Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors

Associations Between Gender Dysphoria, Eating Disorders, and Mental Health Diagnoses Among Adolescents

PURPOSE

Transgender adolescents and adolescents with eating disorders (EDs) are known to have increased mental health comorbidity; however, little is understood about how gender dysphoria (GD), disordered eating and mental health disorders relate to each other. The purpose of this study was to examine associations between GD, ED, and mental health diagnoses among adolescents.

METHODS

Data were extracted from the electronic health records of 57,353 patients aged 9-18 seen at a single pediatric health system between 2009 and 2022. Adjusted logistic regression models tested for associations between GD, ED, and mental health diagnoses.

RESULTS

Youth with a GD diagnosis had significantly greater odds of also having an ED diagnosis compared to those without a GD diagnosis (adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI]: 2.98-4.64). Among those with an ED diagnosis, youth with a GD diagnosis had significantly lower odds of having an anorexia nervosa diagnosis (aOR = 0.34, 95% CI: 0.18-0.61) and significantly greater odds of having an unspecified or other specified ED diagnosis (aOR = 2.48, 95% CI: 1.56-3.93) compared to those without a GD diagnosis. Youth with both GD and ED diagnoses had significantly greater odds of also having a diagnosis of anxiety (aOR = 24.01, 95% CI: 14.85-38.83), depression (aOR = 48.41, 95% CI: 30.38-77.12), suicidality (aOR = 26.15, 95% CI: 16.65-41.05) and self-harm (aOR = 35.79, 95% CI: 22.48-56.98) as compared to those with neither a GD nor an ED diagnosis.

DISCUSSION

Adolescents with co-occurring GD and ED diagnoses are at greater risk for anxiety, depression, suicidality, and self-harm as compared to youth with neither diagnosis. Further research is essential to understand the complex interplay of mental health concerns and EDs among gender diverse adolescents and to inform appropriate interventions.

Beyond Age, BMI, Gender Identity, and Gender Minority Stress, Weight Bias Internalization Is Uniquely Associated With More Eating and Body Image Disturbances and Poor Physical and Mental Health in Chinese Gender-Diverse Adults

OBJECTIVE

Weight bias internalization (WBI) is a robust, positive correlate of negative health outcomes; however, this evidence base primarily reflects cisgender individuals from Western cultural contexts. Gender-diverse individuals from non-Western cultural contexts (e.g., China) are at potentially high risk for WBI. Yet, no research has examined WBI and associated negative health consequences in this historically underrepresented population.

METHOD

A cross-sectional, online survey sampled Chinese gender-diverse individuals (N = 410, Mage = 22.33 years). Variables were self-reported, including demographics, WBI, body shame, body dissatisfaction, disordered eating, physical and mental health status, and gender minority stress (e.g., internalized cisgenderism). Analyses included correlations and multiple hierarchical regressions.

RESULTS

Pearson bivariate correlations demonstrated associations between higher WBI and more eating and body image disturbances and poor physical and mental health. After adjusting for age, BMI, gender identity, and gender minority stress, higher WBI was uniquely and positively associated with higher body shame, higher body dissatisfaction, higher disordered eating, and poor physical and mental health. Notably, WBI accounted for more unique variance in eating and body image disturbances (13%-25% explained by WBI) than physical and mental health (1%-4% explained by WBI).

DISCUSSION

While replication with longitudinal and experimental designs is needed to speak to the temporal dynamics and causality, our findings identify WBI as a unique, meaningful correlate of eating and body image disturbances in Chinese gender-diverse adults.

Gender diversity among adolescents with obesity in a weight management programme

Gender dysphoria (GD) and obesity share commonalities, including associations with mental health comorbidities, disordered eating, body dissatisfaction and may intensify with physical and developmental changes during adolescence. While associations of obesity and gender diversity have been identified, rates of gender diversity among adolescents with obesity remain unclear. The aim was to examine gender diversity among adolescents with obesity in a weight management programme. A single-centre cross-sectional questionnaire study was conducted. Eligible adolescents received the Gender Identity/GD Questionnaire for Adolescents and Adults (GIDYQ-AA), a validated instrument measuring gender diversity and GD. Gender identities, sexual orientations, questionnaire scores, and frequency of GD (GIDYQ-AA score <3) were determined. The relationship of GIDYQ-AA scores and BMI Z-score (BMIz) was assessed. Of 72 consenting youth, 29 assigned females (AF) and 17 assigned males (AM) completed GIDYQ-AA and demographic questions. Seventeen (59%) AF reported non-heterosexual orientations, and 6 (21%) reported non-cisgender identities. One (6%) AM reported non-cisgender identity. Two (4%) AF individuals had GD based on GIDYQ-AA scores. GIDYQ-AA scores did not correlate with BMIz. In conclusion, adolescents with obesity, particularly AF with non-heterosexual orientation, reported high rates of non-cisgender identity and GD. Routine screening for gender-related concerns in weight management settings may be warranted.

Experiences of body image in the gender non-binary community: A qualitative analysis

Body image concerns are prevalent within transgender communities - many transgender people engage in disordered eating to suppress or accentuate secondary sex characteristics and reduce gender dysphoria. However, this research has mostly been conducted with binary transgender people. Here, we examine how non-binary people experience and relate to their bodies. Semi-structured one-on-one interviews were conducted with 13 gender non-binary individuals living in Australia. Photo elicitation techniques were utilised, and the transcribed interview data were analysed using reflexive thematic analysis. Six themes were identified: Expansive Understandings of Body Image, Body Image can be Linked to Gender Dysphoria, Cultivating a Preferred Body can Lead to Gender Euphoria, Appreciating Diversity in Non-Binary Body Ideals, The Androgynous Body Ideal is not Universally Accepted, and Experiencing the Body as Functional rather than Aesthetic. The present findings highlight the diversity of experiences of body image for non-binary people. The non-binary concept of body image was found to be expansive, stressing various physical attributes involved in social gender recognition and physiological sources of gender dysphoria. Some participants valued gender-affirming medical intervention, others were accepting of their bodies as they are, attributing their body confidence to the process of affirming their non-binary gender.

