The impact of relationships on the association between sexual orientation and disordered eating in men

"I felt so powerful to have this love in me": A grounded theory analysis of the experiences of people living with and recovering from eating disorders while in diverse romantic relationships

Romantic partners have the potential to influence attitudes and behaviors related to body image and disordered eating. However, the role that romantic relationships can play in eating disorder (ED) recovery has not been comprehensively investigated. The present study aimed to explore the ways that people living with and recovering from EDs experience their romantic relationships, with the specific objective of developing a novel theoretical framework, grounded in the experiences of people in diverse romantic relationships, to guide future research on the topic. Semi-structured individual interviews were conducted with 66 people (45 cisgender women, 11 cisgender men, 9 nonbinary people, and 1 transgender man) living with and recovering from EDs while in romantic relationships. Our grounded theory analysis yielded a theoretical model of ED management in romantic relationships, revealing that Individual and Relationship Characteristics intersected with Relationship-Related Stressors and were navigated using Eating Disorder and Relationship Management Strategies. Combined with Partner Support and Tensions, these management strategies were related to Relationship and Mental Health Outcomes, which affected and were affected by Future Concerns. Future researchers should continue to build on, expand, and modify this model and further explore the role of romantic relationships in the experience of people living with EDs.

Daily Relationship Functioning and Disordered Eating Behaviors Among Sexual Minority Women in Same-Sex Relationships

BACKGROUND AND PURPOSE

The present study aimed to examine associations between different types of relationship functioning and disordered eating behaviors (DEBs) in the everyday lives of sexual minority women in same-sex relationships-an at-risk population that has not been assessed in this context.

METHODS

Participants included 321 young sexual minority women (Mage = 27.56, SD = 3.67) in same-sex relationships who completed surveys assessing their daily relationship functioning and DEB use each day for a 14-day daily diary period. Multilevel structural equation modeling was used to examine daily-, person-, and couple-level associations among women's daily relationship functioning (general relationship functioning, positive and negative relational behaviors they and, separately, their partners engaged in) and DEBs (overeating, loss of control eating, emotional eating, and dietary restriction).

RESULTS

Results generally indicated that more positive and less negative daily relationship functioning across all assessed constructs was associated with less same-day emotional eating. In contrast, associations between all daily relationship functioning constructs and loss of control eating were not significant, nor were any relationship functioning-DEB associations at the couple level. More circumscribed patterns of association were identified for associations between the relationship functioning constructs, and overeating and dietary restriction.

CONCLUSIONS

Collectively, these findings provide insight into how aspects of daily relationship functioning map onto sexual minority women's daily engagement in DEBs that are linked to poor health long-term, and directions for future research and clinical practice that may warrant consideration moving forward to help advance the evidence-base and care for this historically overlooked and underserved population.

Status, sexual capital, and intraminority body stigma in a size-diverse sample of gay men

Gay men are more likely than heterosexual men to experience social pressure based on body weight, shape, and muscularity, which may drive disparities in body image concerns and eating disorders. Utilizing a sample of 1723 gay men living in the United States, the present study examined whether sociodemographic factors (used as proxies for status and sexual capital) and frequency of attending gay-specific establishments or gatherings (community involvement) were associated with gay men's experiences of negative or discriminatory pressures based on body size and shape specifically from other gay men (intraminority body stigma). Experiences of intraminority body stigma were significantly more common among gay men who identified as higher-weight (r = 0.28), less masculine (r = -0.21), less wealthy (r = -0.21), younger (r = -0.21), or people of color (ds = 0.25-0.28). Furthermore, indicators of low status and sexual capital were indirectly associated with less frequent community involvement via more frequent experiences of intraminority body stigma. In addition to frequency, the valence of interactions between gay men should be considered when assessing body image and eating disorder risk in this population. Future research is encouraged to examine intraminority body stigma as an intersectional source of intraminority stress to inform prevention and treatment efforts for gay men.

Understanding eating disorder symptoms in same-gender couples: social environmental factors

BACKGROUND

Sexual minority individuals are at disproportionately greater risk for eating disorders, yet little is known about the ways in which factors in the social environment relate to eating disorder symptoms in this population. Utilizing an ecological systems theory framework, we investigated the relative relationships of macro level (i.e., internalization of sociocultural attitudes about appearance) and micro level (i.e., quality of romantic relationship) social environment influences.

