compassionate care that begins with open-mindedness and does not involve assumptions. That may include checking our own biases and having conversations with our colleagues about best practices. Most importantly, we should listen to our LGBTQ clients to determine their desires and needs to help them overcome their disordered eating and mental health concerns and live an empowered life.

— Lauren Anderson, LMSW, specializes in family-based treatment and family therapy at The Center for Eating Disorders at Sheppard Pratt, an eating disorder treatment program located in the Baltimore area.

References
Bowman, M. K. (2018). The lived experience of transgender individuals with eating disorders. College of Science and Health Theses and Dissertations. 255. Retrieved from https://via.library.depaul.edu/csh_etd/255/.

Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57(2), 144-149.

Gordon, A. R., Austin, S. B., Pantalone, D. W., Baker, A. M., Eiduson, R., & Rodgers R. (2019). Appearance ideals and eating disorders risk among LGBTQ college students: The Being Ourselves Living in Diverse Bodies (BOLD) study. Journal of Adolescent Health, 64(2), S43-S48.

Institute of Medicine. (2010). The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: The National Academies Press.

Mason, T. B., & Lewis, R. J. (2016). Minority stress, body shame, and binge eating among lesbian women: Social anxiety as a linking mechanism. Psychology of Women Quarterly, 40(3).

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin, 129(5), 674-697.

Miller, J. M., & Luk, J.W. (2019). A systematic review of sexual orientation disparities in disordered eating and weight-related behaviors among adolescents and young adults: Toward a developmental model. Adolescent Research Review, 4(2), 187-208.

National Eating Disorders Association (NEDA). (2018A). Anxiety, depression & obsessive compulsive disorder. Retrieved from https://www.nationaleatingdisorders.org/anxiety-depression-obsessive-compulsive-disorder.

National Eating Disorders Association (NEDA). (2018B). Eating disorders in LGBTQ+ populations. Retrieved from https://www.nationaleatingdisorders.org/learn/general-information/lgbtq.

National Eating Disorders Association (NEDA). (2018C). Health consequences. Retrieved from https://www.nationaleatingdisorders.org/health-consequences.

Watson, R. J, Adjei, J., Saewyc, E., Homma, Y., & Goodenow, C. (2017). Trends and disparities in disordered eating among heterosexual and sexual minority adolescents. International Journal of Eating Disorders, 50(1), 22-31.