Gender stereotypes in eating disorder recognition

PURPOSE

Eating disorder (ED) awareness is low. We assessed if ED symptom recognition, perceived need for treatment, perceived distress, perceived acceptability, and perceived prevalence differed depending on the gender of the individual with the ED.

METHODS

276 community participants were randomly assigned to one of three gender conditions (female, male, and non-binary), read three vignettes describing three different individuals with ED symptoms [anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED)], and then answered a series of questions related to participants ED symptom recognition, perceived need for treatment, perceived distress associated with having ED symptoms, perceived acceptability (e.g., the extent to which it may not be too bad to have an ED), and perceived prevalence. Mixed ANOVAs and chi-square analyses were conducted to examine differences between groups.

RESULTS

There were no significant main effects of gender condition across the outcome variables. There were main effects of ED type for problem recognition, perceived need for treatment, perceived level of distress, and perceived prevalence, with participants being more likely to recognize a problem in the AN and BN vignettes than the BED vignettes, refer for treatment and rate a higher perceived level of distress in then AN vignette than the BN and BED vignettes, and perceive a higher prevalence rate in the BN vignette than the AN vignette. There was a significant gender by condition interaction for perceived prevalence, with participants rating a higher prevalence of AN in women and non-binary individuals than men and a higher prevalence of BN in women than non-binary individuals and men.

CONCLUSION

These results highlight the importance of education on EDs and awareness that EDs can occur in any individual, regardless of their gender identification.

LEVEL OF EVIDENCE

Level I, experimental study with randomization.

The association between gender-affirming care and disordered eating in transgender and gender diverse individuals: Exploring appearance congruence and gender-related motivating factors for weight loss

OBJECTIVE

The objective of this study is to explore between-group differences across different stages of gender-affirming care, and associations between appearance congruence, gender-related motivations for weight loss, and disordered eating in transgender and gender expansive (TGE) individuals.

METHOD

A total of 160 TGE adults (aged 18-30) were recruited across the United States. Participants completed a comprehensive online survey. Data were analyzed using generalized linear models and bivariate correlations.

RESULTS

Significant differences in appearance congruence among participants at different transition stages were revealed, with the group that achieved their desired transition reporting the highest appearance congruence compared to all other groups. Furthermore, gender-related motivations for weight loss were significantly lower in individuals who achieved their desired transition compared to those with no plans to transition.

DISCUSSION

Findings suggest significantly higher appearance congruence in those who achieved their desired transition compared to other groups, and individuals who attained their desired transition exhibited significantly reduced gender-related motivations for weight loss compared to those with no plans to transition. These findings underscore the potential psychological benefits associated with successful gender-affirming care, highlighting its role not only in fostering appearance congruence but also in mitigating gender-related motivations for weight loss among TGE individuals. Future research should include larger and more diverse samples, longitudinal designs, and considerations of other factors influencing body image outcomes in this population.

PUBLIC SIGNIFICANCE

This study sheds light on the crucial relationship between gender-affirming care and body image outcomes in TGE individuals. Understanding how appearance congruence and gender-related motivations for weight loss are associated with disordered eating can inform tailored support and interventions. By recognizing the association of gender affirming care and well-being, healthcare providers can enhance care for TGE individuals.

The Sick, Control, One Stone, Fat, Food (SCOFF) is a Valid Eating Disorder Questionnaire to Use With Transgender Youth

Transgender youth experience elevated rates of eating disorders, yet few screening measures have been validated with transgender patients. The purpose of this study was to provide initial evidence for the internal consistency and convergent validity of the Sick, Control, One Stone, Fat, Food (SCOFF) in a sample of transgender youth. Two hundred eight participants completed the SCOFF as part of a routine screening protocol. Exploratory factor analysis and confirmatory factor analysis were used to establish the factor structure of the SCOFF in this sample. Relationships between the SCOFF, Adolescent Binge Eating Disorder (ADO-BED), Nine-Item Avoidant/Restrictive Intake Disorder (NIAS), Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and demographic characteristics were explored. The SCOFF was significantly related to all convergent validity variables, with moderate correlations with other eating disorder scales (ADO-BED and NIAS). The SCOFF is a valid measure to screen for eating disorders among transgender youth and young adults.

Eating Disorders in Sexual and Gender Minority Adolescents

PURPOSE OF REVIEW

To consolidate recent literature addressing eating disorders and disordered eating behaviors among sexual and gender minority (SGM) adolescents, including but not limited to lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents.

RECENT FINDINGS

Sexual and gender minority adolescents are at heightened vulnerability to eating disorders and disordered eating behaviors compared to their cisgender and heterosexual peers, potentially due to minority stress, gender norms, objectification, and the influence of the media, peers, and parents. We report findings from recent literature on the epidemiology and prevalence, assessment, mental health comorbidity, quality of life and psychosocial functioning, risk and protective factors, and treatment and interventions for eating disorders in sexual and gender minority adolescents. Addressing eating disorders in sexual and gender minority adolescents requires an integrated approach consisting of screening, tailored treatment, and comprehensive support to address intersectional challenges. Gender-affirming and trauma-informed care approaches may be considered.

Comparing eating disorder treatment outcomes of transgender and gender diverse adolescents with those of cisgender adolescents

OBJECTIVE

Eating disorder (ED), depression, and anxiety symptoms at admission and discharge were compared, as were admission-to-discharge changes, for transgender and gender diverse (TGD), and cisgender adolescents receiving intensive treatment for EDs.

METHOD

Participants were 44 TGD and 573 cisgender adolescents admitted to a treatment facility. Participants completed the Eating Disorder Examination Questionnaire (EDE-Q), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7) at admission and discharge.

