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

Disordered eating and considerations for the transgender community: a review of the literature and clinical guidance for assessment and treatment

BACKGROUND

It has been well established that individuals who identify as lesbian, gay, bisexual, transgender, and queer are at increased risk for mental health pathology, including eating disorders/disordered eating behaviors (ED/DEB). However, less is understood about the unique experiences of transgender and gender diverse (TGD) people who struggle with ED/DEB.

AIMS

The purpose of this literature review is to examine the literature regarding the unique risk factors for TGD individuals who experience ED/DEB through a lens informed by the minority stress model. Additionally, guidance around the assessment and clinical management of eating disorders for TGD individuals will be presented.

RESULTS

TGD people are at increased risk for developing ED/DEB due to a number of factors including: gender dysphoria, minority stress, the desire to pass, and barriers to gender affirming care.

CONCLUSION

While guidance around assessment and treatment of ED/DEB for TGD individuals is still limited, adhering to a gender affirmative care model is essential.

Beyond Binge Eating: The Impact of Implicit Biases in Healthcare on Youth with Disordered Eating and Obesity

(1) Background: Obesity and eating disorders (ED) can coexist resulting in worse health outcomes. Youth with ED are more likely to have obesity relative to peers with a healthy weight. Pediatric providers deliver first-line care to children and youth of all sizes and body shapes from infancy to adolescents. As healthcare providers (HCPs), we bring biases into our practice. Learning to recognize and address these biases is needed to provide the best care for youth with obesity. (2) Purpose: This paper aims to summarize the literature regarding the prevalence of ED beyond binge eating in youth with obesity and discuss how the intersection of weight, gender, and racial biases impact the assessment, diagnosis, and treatment of ED. We provide recommendations for practice and considerations for research and policy. (3) Conclusions: The assessment and treatment of ED and disordered eating behaviors (DEBs) in youth with obesity is complex and requires a holistic approach. This approach begins with identifying and understanding how one's implicit biases impact care. Providing care from a patient-centers lens, which considers how the intersection of multiple stigmatized identities increases the risk for DEBs in youth with obesity may improve long-term health outcomes.

Do the SCOFF items function differently by food-security status in U.S. college students?: Statistically, but not practically, significant differences

Despite food insecurity (FI) being associated with eating disorders (EDs), little research has examined if ED screening measures perform differently in individuals with FI. This study tested whether items on the SCOFF performed differently as a function of FI. As many people with FI hold multiple marginalized identities, this study also tested if the SCOFF performs differently as a function of food-security status in individuals with different gender identities and different perceived weight statuses. Data were from the 2020/2021 Healthy Minds Study (N = 122,269). Past-year FI was established using the two-item Hunger Vital Sign. Differential item functioning (DIF) assessed whether SCOFF items performed differently (i.e., had different probabilities of endorsement) in groups of individuals with FI versus those without. Both uniform DIF (constant between-group difference in item-endorsement probability across ED pathology) and non-uniform DIF (variable between-group difference in item-endorsement probability across ED pathology) were examined. Several SCOFF items demonstrated both statistically significant uniform and non-uniform DIF (ps < .001), but no instances of DIF reached practical significance (as indicated by effect sizes pseudo ΔR2 ≥ 0.035; all pseudo ΔR2's ≤ 0.006). When stratifying by gender identity and weight status, although most items demonstrated statistically significant DIF, only the SCOFF item measuring body-size perception showed practically significant non-uniform DIF for perceived weight status. Findings suggest the SCOFF is an appropriate screening measure for ED pathology among college students with FI and provide preliminary support for using the SCOFF in individuals with FI and certain marginalized identities.

Understanding the Complex Relationship Between One's Body, Eating, Exercise, and Gender-Affirming Medical Care Among Transgender and Nonbinary Adolescents and Young Adults

Purpose

Gender dysphoria has been linked to body dissatisfaction, which can affect an individual's eating and exercise habits and increase their risk for disordered eating. The prevalence of eating disorders among transgender and nonbinary (TGNB) adolescents and young adults (AYA) ranges from 5% to 18% and studies have found a higher risk of disordered eating among these AYA in comparison to their cisgender peers. However, there is minimal research on why TGNB AYA are at higher risk. The aim of this study is to understand unique factors that define a TGNB AYA's relationship between their body and food, how this relationship may be affected by gender-affirming medical care, and how these relationships may contribute to disordered eating.

Methods

A total of 23 TGNB AYA were recruited from a multidisciplinary gender-affirming clinic to participate in semistructured interviews. Transcripts were analyzed using Braun and Clarke's theory of thematic analysis (2006).

Results

The average age of participants was 16.9 years. Forty-four percent of participants identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Five themes emerged regarding TGNB participants' relationship to food and exercise: gender dysphoria and control over one's body, societal expectations of gender, mental health and safety concerns, emotional and physical changes with gender-affirming medical care, and recommended resources for TGNB AYA.

Conclusion

By understanding these unique factors, clinicians can provide targeted and sensitive care when screening and managing disordered eating among TGNB AYA.

Validation of the Nine-Item Avoidant/Restrictive Food Intake Disorder Screen Among Transgender and Nonbinary Youth and Young Adults

Purpose

The purpose of the study was to provide initial evidence for the internal consistency and convergent validity of the nine-item avoidant/restrictive food intake disorder screen (NIAS) in a sample of transgender and nonbinary (TGNB) youth and young adults.

Methods

Returning patients at a Midwestern gender clinic (n=164) ages 12-23 completed the NIAS, sick, control, one stone, fat, food (SCOFF), patient health questionnaire 9 (PHQ-9), and generalized anxiety disorder 7 (GAD-7) during their clinic visit. Age, sex assigned at birth, gender identity, weight, and height were also collected. Confirmatory factor analysis was used to establish the hypothesized three-factor structure of the NIAS in this sample. Relationships between the NIAS subscales and anthropometric data, SCOFF, PHQ-9, GAD-7, and sex assigned at birth were explored for convergent and divergent validity, and proposed screening cutoff scores were used to identify the prevalence of likely avoidant/restrictive food intake disorder (ARFID) in this population.

Results

The three-factor structure of the NIAS was an excellent fit to the current data. Approximately one in five (22%) of the participants screened positive for ARFID. Approximately one in four participants scored above the picky eating (27.4%) or appetite (23.9%) cutoffs. Assigned female at birth participants scored significantly higher on the NIAS-Total, Appetite, and Fear subscales than those assigned male at birth. NIAS-Total was significantly related to all convergent validity variables other than age, with a moderate-strong correlation with other symptom screeners (SCOFF, PHQ-9, GAD-7), and a small negative correlation with body mass index percentile.

Conclusions

Evidence supports the NIAS as a valid measure to screen for ARFID among TGNB youth and young adults.

More than an outcome: a person-centered, ecological framework for eating disorder recovery

BACKGROUND

Eating disorder recovery is a complex phenomenon. While historical understandings focused on weight and behaviours, the importance of psychological factors is now widely recognized. It is also generally accepted that recovery is a non-linear process and is impacted by external factors. Recent research suggests a significant impact of systems of oppression, though these have not yet been named in models of recovery. BODY: In this paper, we propose a research-informed, person-centered, and ecological framework of recovery. We suggest that there are two foundational tenets of recovery which apply broadly across experiences: recovery is non-linear and ongoing and there is no one way to do recovery. In the context of these tenets, our framework considers individual changes in recovery as determined by and dependent on external/personal factors and broader systems of privilege. Recovery cannot be determined by looking solely at an individual's level of functioning; one must also consider the broader context of their life in which changes are being made. To conclude, we describe the applicability of the proposed framework and offer practical considerations for incorporating this framework in research, clinical, and advocacy settings.