METHODS

Men (n = 144) and women (n = 144) in committed same-gender relationships were recruited as a dyad and completed study questionnaires, including multiple measures of eating disorder symptoms. Multilevel models controlling for key variables (e.g., body mass index) were used to examine gender differences, main effects, and interactions.

RESULTS

Men reported greater internalization of sociocultural attitudes and uncontrolled eating. Greater internalization of sociocultural attitudes was related to greater eating pathology across all measures. For men, greater relationship quality was related to less uncontrolled eating.

CONCLUSIONS

Individuals in same-gender relationships experience macro (e.g., sociocultural) level vulnerability factors in relation to disordered eating; however, internalization of sociocultural attitudes may be greater for men. Support at the microsystem level in the form of a high quality committed romantic relationship appears to be helpful protection against uncontrolled eating for men.

Associations among romantic and sexual partner history and muscle dysmorphia symptoms, disordered eating, and appearance- and performance-enhancing drugs and supplement use among cisgender gay men

This study examined relationship status (e.g., single versus not single) and number of sexual partners in relation to muscularity- and disordered eating-related attitudes and behaviors among 1090 cisgender gay men enrolled in The PRIDE Study in 2018. Participants completed measures assessing muscle dysmorphia (MD) symptoms, disordered eating attitudes and behaviors, and appearance- and performance-enhancing drug or supplement (APEDS) use. In linear regression models adjusting for theoretically relevant covariates, neither relationship status nor number of past-month sexual partners was associated with disordered eating attitudes. In terms of MD symptoms, single (versus not single) relationship status was associated with greater appearance intolerance, and a greater number of sexual partners was associated with greater drive for size and functional impairment. In adjusted logistic regression models, a greater number of past-month sexual partners was associated with use of anabolic-androgenic steroids, synthetic performance-enhancing substances, protein supplements, and creatine supplements, as well as greater likelihood of engaging in compelled/driven exercise. Across all associations, effect sizes were generally small. Overall, results support that inquiring about sexual partners may have utility in evaluating risk for muscularity-oriented attitudes and behaviors among cisgender gay men. Future work will need to replicate these findings, particularly in more diverse samples.

Demographic predictors of body image satisfaction: The U.S. Body Project I

We examined how gender, body mass, race, age, and sexual orientation were linked to appearance evaluation, overweight preoccupation, and body image-related quality of life among 11,620 adults recruited via Mechanical Turk. Men were less likely than women to report low appearance evaluation, high overweight preoccupation, negative effects of body image on their quality of life, being on a weight-loss diet, and trying to lose weight with crash diets/fasting. Racial differences were generally small, but greater appearance evaluation was reported by Black men versus other groups and Black women versus White women. Across all measures, gay and bisexual men reported poorer body image than heterosexual men, with only small effect sizes observed for sexual orientation differences among women. Body mass, but not age, was strongly associated with body image. The prevalence of poor body image highlights the need for interventions. On the positive side, half of men and women reported high appearance evaluation. Examination of this group could identify factors promoting positive body image.

Sexual attraction to men as a risk factor for eating disorders: the role of mating expectancies and drive for thinness

BACKGROUND

Men tend to give more importance than women to physical aspects when selecting a partner; thus, the internalization of beauty standards and the ideal of thinness may be greater in populations attracted to men, placing them at a higher risk of eating disorders.

METHODS

In a sample (n = 398) of heterosexual and gay men and women, we evaluated the drive for thinness, body dissatisfaction, and bulimic symptomatology. Using ANCOVAs, we analyzed the differences in symptoms score according to sex, sexual orientation and relational status including body mass index (BMI) as covariate; we also evaluated the mediating role of drive for thinness in the relationship between sexual orientation and body dissatisfaction.

RESULTS

We found an increased drive for thinness and body dissatisfaction in men-attracted compared with women-attracted participants; also, body dissatisfaction was greater in women than in men. Heterosexual women presented higher bulimia scores than lesbian women. Gay men open to relationships presented higher drive for thinness and body dissatisfaction scores than those not-open to relationships. Finally, differences in body dissatisfaction between gay and heterosexual men were fully explained by drive for thinness, while, in the case of women, drive for thinness only partially explained these differences.