RESULTS

Both groups had elevated EDE-Q scores at admission (TGD: M = 3.78, standard deviation [SD] = 1.70; cisgender: M = 3.33, SD = 1.74) that improved by discharge (TGD: M = 2.27, SD = 1.83, Cohen's d = .98; cisgender: M = 2.10, SD = 1.54, Cohen's d = .79); there were no differences in EDE-Q between groups at admission (p = .09; odds ratio [OR] = 1.18, 95% confidence interval [CI] [.98, 1.44]) or discharge (p = .48; OR = 1.07, 95% CI [.88, 1.30]). On admission, TGD adolescents had higher suicidality, measured by PHQ-9, item 9 (p < .001; OR = 1.94, 95% CI [1.51, 2.52]), and depression (p < .001; OR = 1.10, 95% CI [1.05, 1.16]) than cisgender participants. Severity decreased over treatment for all measures. Both groups showed similar improvement on suicidality (p = .93; OR = .98, 95% CI [.70,1.36]), depression (p = .42; OR = 1.02, 95% CI [.97, 1.07]), and anxiety (p = .14; OR = 1.05, 95% CI [.99, 1.12]). However, at discharge, suicidality (p = .02; OR = 1.40, 95% CI [1.04, 1.85]), depression (p < .01; OR = 1.06, 95% CI [1.02, 1.11]), and anxiety (p = .02; OR = 1.06, 95% CI [1.01, 1.12]) were higher for TGD adolescents than their cisgender peers.

DISCUSSION

All participants had similar ED symptom severity and improvement. Depression, anxiety, and suicidality remained elevated for TGD adolescents compared to their cisgender peers at discharge, suggesting the need for targeted treatment.

PUBLIC SIGNIFICANCE

Transgender and gender diverse (TGD) adolescents have increased risk of eating disorders (EDs); few studies examine how they respond to ED treatment. We examine treatment outcomes of TGD adolescents receiving ED treatment compared to their cisgender peers. We measured ED symptoms along with depression, anxiety, and suicidality at the beginning and end of treatment. While TGD adolescents showed similar improvement in ED symptoms, measures of depression, anxiety, and suicidality remained elevated at the time of discharge.

Charting a Path Toward Improving Detection and Clinical Outcomes for Eating Disorders in Cismales and Gender-Diverse Patients

Historically, eating disorders (EDs) have been conceptualized from a female-centric lens. However, consistent research demonstrates that EDs afflict individuals across the gender spectrum, including cismales and gender-diverse individuals. Despite this evidence, a consensus regarding gender-sensitive assessment practices, theoretical formulations, and treatment considerations has yet to be established. The present review briefly summarizes research to date on the presentation of EDs in cismales and gender-diverse individuals, suggests appropriate assessment and treatment practices, and offers recommendations for gender-inclusive ED treatment. To effectively serve patients with EDs across the gender spectrum, more research is needed to validate gender-sensitive assessment tools, comprehensively study ED pathology within gender-representative samples, and conduct randomized controlled trials that serve cismales and gender-diverse patients. In doing so, clinicians and researchers may better detect EDs across the gender spectrum and implement gender-appropriate, evidence-based interventions, thereby reducing impairment and mortality related to EDs for all patients.

Pride and body image among transgender and nonbinary adults: the mediating role of body appreciation between gender identity pride and intuitive eating

Studies exploring disordered eating among transgender and nonbinary populations have primarily focused on minority stressors with a dearth of research examining the role of gender identity pride on body appreciation and intuitive eating. To address this gap in the literature, the present study, comprised of 148 transgender and nonbinary adults (Mage = 24.68, SD = 6.64), tested the associations among gender identity pride, body appreciation, and intuitive eating, controlling for demographics and minority stress variables. The study also tested body appreciation as a mediator in the cross-sectional association between gender identity pride and intuitive eating. Regression models indicated that greater gender identity pride was significantly associated with greater body appreciation, but not intuitive eating. Greater body appreciation was a significant mediator in the positive association between gender identity pride and intuitive eating. Findings support the significant role and relevance of examining gender identity pride as related to body appreciation and intuitive eating. Future research may determine the causal impact of gender identity pride on body image and eating behaviors in transgender and nonbinary populations. Clinicians may consider the positive role of gender identity pride when addressing body image and eating behaviors with their transgender and nonbinary clients.

The role of minority stress in disordered eating: a systematic review of the literature

PURPOSE

Sexual and gender minorities (SGMs) show a heightened risk of disordered eating compared to heterosexual and cisgender people, a disparity which may be caused by exposure to minority-specific stressors, such as discrimination and violence. This systematic review aims to summarize available evidence on the role of minority stress in disordered eating and SGM-specific aspects.

METHODS

Following PRISMA guidelines, scientific search engines (EBSCO, PUBMED, Web of Science) were screened up to 31st of January 2024, including English-language original research papers containing analyses of the relationship between minority stress and disordered eating. 2416 records were gathered for screening. After application of inclusion and exclusion criteria, thematic analysis was conducted regarding 4 research questions: effects of minority stress on disordered eating, mediating factors, specificities of SGMs and differences between identity categories.

RESULTS

30 studies were included. Several aspects of minority stress are reliably associated with different forms of disordered eating. The relationship between minority stressors and disordered eating is mediated by aspects such as shame, body shame, or negative affect. SGMs show several specificities, such as the presence of a role of LGBTQIA + communities and additional gender-related pressures. Bisexual people and gender minorities appear to feature comparatively higher risks, and gender-related factors shape paths leading to disordered eating risk.

CONCLUSION

Minority stress is an important predictor of disordered eating, making SGM people's health particularly at risk. Institutional and organizational anti-discrimination policies are needed, as well as further research. Clinical interventions may benefit from exploring and incorporating how minority stressors impact SGM people. Evidence level I-Systematic review.