Body Uneasiness and Dissatisfaction Among Lesbian, Gay, Bisexual, and Heterosexual Persons

Introduction

While sexual minority people have been widely considered at risk for developing a range of body image concerns, evidence of body dissatisfaction and shame amongst LGB (lesbian, gay, and bisexual) individuals is mixed. This study investigated differences in body uneasiness, body dissatisfaction, and self-blaming/attacking attitudes between LGB and heterosexual individuals, as well as within LGB groups, while also examining the predictive role of body mass index (BMI).

Methods

A sample of cisgender lesbian women (n = 163), gay men (n = 277), bisexual women (n = 135), bisexual men (n = 39), heterosexual women (n = 398), and heterosexual men (n = 219) completed an online survey assessing different aspects of body image between May and July 2020.

Results

Gay and bisexual men reported greater body image disturbance and self-blaming attitudes relative to heterosexual men. In contrast, lesbian women reported lower body uneasiness than their bisexual and heterosexual counterparts, but greater self-hate. Moreover, lesbian and bisexual women showed more body dissatisfaction than gay men, and bisexual individuals reported more body uneasiness than individuals in other sexual minority subgroups. Higher BMI emerged as a significant predictor of body image concerns and dissatisfaction.

Conclusions

Body image dimensions showed sexual identity-based differences. Determining the specific nuances of body image in LGB individuals can provide important information on potential risk factors that may impact mental health outcomes.

Policy Implications

In-depth knowledge of body dissatisfaction and uneasiness in individuals with LGB identities may have critical implications for the development of personalized prevention and treatment strategies.

Provider perceptions of barriers and facilitators to care in eating disorder treatment for transgender and gender diverse patients: a qualitative study

BACKGROUND

The prevalence of eating disorders is higher in transgender and non-binary compared to cisgender people. Gender diverse people who seek eating disorder treatment often report struggling to find affirming and inclusive treatment from healthcare clinicians. We sought to understand eating disorder care clinicians' perceptions of facilitators of and barriers to effective eating disorder treatment for transgender and gender diverse patients.

METHODS

In 2022, nineteen US-based licensed mental health clinicians who specialized in eating disorder treatment participated in semi-structured interviews. We used inductive thematic analysis to identify themes around perceptions and knowledge of facilitators and barriers to care for transgender and gender diverse patients diagnosed with eating disorders.

RESULTS

Two broad themes were identified: (1) factors affecting access to care; and (2) factors affecting care while in treatment. Within the first theme, the following subthemes were found: stigmatization, family support, financial factors, gendered clinics, scarcity of gender-competent care, and religious communities. Within the second theme, prominent subthemes included discrimination and microaggressions, provider lived experience and education, other patients and parents, institutions of higher education, family-centered care, gendered-centered care, and traditional therapeutic techniques.

CONCLUSION

Many barriers and facilitators have potential to be improved upon, especially those caused by clinicians' lack of knowledge or attitudes towards gender minority patients in treatment. Future research is needed to identify how provider-driven barriers manifest and how they can be improved upon to better patient care experiences.

Examining the Role of Body Image Instability in Young Adult Women: Conceptualization, Development, and Psychometric Evaluation of the Vacillating Body Image Scale (VBIS)

The current study conceptualized body image instability as a maladaptive tendency to vacillate between different self-perceptions of one's overall body image and developed a corresponding measure to assess body image instability. Results from a series of studies of young adult women demonstrated the validity, reliability, and utility of the Vacillating Body Image Scale (VBIS) as a meaningful measure of body image instability. In Study 1, we found that body image instability, as assessed by the VBIS, represents a unidimensional and reliable construct. In Study 2, we found evidence for both the convergent and discriminant validity of the VBIS in relation to other individual differences measures (i.e., self-concept schema, broad personality factors). In Study 3, the concurrent criterion validity of the VBIS was supported for young adult women in relation to a range of adjustment measures. Finally, in Study 4, we found consistent evidence for the incremental validity of the VBIS in predicting subsequent variations in eating disturbances, even after controlling for global self-esteem and self-concept instability. Overall, our findings offer promising support for our contention that body image instability, as measured by the VBIS, represents an important construct for understanding eating-related disturbances and other health outcomes in young adult women.

"How Do I Exist in This Body…That's Outside of the Norm?" Trans and Nonbinary Experiences of Conformity, Coping, and Connection in Atypical Anorexia

Addressing eating disorders (EDs) within trans and nonbinary (TNB) populations is a growing concern, as TNB individuals are two to four times more likely to experience EDs than cisgender women. This study explored the lived experiences of TNB people with atypical anorexia by examining how gender identity impacted experiences of ED illness and (potential) recovery. Nine TNB adults with atypical anorexia were followed for one year and completed semi-structured, in-depth, longitudinal qualitative interviews at baseline, 6 months, and 12 months. Interviews were coded using Braun and Clark's thematic analysis procedures. Four themes, along with subthemes, emerged regarding the intersection of gender identity and ED experiences: (1) Conforming, (2) Coping, (3) Connecting, and (4) Critiquing. In Conforming, participants highlighted how societal pressures around gender contributed to ED vulnerability. In Coping, participants explained that their EDs represented attempts to cope with the overlapping influences of body dissatisfaction, gender dysphoria, and body disconnection. In Connecting, participants described ED recovery as a process of connecting to self, others, and communities that welcomed and affirmed their diverse identities. In Critiquing, participants described how current ED treatment settings were often unwelcoming of or unprepared for non-cisgender patients. Overall, participants viewed their EDs as intricately linked to their gender identity and experiences of social pressure and discrimination. This study suggests the need for targeted ED prevention and intervention efforts within TNB communities, and the ethical imperative to meaningfully address the needs of TNB patients in ED treatment settings.

Eating disorders and substance use: Examining associations among US college students

OBJECTIVE

To investigate associations between reported eating disorder (ED) diagnosis and substance use disorder (SUD) diagnosis, substance misuse, and illicit drug use among US college students.

METHOD

Data consisting of n = 414,299 students' responses to the National College Health Assessment survey conducted by the American College Health Association between fall 2015 and spring 2019 were utilized for this study. Unadjusted and adjusted odds ratios were used to determine the association of reported ED diagnosis with reported SUD diagnosis, misuse of cigarettes, e-cigarettes, alcohol, marijuana, cocaine/methamphetamine, sedatives, hallucinogens, opiates, inhalants, MDMA, and other club drugs, as well as illicit use of prescription pain killers, prescription sedatives, and prescription stimulants. A sensitivity analysis investigating associations between reported anorexia nervosa (AN), bulimia nervosa (BN), and each substance use outcome was also conducted.

RESULTS

Among all in our analytic cohort, 7.15% reported receiving an ED diagnosis or being treated for an ED in the last 12 months. Students with ED indications were significantly more likely to report each of the substance use outcomes investigated in this study, including SUD diagnosis (aOR: 7.43; 95% CI: 6.98, 7.92; p < .0001), opiate misuse (aOR: 8.35; 95% CI: 7.38, 9.45; p < .0001), and misuse of other club drugs (aOR: 10.37; 95% CI: 9.10, 11.81; p < .0001) than peers without reported EDs. Both AN and BN were associated with an increased likelihood of SUD diagnosis.

DISCUSSION

These findings demonstrate strong associations between EDs and the most extensive list of substance use outcomes explored in the context of college setting ED research to date.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization

BACKGROUND

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.

METHODS

A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.

RESULTS

Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).

CONCLUSIONS

Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

Training clinicians in culturally relevant care: a curriculum to improve knowledge and comfort with the transgender and gender diverse population

PURPOSE

To design a replicable simulation curriculum collaboratively with the transgender and gender diverse community to improve clinician knowledge and comfort with providing reproductive care to this population.