CONCLUSIONS

Attraction to men seems to be a risk factor for EDs in the case of gay men and heterosexual women. In addition, in the case of heterosexual women, other factors independent of the desire to attract men seem to be important.

Body-related shame or guilt? Dominant factors in maladaptive eating behaviors among Hungarian and Norwegian university students

The main purpose of our study was to examine the psychometric properties of Conradts' Weight- and Body-Related Shame and Guilt Scale (WEB-SG) and associations of body shame and guilt with maladaptive eating behaviors and general chronic shame among Hungarian and Norwegian university students. Therefore, we collected data from 561 university students from both nations in a cross-sectional questionnaire study. Participants completed the following standardized self-report questionnaires in this online survey: WEB-SG, Eating Attitude Test-26 (EAT-26) and Experience of Shame Scale (ESS). We tested the measurement model of the WEB-SG with confirmatory factor analysis (CFA), and we performed CFA with covariates analysis to examine the association between WEB-guilt (WEB-G) and WEB-shame (WEB-S) and predictors. Our empirical model of WEB-SG has adequate fit with Conradts’ theoretical model among both samples. The body-related guilt positively associated with dieting and negatively related to oral control in both groups. We found a significant positive relationship between WEB-S and BMI in Hungarian sample. According to our results, WEB-SG is an adequate questionnaire for assessing weight and body-related shame and guilt in Hungarian and Norwegian non-clinical samples. Maladaptive weight and body-related guilt could be a relevant factor in proneness to anorexia. Our results highlight WEB-G and WEB-S as two critical factors in the assessment and treatment of eating difficulties.

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The two-factor model of WEB-SG was confirmed in Hungary and Norway.

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WEB-guilt is associated with dieting as a restrictive eating attitude.

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WEB-shame is associated with higher BMI and chronic body shame.

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WEB-guilt and WEB-shame may be two important factors in eating disorders.

The Annual Examination for Lesbian, Gay, and Bisexual Patients

The annual examination is a comprehensive evaluation of patients in which all aspects of health and well-being are considered, including proper screening, appropriate preventive care, and recommendations and resources for healthy living. Clinicians commonly avoid certain topics with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients because they may be unprepared to address their health needs. Therefore, clinicians should learn how to conduct an LGBTQ-friendly annual examination in order to provide high-quality care. This article focuses on both the general and unique health needs of lesbian, gay, bisexual, and queer patients; care for transgender and gender-diverse patients is considered elsewhere.

Sexual orientation and disordered eating in women: a meta-analysis

PURPOSE

Homosexuality is a clear risk factor for disordered eating in men; however, for women, research has yielded contradictory results. We conducted a meta-analysis to examine the association between sexual orientation and disordered eating in women.

METHODS

PRISMA guidelines were used. Studies comparing disordered eating between lesbians and heterosexual women were identified using PsycNet database and Google Scholar. Twenty-one studies met inclusion criteria. Overall disordered eating, restricting, binging and purging were examined for heterosexual, lesbian, bisexual and 'mostly heterosexual' women.

RESULTS

Whereas there was no significant difference in overall disordered eating between lesbians and heterosexual women, lesbians reported restricting less and binging more than heterosexual women. Bisexual women were more likely than lesbian women to restrict food intake and purge, and more likely than heterosexual women to have overall disordered eating and restrict food intake. "Mostly heterosexual" women were more likely than heterosexual women to restrict food intake, binge and purge.

CONCLUSIONS

Women of different sexual orientations show distinct patterns of disordered eating. Bisexual and "mostly heterosexual" women appear to be particularly at risk. Stress resulting from binegativity and rigid views of sexuality in a dichotomous society, rather than sexual orientation itself, may be associated with disordered eating in women. Findings should be viewed with caution because there were few studies with bisexual and "mostly heterosexual" women. This study elucidates the nature of the association between disordered eating and sexual orientation. Findings provide a possible explanation for previous inconsistencies, since opposing trends for different behaviors cancel each other out.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

Eating disorders and disordered eating behaviors in the LGBT population: a review of the literature

BACKGROUND

According to past research, lesbian, gay, bisexual, and transgender (LGBT) individuals experience a higher prevalence of psychopathology, which is attributable to the increased stress (i.e., stigma and prejudice) that they experience, as detailed by the minority stress model (MSM).