Body Mass Index Categories of Transgender and Gender Diverse Youth: Clinical Associations and Predictors

Background: Transgender/gender diverse (TGD) youth are at risk for weight-related problems. We describe factors associated with their body mass index (BMI) category. Methods: Chart review of 228 TGD patients, 12-20 years (u = 15.7, standard deviation 1.3), 72% female assigned at birth. BMI percentile was calculated using CDC growth charts. We examined bivariate relationships of 18 clinically derived factors, utilizing analysis of variance (ANOVA) for continuous variables and chi-squared/Fisher's exact test for categorical variables. Nonparametric Classification and Regression Tree (CART) analyses were used to predict BMI category. Results: Almost half (49.6%) of TGD youth presenting for their initial visit for pediatric gender-affirming care fell in the healthy weight range, 4.4% in the underweight range, 16.7% in the overweight range, and 29.4% in the obese range. Self-described weight, weight management intentions, unhealthy weight management, prescription of psychiatric medications, and medications associated with weight gain were associated with BMI category. Use of psychiatric medications (54.8%) and medications associated with weight gain (39.5%) was associated with BMI in the overweight/obese categories. Youth with obesity most often reported unhealthy weight management. In CART models, self-described weight was the strongest predictor of BMI category. Conclusion: TGD youth have high rates of underweight and overweight/obesity. Unhealthy BMI should be treated as part of gender-affirming care. Self-described body weight is associated with weight category. More than half of TGD youth were prescribed psychiatric medications; those with overweight and obesity were more likely prescribed psychiatric and medications with associated weight gain. Youth with obesity were most likely to use unhealthy weight management.

Prevalence of Eating Disorder Symptoms in Transgender and Gender Diverse Adolescents Presenting for Gender-Affirming Care

PURPOSE

To describe the prevalence of eating disorder symptoms among adolescents seeking gender-affirming care.

METHODS

Cross-sectional study of 660 gender-diverse adolescents who completed the Branched Eating Disorder Test to measure anorexia and bulimia symptoms.

RESULTS

23.9% (95% CI 20.7-27.4) reported both anorexia symptoms, namely overvaluation of weight and fear of (or recurrent interference with) weight gain. 0.9% (95% CI 0.3-2.0) reported all bulimia symptoms, namely overvaluation of weight, recurrent binge eating, and recurrent compensatory behaviors (e.g., weekly purging). For all symptoms, prevalence was higher among i) adolescents assigned female at birth compared to those assigned male at birth, and ii) adolescents who felt unsure about their gender identity compared to those who identified as trans or nonbinary.

DISCUSSION

Clinicians should monitor eating disorder symptoms among adolescents presenting for gender-affirming care, especially among those assigned female at birth or who are unsure about their gender identity.

Disordered eating behaviors in gender-affirmative treatment seeking transgender people

This study aimed to explore disordered eating behaviors in gender-affirming treatment (GAT)-seeking transgender (TG) adults and cisgender people, in addition to analyzing the association between gender dysphoria intensity, body mass index, and disordered eating behaviors. Data were collected from 132 GAT-seeking TG people with gender dysphoria who had never received GAT (91 TG men, 41 TG women), and 153 cisgender (99 cisgender men, 54 cisgender women) participants from Turkey. The Utrecht Gender Dysphoria Scale was used to evaluate the intensity of gender dysphoria. Eating Disorder Examination Questionnaire and Questionnaire on Eating and Weight Patterns-5 were utilized to assess disordered eating. There was no difference between TG women and TG men in terms of ED psychopathology. The most prominent characteristic in all four groups was shape concern, which was significantly higher in TG men and TG women when compared to cisgender men and cisgender women. Binge eating was notably more frequent in TG men and TG women compared to cisgender men, with 11% of the TG men and 7.3% of the TG women meeting the criteria for possible binge eating disorder. Screening for disordered eating behaviors, particularly binge eating, may be recommended in routine care for TG people.

Analyzing body dissatisfaction and gender dysphoria in the context of minority stress among transgender adolescents

BACKGROUND

Gender dysphoria among transgender adolescents has predominantly been examined in relation to body dissatisfaction. While in adult transgender samples, body dissatisfaction is higher than in cisgender controls, this has so far rarely been investigated for adolescents. In the context of a cisnormative society, the impact of influences from the social environment on body dissatisfaction and gender dysphoria has been neglected in research. Therefore, this study aimed to (1) provide a detailed analysis of body dissatisfaction among young transgender people and (2) investigate whether body dissatisfaction and gender dysphoria are associated with experiences of minority stress such as trans hostility and poor peer relations (PPR).

METHODS

The paper presents a cross-sectional study among a sample of transgender adolescents, presenting at a specialized outpatient counseling clinic (N = 99; age M = 15.36, SD = 1.85). First, body dissatisfaction (assessed by the Body-Image-Scale; BIS), was explored and compared to data from a population-based control group of cisgender peers (N = 527; age M = 14.43, SD = 0.97). Second, within a clinic-referred transgender subsample (n = 74), associations between body dissatisfaction and gender dysphoria (measured by Utrecht Gender Dysphoria Scale; UGDS), PPR (measured by the Youth-Self-Report; YSR-R), and trans hostile experiences (assessed in clinical interview) were examined by correlations, t-tests and multivariate regression.

RESULTS

Transgender adolescents reported more body dissatisfaction than cisgender peers. The dissatisfaction with sex characteristics, non-hormonal reactive body regions and the total score for body dissatisfaction were positively related with gender dysphoria. The majority had experienced trans hostility in the present and/or past (54.1%) and PPR (63.5%). More body dissatisfaction was correlated with more PPR regarding visible body parts i.e., hair, overall appearance and muscles, whilst PPR and gender dysphoria were not associated. Transgender adolescents who experienced trans hostility showed higher gender dysphoria and PPR, but not more body dissatisfaction. In multiple regression, trans hostility predicted gender dysphoria, whilst age and PPR predicted body dissatisfaction.

DISCUSSION

Experiences of minority-stress differentially interact with body dissatisfaction and gender dysphoria among transgender adolescents. Social correlates of body dissatisfaction and gender dysphoria must be considered when working with young transgender people.