METHODS

This is a prospective, single arm pre-post analysis of obstetrics and gynecology residents at a single academic institution after completion of a novel simulation curriculum. The primary outcome was the change in resident comfort and knowledge in providing transgender and gender diverse patient care. A thematic analysis of learner and standardized patient free text responses was analyzed for insights on perceived learner experiences.

RESULTS

This curriculum was created with iterative feedback from the transgender community and involved only transgender and gender diverse-identified standardized patients. Thirty residents participated, with 22 responding to both the pre-and post-curriculum surveys, and 11 responding to a 6-month post-curriculum survey. There were significant improvements in learner comfort and knowledge after participation that were found to persist at 6 months. Qualitative analysis demonstrated that this was a positive and powerful learning experience for both residents and standardized patients.

CONCLUSIONS

This simulation curriculum may be an effective and impactful tool to increase trainee comfort and knowledge of transgender and gender diverse patient care, which is important given the lack of physician training in the care for these individuals. By building the foundation with resident learners, the ultimate goal is to enhance the pool of clinicians confident and capable of caring for transgender and gender diverse patients, to increase access to care, and to improve health outcomes in this vulnerable population.

Validation of the Body Appreciation Scale-2 in cisgender, heterosexual and sexual and gender minority adolescents and sexuality-related correlates

Body dissatisfaction has received considerable scientific attention, while research about positive body image has been neglected, particularly among adolescents. The aims of the present study were to examine (1) the factor structure of the Body Appreciation Scale-2 (BAS-2) in a large sample of cisgender, heterosexual and sexual and gender minority adolescents, (2) measurement invariance across language, gender and sexual orientation-based groups, (3) convergent validity with sexuality-related outcomes and (4) one-year temporal stability. Results of a confirmatory analysis among 2419 adolescents (M_age=14.6 years, SD=0.62; 52.6% girls) corroborated the proposed one-dimensional factor structure of the scale. The BAS-2 demonstrated adequate reliability and one-year temporal stability. The scale was partially invariant across gender and fully invariant across language and cisgender heterosexual and sexual and gender minority adolescents. Boys (cis and trans) had higher levels of body appreciation than girls (cis and trans), while no significant differences were observed between heterosexual and sexual minority adolescents. The BAS-2 correlated positively with sexual satisfaction and sexual body-esteem as well as negatively with sexual distress. Our findings support the validity and reliability of the BAS-2 in French and English for measuring body appreciation in adolescents.

Loss of control may uniquely predict negative affect among the disinhibited eating experiences of high-risk young men

OBJECTIVE

Loss of control (LOC) eating is a disordered eating behavior that is prevalent but understudied among men. It is common for men with LOC eating to concurrently engage in diverse eating behaviors characterized as disinhibited. It remains unclear which eating qualities are most distressing for men. This study evaluated the link between disinhibited eating qualities and subsequent negative affect in young men.

METHODS

42 men (18-35 y) who reported engaging in ≥4 LOC eating episodes in the prior month completed a 14-day ecological momentary assessment protocol. For each meal and snack, participants were asked to rate the extent to which they felt they overate; lost control; ate more than planned; ate mindlessly; had concerns about wasting food; and were encouraged to eat more by others. State negative affect was evaluated during random intervals five times per day.

RESULTS

After adjusting for previous negative affect and time between ratings, five of the six eating qualities were significantly and positively associated with subsequent negative affect according to between-participant findings (ps < 0.026). In within-participant analyses, only LOC was significantly and positively associated with subsequent negative affect (p = 0.044).

DISCUSSION

While a range of disinhibited eating qualities are correlated with negative affect in a sample of young men, a sense of LOC while eating may be a promising target for interventions focused on improving the psychological functioning of high-risk young men.

Care of Gender Diverse Youth with Obesity

PURPOSE OF REVIEW

The relationships between gender identity, body image, and gender expression are complex, requiring a gender affirming approach to address weight management. This purpose of this review is to describe the essentials to caring for gender diverse youth, as well as the differences and intersections among those with obesity.

RECENT FINDINGS

Gender-affirming hormone therapy may lead to abnormal weight gain and increased body mass index, or worsen obesity and exacerbate weight-related complications. Moreover, given the high prevalence of victimization, marginalization, and stigmatization among gender diverse people and youth with obesity, care guidelines and treatment goals should also include reducing the negative impact of social-related complications. Despite the overlap in clinical care and lived experiences that impact the health of gender diverse youth with obesity, there is very little research to help guide clinicians. Careful attention to medical and behavioral comorbidities, barriers to care, and health disparities can inform clinical practice. Future research that specifically addresses nuances to care for gender diverse youth with obesity can help to establish standards of care to address their unmet needs and further support clinicians, patients and their families.

Medical considerations in the care of transgender and gender diverse patients with eating disorders

Transgender and gender diverse (TGD) individuals are at increased risk for the development of eating disorders, but very little has been published with regards to the unique aspects of their medical care in eating disorder treatment. Providing gender affirming care is a critical component of culturally competent eating disorder treatment. This includes knowledge of gender affirming medical and surgical interventions and how such interventions may be impacted by eating disordered behaviors, as well as the role of such interventions in eating disorder treatment and recovery. TGD individuals face barriers to care, and one of these can be provider knowledge. By better understanding these needs, clinicians can actively reduce barriers and ensure TGD individuals are provided with appropriate care. This review synthesizes the available literature regarding the medical care of TGD patients and those of patients with eating disorders and highlights areas for further research.

Social and contextual influences on eating pathology in transgender and nonbinary adults

Eating pathology (EP) is reported at alarmingly high rates among transgender and nonbinary (TNB) people. The present study investigates key associations between experiences that are common in TNB populations and EP. TNB individuals located within the United States (N = 212) who self-identified as currently experiencing disordered eating or an eating disorder were recruited from social media outlets and completed an online survey that included measures of EP, discrimination-based trauma symptoms, internalized transphobia, and gender dysphoria. The average age of participants was just over 27 years old (SD = 6.22) and the majority of participants (68.9%) were nonbinary. Data were analyzed using IBM SPSS version 28 and PROCESS 4.0. Discrimination trauma [β = .27, t(211) = 3.90, p < .001] and internalized transphobia [β = .21, t(211) = 3.03, p = .003] were significant predictors of EP in a multiple regression model. Additionally, internalized transphobia partially mediated the association between discrimination trauma and EP. Findings reinforce the need for trauma-informed and multiculturally competent provision of services for TNB populations presenting with eating concerns. Results also highlight the complex role that previously unexplored variables play in the etiology of EP for TNB populations. Implications and clinical recommendations are discussed.

Comparing eating disorder treatment outcomes of transgender and nonbinary individuals with cisgender individuals

OBJECTIVE

The purpose of this study was to compare symptom severity of eating disorders (EDs), depression and anxiety at admission and discharge for transgender and nonbinary (TNB) individuals and cisgender adult individuals receiving treatment for EDs at higher levels of care (HLOC), adding to the limited research in this area.

METHOD

Participants were 25 TNB individuals and 376 cisgender individuals admitted to a HLOC ED treatment facility. Participants completed the Eating Disorder Examination Questionnaire (EDE-Q), Patient Health Questionnaire-9, and Beck Anxiety Inventory at admission and discharge.

RESULTS

TNB individuals showed significant improvements on EDE-Q global scores between admission and discharge (Cohen's d = 1.27), and showed similar improvements on the EDE-Q over the course of treatment (Cohen's d = 0.06) when compared to cisgender individuals. TNB individuals had more severe depression at admission (Cohen's d = 0.61). Although depression improved over the course of treatment for both groups, TNB individuals showed less improvement (Cohen's d = 0.59). Suicidality was higher for TNB individuals on admission and discharge and did not improve significantly over the course of treatment (Cohen's d = 0.38).