MAIN

This current literature review examined the empirical literature regarding the rates and types of, and risk factors for eating disorders and disordered eating behaviors in LGBT adults and adolescents, in addition to each individual subgroup (i.e., lesbians, gay males, bisexuals, transgender and gender-nonconforming individuals).

CONCLUSION

LGBT adults and adolescents experience greater incidence of eating disorders and disordered eating behaviors than their heterosexual and cisgender counterparts. Additionally, gay, bisexual, and transgender adults and adolescents were all at increased risk for eating disorders and disordered eating behaviors. Mixed results were found for lesbian adults and adolescents. Results are discussed within the framework of the MSM.

A systematic review of the roles of body image flexibility as correlate, moderator, mediator, and in intervention science (2011-2018)

The emergence of body image flexibility into the positive body image nomenclature has innovatively expanded the conceptualization of how individuals may adaptively respond to body image threats. Given the notable growth of interest in researching this construct over nearly the past decade, the present analysis provides a systematic and critical review of evidence examining the roles of body image flexibility as correlate, mediator, moderator, and in intervention research. Results indicated that body image flexibility tended to demonstrate a pattern of relationships with correlates in directions predicted by its conceptualization and showed promise in functioning as both effect modifier and as an explanatory variable in the associations evaluated. Multiple studies demonstrated susceptibility to change following intervention. Although the current state of the literature is bound by notable limitations, the results of this review point to pertinent future steps in advancing the theory and application of body image flexibility scholarship.

Body Image Disturbances as Predictors of Reduced Mental Health Among Australian Gay Men: Being in a Relationship Does Not Serve as a Protective Factor

Past studies have demonstrated associations between gay men's body image disturbances and poorer mental health. However, little research has considered whether relationship status, or sexual agreements within relationships, moderates these associations. The present study was designed to address this gap. Results from a survey involving 796 Australian gay men between the ages of 18-39 showed that various measures of body image disturbance significantly and independently predicted satisfaction with life, self-esteem, positive well-being, and psychological distress. However, neither relationship status nor sexual agreement type (monogamous vs. non-monogamous) moderated these associations. These findings suggest that, although gay men may experience appearance-related pressure in order to attract sexual or relationship partners, simply being in a relationship does not reduce the detrimental associations of body image disturbance with mental health. Future research could examine specific aspects of relationship quality and dynamics that may serve as risk or protective factors in this context.

The Science Behind the Academy for Eating Disorders' Nine Truths About Eating Disorders

OBJECTIVE

In 2015, the Academy for Eating Disorders collaborated with international patient, advocacy, and parent organizations to craft the 'Nine Truths About Eating Disorders'. This document has been translated into over 30 languages and has been distributed globally to replace outdated and erroneous stereotypes about eating disorders with factual information. In this paper, we review the state of the science supporting the 'Nine Truths'.

METHODS

The literature supporting each of the 'Nine Truths' was reviewed, summarized and richly annotated.

RESULTS

Most of the 'Nine Truths' arise from well-established foundations in the scientific literature. Additional evidence is required to further substantiate some of the assertions in the document. Future investigations are needed in all areas to deepen our understanding of eating disorders, their causes and their treatments.

CONCLUSIONS

The 'Nine Truths About Eating Disorders' is a guiding document to accelerate global dissemination of accurate and evidence-informed information about eating disorders. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Eating Disorders and Disordered Weight and Shape Control Behaviors in Sexual Minority Populations

PURPOSE OF REVIEW

This review summarized trends and key findings from empirical studies conducted between 2011 and 2017 regarding eating disorders and disordered weight and shape control behaviors among lesbian, gay, bisexual, and other sexual minority (i.e., non-heterosexual) populations.

RECENT FINDINGS

Recent research has examined disparities through sociocultural and minority stress approaches. Sexual minorities continue to demonstrate higher rates of disordered eating; disparities are more pronounced among males. Emerging data indicates elevated risk for disordered eating pathology among sexual minorities who are transgender or ethnic minorities. Dissonance-based eating disorder prevention programs may hold promise for sexual minority males. Continued research must examine the intersections of sexual orientation, gender, and ethnic identities, given emergent data that eating disorder risk may be most prominent among specific subgroups. More research is needed within sexual minorities across the lifespan. There is still a lack of eating disorder treatment and prevention studies for sexual minorities.