Disordered eating in transgender and gender non-conforming youth: A comparison to community-based and clinical samples

OBJECTIVE

This study investigates eating pathology in transgender and gender non-conforming (TGNC) youth compared to a community-based sample and individuals with eating disorders (EDs).

METHOD

Participants (ages 13-21 years) included TGNC youth from a paediatric gender clinic (N = 97), a demographically matched community-based sample of cisgender males (N = 97) and cisgender females (N = 97), and treatment-seeking patients with EDs (N = 112). The Eating Disorder Examination Questionnaire (EDE-Q) was used to assess ED cognitions and behaviours.

RESULTS

Transgender and gender non-conforming participants reported significantly higher EDE-Q global scores compared to the cisgender samples, but significantly lower than the ED sample. Transgender and gender non-conforming individuals reported a higher likelihood of objective binge episodes (OBEs) than the cisgender groups, albeit lower than youth with EDs. A substantial proportion of TGNC participants scored in elevated ranges on the EDE-Q global score (35% ≥ score of 3, 17% ≥ score of 4), significantly higher than cisgender males (0% ≥ score of 3, 0% ≥ score of 4) and females (9% ≥ score of 3, 3% ≥ score of 4).

CONCLUSIONS

Findings indicate that TGNC youth exhibit increased ED cognitions and OBEs compared to cisgender samples, highlighting the need for screening and addressing ED symptoms in this population.

Emerging Evidence: A Systematic Literature Review of Disordered Eating Among Transgender and Nonbinary Youth

PURPOSE

This systematic literature review explores the evidence base related to the diagnosis and clinical management of eating disorders among transgender and gender nonbinary (TGNB) youth. Through an exploration of the literature, this review highlights key considerations for providers working with this population, including the complex relationship between body image and gender, the assessment of subthreshold eating disorder symptoms, the impact of gender-affirming care on eating disorder treatment outcomes, and available evidence-based metrics, with attention to factors impacting treatment, including family support, psychiatric comorbidities, and community safety.

METHODS

We conducted a search of the databases PubMed and Ovid MEDLINE for articles pertaining to eating disorders and TGNB youth, with forward citation chaining conducted via Google Scholar to provide a review of recent publications. Twenty-six articles published from 2017 to 2022 met the criteria for full-text review.

RESULTS

The selected articles primarily explored data from the United States and varied widely in methodology, including a systematic literature review (n = 1), narrative literature reviews (n = 3), case series (n = 4), case studies (n = 2), cross-sectional population surveys (n = 7), cross-sectional patient surveys (n = 3), other cross-sectional studies (n = 3), retrospective chart reviews (n = 2), and a retrospective longitudinal cohort study (n = 1). Most commonly, researchers sampled patients within the setting of gender clinics. Researchers used a range of validated measures in clinical settings, with the Eating Disorder Examination Questionnaire most frequently reported. The literature highlights several considerations unique to transgender populations, including the complex relationship between gender dysphoria, body dissatisfaction, disordered eating behavior, and gender-affirming care.

DISCUSSION

In clinical settings with TGNB youth, providers may consider implementing validated screening measures to assess for eating disorders. Future research should emphasize a nuanced understanding of the heterogeneity among TGNB patient populations and the impact of gender identity on treatment of eating disorders.

Eating disorder symptoms among transgender and gender diverse youth

Compared to cisgender peers, transgender and gender diverse (TGD) youth and adults report elevated eating disorder (ED) symptoms likely related to gender dysphoria and attempts to modify their bodies accordingly. Less is known about the impact on gender-affirming care and ED symptoms. This study aimed to expand on extant research and describe ED symptoms in TGD youth seeking gender-affirming care while exploring potential associations between gender-affirming hormone use and ED symptoms. A total of 251 TGD youth completed the Eating Disorders Examination-Questionnaire (EDE-Q) as part of routine clinical care. ANCOVAs and negative binomial regressions examined differences in ED symptoms among transgender females (identifying as female but assigned male at birth) and transgender males (identifying as male but assigned female at birth). ED severity was not significantly different among transgender females versus transgender males, (p = .09), or associated with gender-affirming hormone use (p = .07). Transgender females receiving gender-affirming hormones reported a greater proportion of objective binge eating episodes compared to those who were not (p = .03). Over a quarter of TGD youth reported engagement in ED behaviors suggesting assessment and intervention related to ED behaviors among TGD youth is imperative since adolescence is a particularly vulnerable period for adolescents and engagement in ED behaviors could lead to full ED development and medical risk.

Gender-Affirming Nutrition: An Overview of Eating Disorders in the Transgender Population

PURPOSE OF REVIEW

Transgender individuals are vulnerable to many nutrition-related conditions, especially eating disorders due to gender dysphoria. This review aims to summarize the current literature on eating disorders in transgender individuals. The issues that should be considered in nutrition care for the transgender population are discussed regarding public health.

RECENT FINDINGS

Transgender individuals can exhibit disordered eating behaviors to overcome the stress they experience due to stigma, discrimination, social exclusion, and abuse. Recent studies showed that disordered eating and clinical eating disorders are more prevalent among transgender than cisgender people. It is very important for a multidisciplinary team working in the clinic to understand the epidemiology, etiology, diagnostic criteria, and treatment of eating disorders in the transgender population. However, multidisciplinary nutritional care is limited due to the lack of transgender-specific nutrition guidelines. It is safe to say that adhering to a generally healthy nutritional pattern and using standardized nutrition guidelines. We recommend that health professionals working with patients/clients with eating disorders receive continuing education in transgender health, be empowering and inclusive, address patients/clients with their gender identity nouns and pronouns, and develop nutritional treatment plans that are not gender-specific. Eating disorders are a significant public health problem in the transgender population. Therefore, clinical screening and early intervention are necessary to identify and treat eating disorders in transgender people. Eating disorders in the transgender population should be monitored routinely, and gender-affirming care should be provided as well as treatment of eating disorders.