DISCUSSION

This study provides preliminary evidence that TNB and cisgender individuals show similar improvement in ED symptoms during HLOC treatment. However, TNB individuals have more severe depression and less improvement in depression compared to cisgender individuals, without improvement in suicidality. TNB individuals may benefit from care targeting depression and suicidality during ED treatment.

PUBLIC SIGNIFICANCE STATEMENT

TNB individuals have increased risk of EDs. Little research addresses how TNB individuals respond to ED treatment, which was traditionally created for cisgender individuals. We present one of the first studies examining ED treatment outcomes for TNB adults. TNB individuals showed improved ED symptoms with treatment, but less improvement in depression and their suicidality remained elevated. This suggests the need for targeted treatment.

The nature of co-morbid psychopathology in adolescents with gender dysphoria

Gender-referred adolescents (GR) have been reported to present with considerable psychiatric symptomatology compared to their age-peers. There is, however, little research on how they compare to adolescents referred due to mental health problems (MHR). We set out to compare psychopathology in adolescents referred to our specialized gender identity unit (n = 84) and adolescents referred to a general adolescent psychiatric clinic (n = 293) in a university hospital setting in Finland. Of the GR adolescents, 40.9% had not received any psychiatric diagnosis during adolescence. Eating disorders were less common in the GR than in the MHR group, but otherwise the prevalences of disorders did not differ statistically significantly. At the symptom level, the GR adolescents displayed significantly more suicidal ideation and talk and less alcohol abuse and eating disorder symptoms than did the MHR adolescents, but otherwise their symptom profiles were comparable. Additionally, the GR adolescents had significantly fewer total externalizing symptoms than did the MHR adolescents. Adolescents seeking gender affirming treatments present with psychiatric symptoms and disorders comparable to those seen among adolescent psychiatric patients. Medical gender affirming care may not be a sufficient intervention for treating psychiatric comorbidities of adolescents with gender dysphoria.

Relationship between college lifestyle variables, eating disorder education, and eating disorder risk

Objective: This study examined relationships between eating disorder risk (EDR), lifestyle variables (e.g., exposure to healthy eating media), and differences among male and female college students. Participants: College students (N = 323) completed survey questionnaires (Fall, 2016). Fifty-three participants retook the survey at a later time. Methods: Participants completed a survey measuring EDR using EDI-3 subscales and 10 college lifestyle variables. Female and male EDR and Time 1 and Time 2 EDR were compared. Relationships between EDR and college life-style variables were examined. Results: Exercise, fewer daily meals, less face-to-face interactions, more digital interactions, less exposure to healthy eating media, and having conversations about body image were associated with EDR risk. Male college students showed an increase in EDR over time. Conclusions: Several lifestyle factors predicted EDR in college females and males. These lifestyle factors are modifiable and may be addressed by colleges during orientation and within the campus environment.

The association of attachment, mentalization and reflective functioning with mental health in gender diverse children and adolescents: A systematic review

Gender diverse children (here defined as minors under 18) face greater risk for depression, anxiety and suicidality than their cisgender peers. This situation calls for research on protective factors of mental health in this population, and on appropriate therapeutic and supportive interventions. This systematic review aimed at (1) examining literature on the role of attachment, mentalization and reflective functioning in protecting mental health of gender diverse children and identifying the mental health outcomes that have been assessed; and (2) outlining interventions based on attachment, mentalization and reflective functioning that have been proposed. The work was conducted according to the PRISMA guidelines. Fifty-one studies were identified and 9 met the inclusion criteria. Results indicate that, besides a general protective role for mental health, attachment, mentalization and reflective functioning moderate and mediate, through different pathways, (1) the association between gender diversity and emotional/behavioural problems; and (2) the negative effects of minority stress. Mentalization seems to be an individual resilience factor; the capacity of the caregiver to serve as a secure base and validate the internal experience of incongruence of the child promote a healthy psychological development. Three levels of action for interventions were identified: individual, family and community.

Disparities in the prevalence, frequency and trajectories of substance use and disordered eating across first-year university in sexual minority undergraduates

Objective. To compare the prevalence and trajectories of risky health behaviors in sexual minority (SM; lesbian/gay/bisexual/questioning/asexual) versus heterosexual undergraduates across their first year of post-secondary. Participants. First-year undergraduates (N = 704, Mage=17.97 years, 24% SM) from a midsized Canadian university. Methods. Students completed monthly (September-April) online questionnaires assessing substance use (binge drinking, tobacco, cannabis, illicit drug use) and disordered eating (binge eating, fasting, purging). Results. At the outset of the academic year, SM students endorsed more frequent cannabis use, illicit drug use, fasting, and binge eating, but less frequent tobacco use, versus heterosexual students. Over the year, SM students' binge drinking frequency declined less than that of heterosexual students, but their illicit drug use decreased while that of their heterosexual peers increased, and all students reported declining disordered eating frequency. Conclusions. Campus wellness initiatives for SM students should offer prevention and harm-reduction strategies prior to or shortly after their arrival on campus.

Sexual and gender minority (SGM) adolescents' disordered eating: Exploring general and SGM-specific factors

OBJECTIVE

Sexual and gender minority (SGM) adolescents disproportionately report disordered eating, yet have primarily been considered under a larger SGM umbrella. The current study 1) compared disordered eating between sexual minority (SM) and gender minority (GM) adolescents; 2) examined how general psychological factors (self-esteem, depression, and stress) and SGM-specific factors (e.g., feelings about SGM identity, access to SGM resources) were associated with disordered eating; and 3) examined whether associations between these factors differed for SM versus GM adolescents.

METHOD

SGM adolescents in the U.S. (N = 8814; 35.0% GM; 43.7% cisgender girls; 66.9% White; M_age  = 15.6) reported their disordered eating, depressive symptoms, stress, self-esteem, and SGM-related experiences on an anonymous, cross-sectional online survey.

RESULTS

GM adolescents exhibited a higher prevalence of clinical threshold disordered eating than SM adolescents. Self-esteem was associated with lower odds of caloric restriction, purging, and binge eating. Depression was associated with higher odds of caloric restriction, diet pill use, purging, laxatives, and binge eating. Stress was associated with higher odds of purging. Associations were stronger for GM adolescents' caloric restriction. Positive feelings about SGM identity were associated with lower odds of caloric restriction, purging, and binge eating, whereas greater stress of "coming out" was associated with higher odds of caloric restriction, purging, and binge eating.

DISCUSSION

These results suggest that SGM adolescents' disordered eating is associated with both general psychological factors and unique SGM experiences. Results highlight the importance of considering how the unique experiences of SGM youth may leave them vulnerable to disordered eating behaviors.

PUBLIC SIGNIFICANCE STATEMENT

Sexual and gender minority (SGM) youth are disproportionately affected by disordered eating. The current study found that higher depression and stress, and lower self-esteem, were associated with SGM adolescents' disordered eating. Furthermore, unique SGM experiences, such as stress about coming out, were also associated with eating pathology. Results highlight the importance of considering SGM adolescents' perceptions of their identity and social support.

Resilience among LGBTQIA+ youth in out-of-home care: A scoping review

BACKGROUND

Research on the experiences of LGBTQIA+ youth in out-of-home care has mainly focused on these youth's adversities and the resulting negative impact on their wellbeing. Little is known about the ways through which LGBTQIA+ youth in out-of-home care are resilient to these adversities. To date, a review study on resilience in this population is lacking.