The association between sexual orientation, susceptibility to social messages and disordered eating in men

OBJECTIVE

Much research points to higher levels of disordered eating and more negative body image in gay and bisexual men than in heterosexual men. The reasons for this difference, however, remain unclear. We hypothesized that disturbed body image and eating attitudes in gay and bisexual men would be partially explained by susceptibility to social messages.

METHODS

Two hundred and sixty-two men (203 heterosexual, 46 gay and 13 bisexual) between 18 and 35 years of age participated in the study. They completed measures of disordered eating, body image, internalization of attitudes toward appearance, and concern for appropriateness. In addition, they were asked to what extent they were influenced by ten advertisements, four that emphasized physical appearance, and six that did not.

RESULTS

As shown in previous research, gay and bisexual men reported higher levels of disordered eating and dissatisfaction with their bodies than heterosexual men. In addition, the gay and bisexual men were more susceptible than the heterosexual men to social messages, and reported being significantly more influenced than heterosexual men by advertisements focusing on physical appearance, but not by other advertisements. Susceptibility to social messages fully mediated the association between sexual orientation and disordered eating.

DISCUSSION

Results provide support for the hypothesis that sensitivity to social messages about appearance explains, at least partially, the link between sexual orientation and disordered eating in men.

Identity, Relationship Satisfaction, and Disclosure

We tested the usefulness of combining the Interpersonal–Psychological Theory of Suicide and minority stress models in studying suicidality among sexual minority women. According to the Interpersonal–Psychological Theory of Suicide, perceptions of being a burden on others and feelings of failed belongingness predict suicidal ideation. In a sample of sexual minority women ( n = 51), we tested first, if the interaction of perceived burdensomeness and failed belongingness predicted lifetime suicidal behavior; second, if identity affirmation was negatively related to perceived burdensomeness and if this relation was moderated by disclosure; and third, if relationship satisfaction was negatively related to failed belongingness and if this relation was moderated by acceptance concerns. The proposed interaction of perceived burdensomeness and failed belongingness predicted lifetime suicide attempts. Moreover, among sexual minority women with greater disclosure of their sexual minority identities, low identity affirmation was related to higher perceived burdensomeness. For sexual minority women with high acceptance concerns, relationship satisfaction did not relate to lower feelings of failed belongingness. These findings suggest that sexual minority related stressors moderate risk factors for suicidality—in particular, perceptions of burdensomeness and failed belongingness. We suggest clinicians and others encourage sexual minority individuals to engage in activities that promote effectiveness and interpersonal closeness. Online slides for instructors who want to use this article for teaching are available to PWQ subscribers on PWQ's website at http://pwq.sagepub.com/supplemental

A randomized controlled trial of a peer co-led dissonance-based eating disorder prevention program for gay men

OBJECTIVE

Gay males have increased risk for eating disorders compared to heterosexual males, establishing a need to develop and empirically evaluate programs to reduce risk for this population. The present study investigated the acceptability and efficacy of a cognitive dissonance-based (DB) intervention (The PRIDE Body Project(©)) in reducing eating disorder risk factors among gay males in a university-based setting.

METHOD

Eighty-seven gay males were randomized to either a 2-session DB intervention (n = 47) or a waitlist control condition (n = 40). Participants completed eating disorder risk factor assessments pre-intervention, post-intervention, and at 4-week follow-up, and those receiving the intervention completed post-treatment acceptability measures.

RESULTS

Acceptability ratings were highly favorable. Regarding efficacy, the DB condition was associated with significantly greater decreases in body dissatisfaction, drive for muscularity, self-objectification, partner-objectification, body-ideal internalization, dietary restraint, and bulimic symptoms compared to waitlist control from pre- to post-intervention. Improvements in the DB group were maintained at 4-week follow-up, with the exception of body-ideal internalization. Body-ideal internalization mediated treatment effects on bulimic symptoms.

CONCLUSION

Results support the acceptability and efficacy of The PRIDE Body Project(©) and provide support for theoretical models of eating pathology in gay men.