Family connectedness and sexual minority Asian Americans' eating behavior regulation

To date, psychosocial and interpersonal protective factors such as family connectedness have received little attention in studies of eating behaviors among sexual minority Asian Americans. Therefore, we investigated associations of family connectedness and two types of eating behavior regulation motives and the moderating role of individualism in these associations among 134 sexual minority Asian American young adults. Linear regression models assessed the main and interaction effects of family connectedness and individualism on introjected and identified eating behavior regulation motives. We observed a significant interaction effect between family connectedness and individualism only on introjected regulation. For participants with low levels of individualism, those who reported high levels of family connectedness had lower scores for introjected regulation of eating behavior. The findings of this study highlight the importance of examining strengths related to sexual minority Asian Americans by demonstrating the important role family connectedness plays in eating behavior regulation motives, particularly for those with lower individualism.

A qualitative exploration of positive body image experiences among nonbinary individuals

One group whose positive body image experiences remain under-explored is individuals who identify as nonbinary, gender fluid, and/or genderqueer (including other nonbinary identities). Thus, we sought to answer the questions: What does it look like to have a positive body image for a nonbinary person? and How do nonbinary persons form and maintain a positive body image? To answer these questions, we conducted in-depth, semi-structured interviews with 15 nonbinary individuals who were assessed as having positive body image using the Body Appreciation Scale-2 (Tylka & Wood-Barcalow, 2015a). Data were analyzed using reflexive thematic analysis. Four themes were identified as characterizing the core features of positive body image among nonbinary persons: body appreciation, body- and self-acceptance, bodily appearance embodied their authentic self, and holding flexible ideals for ways of being. Six themes were identified as related to on-going processes that explain how body image is formed and maintained among nonbinary persons: reframing negative body image information, staging resistance, experiencing representation, receiving and giving social support, practicing self-compassion and self-care, and using dress to create a satisfying presentation of self. In keeping with the tenets of queer theory, findings reflected how gender identity set a context for participants' positive body image experiences.

"If You Don't Lose Weight, the Government Will Take You Away": An Analysis of Memorable Messages and Eating Disorders in the LGBTQ+ Community

Family communication plays a key role in children's body image, disordered eating, and full-blown eating disorders;. However, much existing communication research on eating disorders has focused on general populations. As the LGBTQ+ community is disproportionately affected by eating disorders , more work is needed to better understand how family communication may be perceived as influencing eating disorders in the LGBTQ+ community. Thus, the current study aimed to further this understanding by examining familial memorable messages reported by LGBTQ+ individuals which they perceived to have influenced their eating disorders. In a Qualtrics survey, participants (n = 73) provided memorable messages received from family members and explained their significance. Results of a thematic analysis indicate five themes among the memorable messages: Problematic Body Size/Weight, Pathologized Eating, Emphasizing Appearance Ideals, Emotion Origins, and Other Focus. Findings support the theory of memorable messages and reveal the ways in which diet culture and LGBTQ+ identity stigma intersect within parent-child communication toward a perceived influence on LGBTQ+ eating disorders. Implications for future communication research on LGBTQ+ eating disorders, as well as practical applications, are discussed.

Nutrition and Health in the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning Community: A Narrative Review

Sexual and gender minorities have a higher risk for health and nutrition-related disparities across the life course compared to the heterosexual or cisgender population. Experiences of stigmatization and discrimination are associated with diminished mental health quality and psychological distress, which are risk factors for developing various eating disorders. Other nutrition disparities include increased risk for food insecurity, body dissatisfaction, and weight complications, such as those experienced by the transgender population in association with gender-affirming hormone therapies. Despite the need for tailored nutrition recommendations that address the unique needs of the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) community, there are currently no such guidelines in North America. The purpose of this review is to summarize major LGBTQ+ nutrition disparities and highlight the need for tailored recommendations. We examine the evidence on mental health and social disparities in this group, including vulnerabilities to disordered eating, food insecurity, and healthcare provider discrimination. Importantly, we identify a scarcity of literature on dietary concerns and nutrition care guidelines for LGBTQ+ groups, including studies that address intersectionality and differences among specific gender and sexual orientations. These gaps underline the urgency of prioritizing nutrition for LGBTQ+ health needs and for developing tailored public health nutrition recommendations for this underserved population. Our review suggests that future LGBTQ+ health and nutrition research agendas should include personalized and precision nutrition, social determinants of health, diet quality, body image, and healthcare provider cultural competency and responsiveness. Moreover, the current evidence on LGBTQ+ nutrition and health will be strengthened when research studies (including clinical trials) with robust methodologies amplify inclusion and representation of this community to elucidate health and nutrition disparities in sexual and gender minorities.

A scoping review of research literature on eating and body image for transgender and nonbinary youth

BACKGROUND

Transgender and nonbinary (TGNB) adolescents and young adults are underrepresented in the literature on eating disorders and body image-related problems, despite increased mental health disparities and emerging research showing high associations between gender dysphoria, body image, and eating disorders among TGNB youth.

AIMS

The scoping review was designed to critically examine the research on TGNB adolescents and young adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this scoping review. The electronic databases of MEDLINE and PsychInfo were used for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for transgender minor children, adolescents, or young adult samples (18 to 25 years old) and address differences in eating/body-related problems by age. The relevant data was extracted and narratively summarized.

RESULTS

49 studies were identified, data extracted, and analyzed. Increased prevalence of eating disorders and body image problems were identified for TGNB youth. Body-gender congruence through gender affirming social and medical interventions (e.g., hormone therapy) were noted as significant for alleviating body image problems and facilitating eating disorder treatment. Family and social factors were not well understood in the literature and a need for increased study of TGNB youth from varied racial/ethnic, neurodiverse, and within specific identities (e.g., nonbinary) and families and cultural contexts is still needed.

CONCLUSIONS

Future research should consider the use of developmental and family theories for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups, neurodiversity, and varied gender identities (e.g., nonbinary and gender queer) for identifying important differences.