OBJECTIVE

To map and synthesize the existing research on resilience among LGBTQIA+ children and youth in out-of-home care. Specific goals were to summarize and analyze 1) the general characteristics of the existing studies, and 2) the resilience resources found at the individual, relational, sociocultural, and ecological levels.

METHODS

We carried out a scoping review examining empirical published academic literature.

RESULTS

The 14 studies included in this scoping review indicated that resilience studies among LGBTQIA+ youth in out-of-home care are mainly qualitative, cross-sectional, US-based, and were centered on gay youth. Studies suggested that resilience resources were mostly focused at the socio/relational level (e.g., foster family acceptance) with fewer studies at the individual (e.g., LGBTQ positive identity), and community levels (e.g., LGBTQ centers). Importantly, no studies explored the interaction of resilience resources across these different domains.

CONCLUSIONS

Resilience among LGBTQIA+ youth in out-of-home care remains understudied and the results of this scoping review point to specific research gaps. Recommendations are provided for research, practice, and policy.

Body dissatisfaction among ethnic subgroups of Latin women: An examination of acculturative stress and ethnic identity

This study investigated (1) ethnic group differences in body dissatisfaction (BD) among specific Latina subgroups, (2) acculturative stress as a mediator between ethnic group and BD, and (3) ethnic identification as a moderator between 3a) ethnic group and BD and 3b) acculturative stress and BD. Mexican (n = 30), Puerto Rican (n = 31), Cuban (n = 29), and non-Hispanic, White (n = 30) women in the US completed self-report questionnaires. Group comparisons indicated Mexicans reported greater BD compared to Whites, while Puerto Ricans and Cubans did not differ from Whites. A significant indirect effect indicated that acculturative stress mediated the association between ethnic group and BD. Acculturative stress predicted BD at low and average levels of ethnic identification. Additionally, there were significant differences comparing Cubans to Mexicans and Puerto Ricans, which were dependent on ethnic identification. Thus, higher ethnic identification may serve as a protective factor for Cubans. Findings support separating subgroups of Latinas and that higher ethnic identification may protect against the development of BD in Latinas experiencing acculturative stress. Assessments and interventions should address acculturative stress since higher levels were associated with higher levels of BD, and the combination of ethnic group, acculturative stress, and ethnic identification may help explain differences in BD among Latinas.

Prevalence of diagnosed eating disorders in US transgender adults and youth in insurance claims

OBJECTIVE

We estimated the prevalence of diagnosed eating disorders, overall and by select demographics, among commercially insured individuals identified as transgender in a national claims database.

METHODS

From the 2018 IBM® MarketScan® Commercial Database, there were 10,415 people identifiable as transgender based on International Classification of Disease (ICD-10) codes and procedure codes, specific to gender-affirming care, from inpatient and outpatient claims. Eating disorders were identified from ICD-10 codes and included anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified, avoidant restrictive feeding and intake disorder, and other specified feeding and eating disorders. We estimated the prevalence of specific eating disorders diagnoses by selecting patient characteristics.

RESULTS

Of individuals receiving some form of gender-affirming care, 2.43% (95% confidence interval: 2.14%-2.74%) were diagnosed with an eating disorder: 0.84% anorexia nervosa, 0.36% bulimia nervosa, 0.36% binge eating disorder, 0.15% avoidant restrictive feeding and intake disorder, 0.41% other specified feeding and eating disorders, and 1.37% with an unspecified eating disorder. Among transgender-identifiable patients aged 12-15 years, 5.60% had an eating disorder diagnosis, whereas 0.52% had an eating disorder diagnosis in patients aged 45-64 years.

DISCUSSION

In patients identifiable as transgender, with receipt of gender-affirming care, the prevalence of diagnosed eating disorders was low compared to extant self-reported data for eating disorder diagnosis in transgender individuals. Among this population, eating disorders were highest in adolescents and young adults. Clinically verified prevalence estimates for eating disorder diagnosis in transgender people with a history of gender-affirming care warrant further investigation.

PUBLIC SIGNIFICANCE

The present study aims to provide clinically validated, contemporary prevalence estimates for diagnosed eating disorders among a medically affirmed population of transgender adults and children in the United States. We report low prevalence of having any eating disorder relative to prevalence estimates reported in prior literature without clinical validation. These findings may be explained by access to affirming care and medical care generally.

A critical examination of disparities in eating disorder symptoms by sexual orientation among US adults in the NESARC-III

OBJECTIVE

Sexual minoritized persons evidence higher prevalence of eating disorders than heterosexual persons, yet it is unclear which specific symptoms drive these disparities. Empirical evidence also documents the importance of considering subclinical eating disorder presentations, as well as potential differentiation in expression of eating disorder symptoms based on gender. The current study complements that of Kamody et al. (2020), who examined sexual orientation-based disparities in eating disorder diagnoses using a nationally representative sample of the US adult population.

METHOD

Using the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), we compared the prevalence of eating disorder symptoms across sexual minority status separately for men and women.

RESULTS

Sexual minoritized men were more likely than heterosexual men to report body mass index (BMI) < 18.5 kg/m² (odds ratio [OR] = 1.76), thus, being screened into questions about restrictive eating. Sexual minoritized women were more likely than heterosexual women to endorse ever engaging in a binge-eating episode (OR = 2.25) and engaging in weekly binge eating for at least 3 months (OR = 1.58), thus, being screened into follow-up questions about binge eating. Sexual minoritized men were more likely than heterosexual men to fear gaining weight even when at their lowest weight (OR = 4.35) and experience a loss of control when overeating (OR = 3.13).

DISCUSSION

Sexual orientation-based disparities in eating disorder symptom endorsement were nuanced when stratifying the entire sample by gender. Findings expand previous research on disparities in clinical/diagnosed eating disorders, highlighting the importance of assessing symptomology beyond diagnosis, as well as the intersectional influence of sexual orientation and gender, in both research and practice.

Weight Status, Medication Use, and Recreational Activities of Treatment-Naïve Transgender Youth

Background: Studies of transgender/gender diverse (TGD) youth indicate a high prevalence of overweight/obesity and concern for unhealthy weight management behavior. This study describes the association of weight status with medication use and recreational activities among treatment-naïve, pediatric TGD patients. Methods: This study is a chart review of 277 patients [aged 9-18 years, 79.1% female sex assigned at birth (SAB), and 86.3% white] seen at a medical center from 2017 to 2020. BMI was calculated by age and SAB using CDC growth charts. BMI percentile (BMI%) and BMI z-score (BMIz) were used to define weight status. Results: By BMI% category, 3.6% patients were in the underweight range (BMI <5%); 50.5% had BMI >85%; and 30.3% had BMI >95%. Overweight and obesity rates were higher than national norms (χ² = 15.152, p < 0.01). Female SAB participants had higher BMIz values than male SAB participants. Youth who reported watching/listening to media (t = 3.50, p < 0.01) and parent-reported creative arts involvement (t = 1.97, p = 0.05) were associated with higher BMIz values. Conversely, spending time with friends and family was associated with a lower BMIz. Over half of the patients were prescribed medications, and those patients taking medications had higher BMIz values than those not taking medications (t = -1.96, p < 0.05). Female SAB, involvement in sedentary recreational activities, and taking medications to treat gastrointestinal conditions were associated with elevated BMIz. Conclusions: Overweight/obesity is a common problem among TGD youth. TGD youth should be considered a high-risk group and targeted in obesity prevention and treatment efforts. Interventions to decrease sedentary activities and improve connections with friends and family are promising strategies to address overweight and obesity among TGD youth.

Appearance and performance-enhancing drugs and supplements, eating disorders, and muscle dysmorphia among gender minority people

OBJECTIVE

Appearance and performance-enhancing drugs and supplements (APEDS) can be used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among gender minority people.