Relationship status predicts lower restrictive eating pathology for bisexual and gay men across 10-year follow-up

OBJECTIVE

Cross-sectional studies support that bisexual and gay (BG) men are at increased risk for eating pathology, and romantic relationships may buffer against risk; however, no studies have examined this association longitudinally. The current study examined how romantic relationships impact the trajectory of eating pathology in BG versus heterosexual men.

METHOD

BG (n = 51) and heterosexual (n = 522) men completed surveys of health and eating behaviors at baseline and 10-year follow-up.

RESULTS

For BG men, being single at baseline prospectively predicted an increase in Drive for Thinness scores over 10-year follow-up. Additionally, for BG men in relationships at baseline, lower relationship satisfaction predicted an increase in Drive for Thinness scores over time. Conversely, these relationship variables did not predict trajectory of eating pathology for heterosexual men.

DISCUSSION

Implications for theoretical models of risk, including objectification theory and sexual minority stress theory, and prevention, including peer-led cognitive dissonance based interventions, are discussed.

Psychological and physical health of mostly heterosexuals: a systematic review

We reviewed whether mostly heterosexuals, a sexual orientation group characterized by a small amount of same-sex sexuality, differ from heterosexuals and bisexuals on a variety of mental and physical health outcomes (e.g., internalizing problems, body dissatisfaction and disordered eating, obesity, sexual/reproductive health, physical health), health risk behaviors (e.g., substance use, sexual risk taking), and risk and protective factors (e.g., victimization, stressful/risky environment, socioeconomic status, personal and social relationships, gender nonconformity). A narrative and quantitative literature review was conducted of 60 papers covering 22 samples from five Western countries. Individual, mean, and median effect sizes (Cohen ds) were calculated whenever possible. Mostly heterosexuals reported higher levels of risk in most reviewed outcomes compared to heterosexuals (unweighted mean effect sizes ranged from 0.20 to 0.50) but typically somewhat lower than bisexuals (unweighted mean effect sizes ranged from -0.10 to -0.30). Various risk factors frequently reduced, but rarely eliminated, health disparities between mostly heterosexuals and heterosexuals. Findings are discussed through the lens of three potential explanations of elevated health risks among nonheterosexuals: minority stress, nonheterosexual lifestyles, and common causes. Because data on many outcomes were scarce or missing, particularly for men and in comparison with bisexuals, further research is needed.

Assessment of anorexia nervosa: an overview of universal issues and contextual challenges

AIM

Anorexia Nervosa (AN) is a complex and clinically challenging syndrome. Intended for specialist audiences, this narrative review aims to summarise the available literature related to assessment in the adult patient context, synthesising both research evidence and clinical consensus guidelines.

METHOD

We provide a review of the available literature on specialist assessment of AN focusing on common trajectories into assessment, obstacles accessing assessment, common presenting issues and barriers to the assessment process, the necessary scope of assessment, and tools and techniques. It describes the further step of synthesising assessment information in ways that can inform resultant care plans.

RESULTS

In addition to assessment of core behaviours and diagnostic skills, considerations for the expert assessor include the functions of primary care, systemic and personal barriers, knowledge of current assessment tools and research pertaining to comorbid pathology in AN, assessing severity of illness, role of family at assessment, as well as medical, nutritional and compulsory elements of assessment.

CONCLUSION

Comprehensive assessment of AN in the current healthcare context still remains largely the remit of the specialist ED clinician. Assessment should remain an on-going process, paying particular attention to available empirical evidence, thereby reducing the gap between research and practice.

The impact of relationships, friendships, and work on the association between sexual orientation and disordered eating in men

Recent research has demonstrated increased eating pathology among single bisexual and gay (BG) men compared to BG men in relationships and all heterosexual men. BG men may be at elevated risk due to pressures to be lean to attract a male partner. No study has examined the specificity of this theory to relationship status or to eating pathology. BG (n = 23) and heterosexual (n = 326) men completed surveys to compare the impact of areas of life satisfaction on the association between sexual orientation and eating pathology, as well as another area of psychopathology (substance use problems). For BG men, but not heterosexual men, being single was associated with drive for thinness. Low friendship satisfaction was more strongly associated with drive for thinness and bulimic symptoms in BG men as compared to heterosexual men. Low work satisfaction was associated with substance use problems among BG men, but not among heterosexual men. Results suggest separate constellations of risk factors differentially impact BG men, depending upon the nature of clinical problems.