Testing the associations between internalized cisgenderism, self-objectification, body shame, and mental health correlates in the framework of the pantheoretical model of dehumanization: A study in Chinese transgender adults

As an integrated framework informed by the Minority Stress Model and Objectification Theory, the Pantheoretical Model of Dehumanization was proposed to better understand mental health outcomes in transgender individuals. With a sample of 200 Chinese transgender adults, the present study tested the associations and potential mechanisms between internalized cisgenderism, self-objectification, body shame, and mental health correlates in the framework of the Pantheoretical Model of Dehumanization. Correlation and regression analyses were used. Results showed that internalized cisgenderism was positively related to body shame, psychological distress, disordered eating, non-suicidal self-injury (NSSI), suicidal ideation, and suicide attempts. Body shame showed significant indirect effects in the association between internalized cisgenderism and suicide attempts, and in the associations between internalized cisgenderism and psychological distress, disordered eating, and NSSI. In addition, body shame had significant indirect effects in the associations between body surveillance and disordered eating, NSSI, and suicide attempts, and in the association between body surveillance and psychological distress. As the first study testing the associations of core variables in the Pantheoretical Model of Dehumanization in a Chinese transgender sample, the findings largely supported the model in describing meaningful variance in Chinese transgender adults' psychological distress, disordered eating, and self-injurious thoughts and behaviors.

Mental Health Disparities in Sexual Minority and Transgender Women: Implications and Considerations for Treatment

Minority stress theory offers an explanation of how discrimination, marginalization, harassment, and violence against sexual minority and transgender women are connected to mental health disparities. Particularly, these groups are vulnerable to body image issues, disordered eating, higher rates of mood and anxiety disorders, suicide and nonsuicidal self-injury, and substance use. Discrimination is also experienced within clinical settings, which may lead this population to postpone or avoid treatment. Clinicians play a crucial role in reducing barriers to health care by developing cultural competency and ensuring safe and affirming spaces within their practice.

A Longitudinal Study on Disordered Eating in Transgender and Nonbinary Adolescents

OBJECTIVE

We longitudinally explored frequency of disordered eating among transgender and nonbinary (TGNB) adolescents and explored trends by gender identity and gender-affirming care.

METHODS

Participants completed an abbreviated version of the Eating Disorder Examination Questionnaire (EDE-Q) at baseline, 3, 6, and 12 months after establishing care in a gender clinic. We analyzed descriptive statistics and multivariate linear regression analyses.

RESULTS

Of the 91 TGNB adolescent participants, 61% were transmasculine, 30% transfeminine, and 7% nonbinary/gender-fluid. Among TGNB adolescents, disordered eating thoughts/behaviors were frequently endorsed with 26% of participants engaging in any occurrence of binge eating, 27% limiting the amount of food they ate, and 30% excluding foods from their diet. Forty percent of participants reported any occurrence of at least 1 disordered eating behavior and 17% at least 3 behaviors. Abbreviated EDE-Q responses did not differ significantly by sex assigned at birth, gender identity, gender-affirming medications, or time spent receiving gender-affirming care. There was a significant effect of age (P value = .003) on abbreviated EDE-Q scores.

CONCLUSIONS

There were no significant changes in disordered eating after initiating gender-affirming medical care, possibly due to the limited study time frame of 12 months. Given the high prevalence of disordered eating behaviors, clinicians should consider screening all TGNB adolescents for disordered eating thoughts/behaviors throughout gender-affirming care. Future longitudinal research should recruit larger samples with a diverse range of gender identities and survey disordered eating thoughts/behaviors at least one year after starting gender-affirming medications.

Between Resilience and Agency: A Systematic Review of Protective Factors and Positive Experiences of LGBTQ+ Students

A negative school climate resulting from homophobic and transphobic bias and discrimination is associated with poor well-being and mental health among LGBTQ+ youth. However, protective factors and mechanisms may buffer against the impact of stigmatization. Drawing on the socio-ecological model, minority stress theory, and positive youth development and agency perspectives, we carried out a systematic review of research focusing on factors that can promote the well-being of LGBTQ+ students in educational settings, outlining the primary outcomes from studies published between 2012 and 2022. The PRISMA protocol was used for this review, and 64 articles were scrutinized. The results of the thematic analysis revealed that both external factors (school-inclusive policies and extracurricular activities; social support from school, family, and the community; and school connectedness) and internal factors (psychosocial characteristics and personal agency) promote positive school experiences, such as the exploration of sexual and gender identities in a safe environment. The present findings highlight the need for inclusive school policies and strategies and individual-level interventions that target the well-being and positive mental health outcomes of sexual and gender minority students.

A scoping review of the research literature on eating and body image for transgender and nonbinary adults

BACKGROUND

Eating disorder treatment approaches and outcome studies have historically centered almost exclusively on cisgender populations. Transgender and nonbinary (TGNB) adults are underrepresented in general and intervention research despite being at increased risk for eating and body image-related problems.

AIMS

This scoping review was designed to gather and examine the research with TGNB adults who experience eating and body image related problems, as well as clinical studies on the effectiveness of treatment approaches.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this review. MEDLINE and PsychInfo were used as electronic databases for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for TGNB adults. The relevant data were extracted and summarized based on quantitative findings and qualitative themes.

RESULTS

After review of over 1258 articles, 59 studies met criteria and data were extracted and summarized. Factors associated with eating disorders and body image problems across studies suggests gender-affirming medical interventions are effective and emphasized treatment for an eating disorder is warranted alongside gender affirming medical care. Body image was associated with eating patterns aimed at meeting gendered ideals of body shape and size. There was variation in guiding theories and absence of consensus in the definition of transgender in the review studies. This likely demonstrates the changing language, social acceptance of TGNB people and identities, diagnostic criteria, and clinical conceptualizations of eating and body image.