METHOD

Participants were 1653 gender minority individuals (1120 gender-expansive [defined as a broad range of gender identities that are generally situated outside of the woman-man gender binary, e.g., genderqueer, nonbinary] people, 352 transgender men, and 181 transgender women) recruited from The Population Research in Identity and Disparities for Equality Study in 2018. Regression analyses stratified by gender identity examined associations of any APEDS use with eating disorder and muscle dysmorphia symptom scores.

RESULTS

Lifetime APEDS use was common across groups (30.7% of gender-expansive people, 45.2% of transgender men, and 14.9% of transgender women). Protein supplements and creatine supplements were the most commonly used APEDS. Among gender-expansive people and transgender men, lifetime use of any APEDS was significantly associated with higher eating disorder scores, dietary restraint, binge eating, compelled/driven exercise, and muscle dysmorphia symptoms. Any APEDS use was additionally associated with laxative use among gender-expansive people. Among transgender women, use of any APEDS was not significantly associated with eating disorder or muscle dysmorphia symptoms.

DISCUSSION

APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in gender-expansive people and transgender men, thus highlighting the importance of assessing for these behaviors and symptoms among these populations, particularly in clinical settings.

PUBLIC SIGNIFICANCE

This study aimed to examine APEDS use among gender minority people. We found that 30.7% of gender-expansive (e.g., nonbinary) people, 45.2% of transgender men, and 14.9% of transgender women reported lifetime APEDS use, which was associated with eating disorder and muscle dysmorphia symptoms in transgender men and gender-expansive people. Clinicians should assess for these behaviors in gender minority populations.

Variability in Eating Disorder Risk and Diagnosis in Transgender and Gender Diverse College Students

PURPOSE

To examine differences in elevated eating disorder risk and self-reported eating disorder diagnosis across subgroups of transgender and gender diverse (TGD) college students.

METHODS

Data from 5057 TGD college students participating in the national Healthy Minds Study between 2014-2019 were analyzed. Chi-square tests and logistic regression analyses examined heterogeneity in prevalence and odds of elevated eating disorder risk, as measured by the SCOFF, and self-reported eating disorder diagnosis by gender, as well as by intersecting gender and sexual orientation identities.

RESULTS

Genderqueer/non-conforming college students reported the highest prevalence of elevated eating disorder risk (38.8%) relative to gender expansive students. Genderqueer/non-conforming (11.1%), gender expansive (12.3%), and trans men/transmasculine students (10.5%) reported higher prevalence of a self-reported eating disorder diagnosis relative to trans women/transfeminine students (6.3%). Heterosexual or straight trans men had lower odds of eating disorder risk and self-reported diagnosis relative to trans men with a minoritized sexual orientation.

CONCLUSIONS

Genderqueer/non-conforming college students may be at heightened eating disorder risk. Moreover, a heterosexual/straight sexual orientation was associated with lower odds of elevated eating disorder risk and self-reported eating disorder diagnoses among trans men and genderqueer/non-conforming college students, but this finding did not hold for other groups. College campuses should aim to reduce eating disorder risk among TGD students.

Screening for Eating Disorders in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Eating disorders (eg, binge eating disorder, bulimia nervosa, and anorexia nervosa) are a group of psychiatric conditions defined as a disturbance in eating or eating-related behaviors that impair physical or psychosocial functioning. According to large US cohort studies, estimated lifetime prevalences for anorexia nervosa, bulimia nervosa, and binge eating disorder in adult women are 1.42%, 0.46%, and 1.25%, respectively, and are lower in adult men (anorexia nervosa, 0.12%; bulimia nervosa, 0.08%; binge eating disorder, 0.42%). Eating disorder prevalence ranges from 0.3% to 2.3% in adolescent females and 0.3% to 1.3% in adolescent males. Eating disorders are associated with short-term and long-term adverse health outcomes, including physical, psychological, and social problems.

OBJECTIVE

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for eating disorders in adolescents and adults with a normal or high body mass index. Evidence limited to populations who are underweight or have other physical signs or symptoms of eating disorders was not considered. The USPSTF has not previously made a recommendation on this topic.

POPULATION

Adolescents and adults (10 years or older) who have no signs or symptoms of eating disorders (eg, rapid weight loss, weight gain, or pronounced deviation from growth trajectory; pubertal delay; bradycardia; oligomenorrhea; and amenorrhea).

EVIDENCE ASSESSMENT

The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. The evidence is limited and the balance of benefits and harms cannot be determined.

RECOMMENDATION

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for eating disorders in adolescents and adults. (I statement).

Ethnic/racial and gender differences in disordered eating behavior prevalence trajectories among women and men from adolescence into adulthood

BACKGROUND

Disordered eating behaviors (DEB) are highly prevalent and are associated with negative long-term health outcomes. Extant research on DEB prevalence trajectories has predominantly focused on white women, thereby lacking both gender and ethnic/racial diversity, which may lead to preventive interventions that are not optimally timed for socially minoritized groups. The purpose of this study was to identify patterns in DEB trajectories from adolescence to adulthood across intersecting gender and ethnic/racial identities.

METHODS

Participants (n = 1314) were from Project EAT (Eating and Activity in Teens and Young Adults), a population-based sample in the United States. Unhealthy weight control behaviors and binge eating were assessed across four waves at 5-year intervals. Gender-stratified generalized estimating equations (GEE) analyses were applied to examine ethnic/racial and gender differences in the prevalence trajectories of two forms of DEB (unhealthy weight control behaviors and binge eating).

RESULTS

Hispanic/Latina young women reported heightened prevalence of unhealthy weight control behaviors and binge eating during adolescence (82.4% and 31.1%) relative to women with other ethnic/racial identities (44-70.2% and 8.8-18.2%) at any other developmental time point. Black/African American women reported linear increases in unhealthy weight control behaviors from adolescence (46.6%) to adulthood (65.5%), with nearly 20% greater prevalence relative to white women (44.6%) during adulthood. Among men, prevalence of unhealthy weight control behaviors was higher among Hispanic/Latinos (60.7-68.0%) and Asian Americans (41.9-56.7%) relative to Black/African American (24.6-36.9%) and white men (25.7-34.9%). Similarly, Hispanic/Latino young men reported up to ten or more times higher prevalence of binge eating during adolescence (22.8%) and adulthood (26.8%) relative to men from other ethnic/racial identities at any other time point (1.7-12.3%).

CONCLUSIONS

Ethnic/racial disparities in DEB prevalence vary across development, DEB subtype, and by gender. Targeted preventive interventions, or interventions that address these different trajectories, that are optimally timed may reduce these disparities.

Appearance and performance-enhancing drugs and supplements (APEDS): Lifetime use and associations with eating disorder and muscle dysmorphia symptoms among cisgender sexual minority people

PURPOSE

Appearance and performance-enhancing drugs and supplements (APEDS) are used to enhance muscle growth, athletic performance, and physical appearance. The aim of this study was to examine the lifetime use of APEDS and associations with eating disorder and muscle dysmorphia symptoms among cisgender sexual minority people.

METHODS

Participants were cisgender sexual minority people (1090 gay men, 100 bisexual plus men, 564 lesbian women, and 507 bisexual plus women) recruited from The PRIDE Study in 2018 who reported lifetime APEDS use and completed the Eating Disorder Examination-Questionnaire (EDE-Q) and the Muscle Dysmorphic Disorder Inventory (MDDI). Regression analyses stratified by gender and sexual orientation examined associations of any APEDS use with EDE-Q and MDDI scores.

RESULTS

Lifetime APEDS use was common across the four groups of cisgender sexual minority people (44% of gay men, 42% of bisexual plus men, 29% of lesbian women, and 30% of bisexual plus women). Protein supplements and creatine supplements were the most commonly used APEDS. Any APEDS use was associated with higher EDE-Q scores on one or more subscales in all sexual minority groups. Further, any APEDS use was associated with higher MDDI Total Scores in all groups; any APEDS use was associated with all MDDI subscale scores in cisgender gay men only.

DISCUSSION

APEDS use is common and associated with eating disorder and muscle dysmorphia symptoms in sexual minority men and women, thus highlighting the importance of assessing for these behaviors and symptoms among these populations in clinical settings.

Expanding the limits of sex: a systematic review concerning food and nutrition in transgender populations

OBJECTIVE

To examine the literature and identify main themes, methods and results of studies concerning food and nutrition addressed in research on transgender populations.

DESIGN

A systematic review conducted through July 2020 in the MedLine/PubMed, Scopus and Web of Science databases.

RESULTS

Of the 778 studies identified in the databases, we selected thirty-seven. The studies were recent, most of them published after 2015, being produced in Global North countries. The most often used study design was cross-sectional; the least frequently used study design was ethnographic. Body image and weight control were predominant themes (n 25), followed by food and nutrition security (n 5), nutritional status (n 5), nutritional health assistance (n 1) and emic visions of healthy eating (n 1).

CONCLUSIONS

The transgender community presents body, food and nutritional relationships traversed by its unique gender experience, which challenges dietary and nutritional recommendations based on the traditional division by sex (male and female). We need to complete the lacking research and understand contexts in the Global South, strategically investing in exploratory-ethnographic research, to develop categories of analysis and recommendations that consider the transgender experience.

Perceived Social Support Mediates the Negative Impact of Insecure Attachment Orientations on Internalized Homophobia in Gay Men

The mediating effect of perceived social support on the influence of insecure attachment orientations on internalized homophobia was assessed in a group of 70 Italian gay men (mean age = 28.8, SD = 6.2, range: 19-46 years). Participants completed self-report measures of adult attachment (Experiences in Close Relationships-Revised), perceived social support (Multidimensional Scale of Perceived Social Support), and internalized homophobia (Measure of Internalized Sexual Stigma for Lesbians and Gay). Higher levels of attachment anxiety and avoidance, and perceptions of lower social support were correlated with higher levels of internalized homophobia. The mediation analyses showed that only attachment anxiety, but not avoidance, may have a direct link with internalized homophobia, while both anxiety and avoidance may have an indirect influence on internalized homophobia mediated by perceived social support. Improving social support can reduce the negative effects of homophobia on gay men, thus mitigating the detrimental fallout of any insecure attachment orientations.

Weight discrimination inflates psychological health risk and academic impairment in sexual minority cisgender college students relative to their heterosexual peers

This study examined whether exposure to weight discrimination modified the association between sexual orientation, self-reported eating disorders, self-reported depression and academic impairment in a large sample of college students. Participants (n = 13,782) were from the 2015-2018 College Student Health Survey. Logistic regressions tested whether weight discrimination magnified psychological health concerns and academic impairment in sexual minority students (i.e., lesbian, gay) relative to their heterosexual peers and were stratified by gender (cisgender men and cisgender women). Sexual minority men and women reported more weight discrimination, eating disorders, depression, and academic impairment than their heterosexual peers, even after controlling for BMI and race. Among sexual minority men and women, weight discrimination was associated with increased eating disorders and academic impairment, but not depression. Weight discrimination increased the rate of eating disorders, depression, and academic impairment, however, the rate was still higher among sexual minority students regardless of weight discrimination status or gender. College-based interventions should aim to reduce weight stigmatization and its associated influence on psychological health and academic functioning, and address the needs of sexual minority college students, as they may be at highest risk. Clinicians should work to reduce the harms of weight discrimination, particularly in sexual minority young adults.

Menstrual Dysfunction and Athletic Performance in a Transgender Runner: A Case Study

ABSTRACT

A 16.5-year-old, distance runner, female gender-assigned at birth, who identifies as male, presented with menstrual dysfunction and impaired athletic performance. The cause of the menstrual dysfunction and decreased athletic performance was identified as inadequate energy availability, largely motivated by a desired avoidance of menstruation and further development of secondary sex characteristics. The patient achieved significant weight gain (4.75 kg) in the year after presentation and resumed normal menses. When evaluating and treating transgender athletes for menstrual dysfunction and inadequate energy availability, psychological motivators related to the complex interplay between gender identity, disordered eating, and athletic performance must be addressed.

Nutrition, Eating Disorders, and Behavior in Athletes

This article provides an overview of the nutrition requirements for athletes, and gives insight into why this is often an area of confusion for both the athletic community and the general population. In addition, the prevalence of eating disorders and disordered eating in athletes is reviewed, and how and why they may go unnoticed. In addition, a discussion is provided on the harmful effects of unhealthy food behaviors on health and performance, and how to assess and establish a care team for an athlete who is struggling.

Women of diverse sexual identities admit to eating disorder treatment with differential symptom severity but achieve similar clinical outcomes

OBJECTIVE

Sexual minority (SM) women may be at increased risk for certain eating disorder (ED) symptoms and report distinct body image concerns compared to heterosexual women. However, it is unclear how such symptoms differ across sexual orientations in treatment-seeking women, or if there are differences in treatment outcomes. This study examined group differences in (1) ED symptomatology at admission in a disaggregated sample of SM and heterosexual women presenting for ED treatment and (2) treatment outcomes.

METHODS

Adult women who admitted to higher levels of ED treatment across 48 locations of one treatment center between 2015 and 2018 completed self-report measures of ED symptomatology and quality of life (QOL) at admission and discharge. Participants identified their sexualities as heterosexual (n = 2,502, 80.2%), lesbian/gay (n = 134, 4.3%), bisexual (n = 270, 8.7%), "other" (n = 136, 4.4%), and unsure (n = 78, 2.5%). Objectives 1 and 2 were tested using one-way and repeated measures analyses of variance, respectively.

RESULTS

Group differences at admission emerged between lesbian/gay and heterosexual, bisexual and heterosexual, and bisexual and "other"-identified women on preoccupation and restriction, fasting, self-induced vomiting, shape and weight concern, and QOL. Bisexual women, in particular, admitted with the highest severity and at younger ages compared to heterosexual women. Despite such differences, women across groups achieved similar treatment outcomes at discharge.

DISCUSSION

Study findings underscore the importance of subgroup analyses of ED symptoms in SM women and have both clinical and research implications related to ED symptomatology in this population.

Disordered Eating, Body Image Dissatisfaction, and Associated Healthcare Utilization Patterns for Sexual Minority Youth

PURPOSE

To determine the prevalence of disordered eating behaviors (DEBs) and body image dissatisfaction (BID) according to sexual minority youth (SMY) status and describe healthcare utilization patterns by SMY status.

METHODS

Retrospective data from 107,528 adolescents, who had a Well Check in Kaiser Permanente Northern California in 2016, were used to compare DEB and BID by SMY status. Multivariate logistic models were used to examine the associations of SMY, birth-assigned sex, age, race/ethnicity, and body mass index on DEB and BID. The utilization of specialized eating disorder (ED) medical and mental health services and general mental health services was described at one Kaiser Permanente Northern California facility.

RESULTS

BID was reported in 20,763 (19.3%) adolescents, DEB in 1,458 (1.7%) adolescents, and 5,363 (5%) adolescents identified as SMY. SMY had higher odds of having DEB and BID than non-SMY, respectively (adjusted odds ratio 2.0 95% confidence interval [1.9-2.2] and adjusted odds ratio 3.8 [3.4-4.2]). Regardless of SMY status, adolescents with older age, female sex, nonwhite race, and elevated body mass index had higher odds of ED risk factors. SMY with ED risk factors had higher ED medical utilization than non-SMY with ED risk factors (4.6% vs. 1.6%). However, SMY status was not associated with utilization of specialized ED mental health services.

CONCLUSIONS

SMY had increased rates of DEB and BID but had underutilization of specialized ED mental health services. Future targeted efforts to prevent eating disorder-related mortality and morbidity for SMY should include targeted eating disorder screening and referral to specialized ED medical and mental health services.

Gender-Affirmative Eating Disorder Care: Clinical Considerations for Transgender and Gender Expansive Children and Youth

Transgender and gender expansive (TGE) children and youth suffer staggering rates of discrimination and are at higher risk of developing eating disorder symptoms and behaviors than cisgender youth. This article presents an overview of current research on identified risk factors for the development of eating disorders for TGE children and youth; provides clinical considerations for professionals in providing gender-affirming, collaborative eating disorder care; outlines specific concepts for staff training and for developing gender-affirming systems of care including policies and practices; and identifies numerous resources for TGE children and youth and their families. The clinical considerations and suggested practices reflect current research and clinical practice. Both the gender-affirmative clinical field and the eating disorder field are constantly evolving, and the recommendations and resources will need ongoing updates to reflect developments in these fields. [Pediatr Ann. 2021;50(9):e371-e378.].

Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based

Body mass index (BMI) requirements for gender affirmation surgery (GAS) are ubiquitous and vary across providers. Requirement variation is not surprising given little data to suggest an association between BMI and GAS outcomes. Implementation of subjective BMI requirements limits access to GAS and negatively impacts patient health and safety. We outline the literature on BMI and GAS outcomes, discuss clinical utility of GAS, and summarize dangers of prescribing weight loss as a prerequisite for surgery. We propose that providers use empirically supported indices of health and comorbidity instead of BMI to determine surgical eligibility for all patients considering GAS.

Associations Between Psychosocial Measures and Digital Media Use Among Transgender Youth: Cross-sectional Study

BACKGROUND

Transgender, nonbinary, and gender-diverse (TNG) youth encounter barriers to psychosocial wellness and also describe exploring identities and communities on the web. Studies of cisgender youth connect increased digital technology use with lower well-being, parent relationships, and body image scores as well as increased loneliness and fear of missing out (FOMO). However, little is known about the psychosocial factors associated with digital technology use among TNG compared with cisgender youth.

OBJECTIVE

This study aims to examine the associations between psychosocial measures and digital technology use and its importance for cisgender and TNG youth.

METHODS

We surveyed a nationally representative sample of adolescents (aged 13-18 years) about psychosocial wellness and digital technology use. Psychosocial measures included assessment of well-being, parental relationships, body image, loneliness, and FOMO. Digital media use assessments included the short Problematic and Risky Internet Use Screening Scale-3 and the Adolescent Digital Technology Interactions and Importance (ADTI) scale and subscales. We compared psychosocial measures between gender identity groups. We also compared stratified correlations for psychosocial measures (well-being, parent relationships, body image, loneliness, and FOMO) with ADTI and Problematic and Risky Internet Use Screening Scale-3 scores between gender identity groups. All comparisons were adjusted for age, race, and ethnicity.

RESULTS

Among 4575 adolescents, 53 (1.16%) self-identified as TNG youth. TNG youth had lower scores for well-being (23.76 vs 26.47; P<.001), parent relationships (19.29 vs 23.32; P<.001), and body image (13.50 vs 17.12; P<.001), and higher scores for loneliness (9.28 vs 6.55; P<.001) and FOMO (27.93 vs 23.89; P=.004), compared with cisgender peers. In a pattern different from that of their cisgender peers, better well-being scores and body image for TNG youth predicted higher problematic internet use (PIU) scores (correlation coefficients of 0.32 vs -0.07; P=.004 and 0.26 vs -0.21; P=.002, respectively). FOMO was a stronger positive predictor of higher ADTI total and subscale scores for cisgender youth compared with TNG youth.

CONCLUSIONS

Overall, this study supports previously demonstrated disparities in the psychosocial wellness of TNG youth and adds that these disparities include loneliness and FOMO. This study shows prediction of PIU by both higher well-being and better body image, indicating that PIU may not be unilaterally driven by problematic factors among TNG youth. We suggest that this may be because of the specific digital media functions that TNG youth engage with as a disenfranchised population.

Weight teasing experienced during adolescence and young adulthood: Cross-sectional and longitudinal associations with disordered eating behaviors in an ethnically/racially and socioeconomically diverse sample

OBJECTIVE

This study assessed cross-sectional and longitudinal relationships between weight teasing and disordered eating in an ethnically/racially and socioeconomically diverse sample of young people and examined these relationships across sociodemographic characteristics.

METHOD

The EAT 2010-2018 study surveyed adolescents (n = 1,534) in the Minneapolis/St. Paul public schools (mean age = 14.4 years) and 8 years later (mean age = 22.2 years).

RESULTS

Weight teasing was prevalent in adolescence (34.1%) and young adulthood (41.5%). In analyses adjusted for sociodemographic characteristics and body mass index, weight teasing was cross-sectionally associated with a higher prevalence of all disordered eating behaviors during both adolescence and young adulthood. For example, 64.5% of young adults who reported being teased about their weight engaged in unhealthy weight control behaviors, compared with 47.9% among those not teased (p < .001). There were fewer observed associations in longitudinal analyses, although weight teasing still predicted prevalent overeating and both prevalent and incident dieting (incident dieting-teased: 48.4% vs. not teased: 38.0%, p = .016). Weight teasing and disordered eating were more prevalent among Black, Indigenous, and People of Color (BIPOC) young people and those from low socioeconomic backgrounds, and the relationship between weight teasing and disordered eating was similar across ethnic/racial, socioeconomic, and gender demographic groups.

DISCUSSION

Results indicate that weight teasing is strongly correlated with disordered eating in both adolescence and young adulthood regardless of ethnicity/race, socioeconomic status, or gender. Finding suggest that future research and policy interventions should address weight stigma and prioritize the needs of BIPOC young people and young people from low socioeconomic backgrounds.

Predictors of eating-related psychopathology in transgender and gender nonbinary individuals

OBJECTIVE

Research examining the prevalence and severity of eating-related psychopathology in transgender and gender nonbinary individuals is limited. This study examined how identity development and minority stress relate to the presence of disordered eating behaviors and cognitions in transgender and gender nonbinary individuals, and improvement at one-year follow-up.

METHODS

Data come from a multi-site, longitudinal study of transgender and gender nonbinary individuals (n = 287) and includes assessment of transgender congruence, receipt of gender-affirming care, minority stress, and disordered eating symptoms. Hierarchical multivariable logistic regression was used to test for associations between identity development, minority stress, and eating-related psychopathology.

RESULTS

Eighty-three participants (28.9%) met criteria for current eating-related psychopathology. Loss of control eating was the most commonly endorsed behavior, followed by laxative, diuretic, or other medication use, and compulsive exercise. Higher transgender congruence was associated with lower odds of disordered eating symptoms (OR = 0.72, 95% CI 0.55-0.94), whereas increased internalized transphobia was associated with greater odds of disordered eating symptoms (OR = 1.41, 95% CI = 1.04-1.91). Participants with eating-related psychopathology had greater odds of having received gender-affirming psychotherapy in the year prior to assessment (OR = 2.33, 95% CI = 1.32-4.14).

CONCLUSIONS

Results suggest that gender identity development and internalized transphobia are associated with eating-related psychopathology in transgender and gender nonbinary individuals. Mental health providers should consider assessing all transgender and gender nonbinary individuals for eating-related psychopathology and unique risk factors associated with disordered eating, including low transgender congruence and internalized transphobia.