CONCLUSIONS

Future research should consider the use of theory for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, future research is needed that centers on nonbinary and genderqueer populations, as well as those from minoritized racial and ethnic groups to inform culturally appropriate concerns, needs, and treatment modalities.

Perspectives on relapse prevention following intensive treatment of anorexia nervosa: A focus group study

OBJECTIVE

Including the perspectives of individuals with lived experience of mental health issues is a critical step in research and treatment development. Focus groups with patients with a history of treatment for anorexia nervosa (AN) were conducted in anticipation of a clinical trial of Relapse Prevention and Changing Habits (REACH+).

METHODS

Seven female adults (23-51 years) who had previously received inpatient treatment for AN, now in remission, participated in one of two semistructured focus groups. Rapid qualitative analysis was used to examine participants' contributions and identify common topics.

RESULTS

Transcript analysis yielded three topics related to relapse prevention: (1) recovery aids, including a sense of agency in treatment decisions and finding new interests/passions, (2) recovery hindrances, such as lack of access to care, and (3) identification of members of support system. Aspects of REACH+ received positive feedback, such as continuity of care from the inpatient setting and the use of telehealth. Viewpoints differed with respect to the helpfulness of obtaining patient weights in treatment. The REACH+ online platform received positive comments regarding content and usability, as well as suggestions for additional content.

DISCUSSION

Qualitative feedback from patients with a history of AN highlighted the value of engaging patients in their own treatment decisions, as well as in treatment design and innovation. Within this small group, there were differences of opinion about treatment components, specifically weight assessment, that suggest the need for further data. User-centered design provides opportunities to improve the acceptability and, therefore, dissemination of novel treatments.

PUBLIC SIGNIFICANCE

Relapse prevention is a critical treatment need for patients with anorexia nervosa, as this illness too often follows a protracted course. There are challenges in both obtaining specialized care and in retaining patients in treatment. Here, patient perspectives on these challenges offer input to allow for optimization of relapse prevention treatment. Shared decision-making may be particularly valuable to support an individual's sense of agency and engagement in care.

Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

Gender and Sexual Health-Related Knowledge Gaps and Educational Needs of Parents of Transgender and Non-Binary Youth

Parents can have a substantial impact on adolescent sexual decision-making, but few studies have explored the role of parents in providing sexual health information to transgender and non-binary (TNB) youth, a population that experiences significant sexual and mental health disparities and lower levels of perceived family support compared with other youth. This study aimed to elucidate existing knowledge gaps and content deemed important for a sexual health curriculum and educational materials for parents of TNB youth. We conducted 21 qualitative interviews with five parents of TNB youth, 11 TNB youth aged 18+, and five healthcare affiliates to identify parents' educational needs. We analyzed the data using theoretical thematic analysis and consensus coding. Parents self-reported multiple knowledge deficits regarding gender/sexual health for TNB individuals and were primarily concerned with long-term impacts of medical interventions. Youth goals for parents included greater understanding of gender/sexuality and sufficient knowledge to support youth through social transition to their affirmed gender identity. Content areas suggested for a future curriculum for parents of TNB youth included: basics of gender/sexuality, diverse narratives of TNB experiences/identities, gender dysphoria, non-medical gender-affirming interventions, medical gender-affirming interventions, and resources for peer support. Parents desired access to accurate information and wanted to feel equipped to facilitate affirming conversations with their child, something that could combat health disparities among TNB youth. An educational curriculum for parents has the potential to provide a trusted information source, expose parents to positive representations of TNB individuals, and help parents support their TNB child through decisions about potential gender-affirming interventions.

Eating disorder symptomatology among transgender individuals: a systematic review and meta-analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis was to synthesize the literature on eating disorders and eating disorder symptomatology among transgender individuals and to summarize the existing literature on gender-affirming treatment and the prevalence of eating disorder symptomatology.

METHOD

The literature search for this systematic review and meta-analysis was performed in PubMed, Embase.com, and Ovid APA PsycInfo. We searched for "eating disorders" and "transgender" using both controlled vocabularies and natural language terms for their synonyms. The PRISMA statement guidelines were followed. Quantitative data from studies on transgender individuals and eating disorders assessed with relevant assessment tools was included.

RESULTS

Twenty-four studies were included for the qualitative synthesis, and 14 studies were included in the meta-analysis. The results revealed higher levels of eating disorder symptomatology among transgender individuals compared with cisgender individuals, especially cisgender men. Transgender men tend to display higher levels of eating disorder symptomatology than transgender women; however, transgender women seem to have higher levels of eating disorder symptomatology than cisgender men and, interestingly, this study also noted a trend toward transgender men having higher levels of eating disorders than cisgender women. Gender-affirming treatment seems to alleviate the presence of eating disorder symptomatology in transgender individuals.

DISCUSSION

The body of research on this subject is extremely limited, and transgender individuals are underrepresented in the eating disorder literature. More research investigating eating disorders and eating disorder symptomatology in transgender individuals and the relationship between gender-affirming treatment and eating disorder symptomatology is needed.

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.

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.

Impact of COVID-19 stress on the psychological health of sexual & gender minority individuals: A systematic review

Introduction

The differential effect of the Covid-19 pandemic on the mental health of the population around the globe is well documented. Social isolation, loss of job, financial crisis, and fear of infection due to the pandemic have widely affected people across countries, and the sexual and gender minority (SGM) group is no exception. However, the additional stressors like stigma, discrimination, rejection, non-acceptance, and violence associated with diverse sexual orientation complicated the situation for the SGM group in the context of the Covid-19 pandemic.

Method

The present study conducted a systematic review of research (n = 16) investigating the impact of Covid-19 stress on the psychological health of SGM individuals. The review had two objectives: (a) to explore the effect of the stress associated with the pandemic on the psychological health of the SGM individuals; and (b) to identify potential stressors associated with the Covid-19 pandemic affecting the mental health of SGM individuals. Studies were selected following a PRISMA protocol and several inclusion criteria.

Results

The review provided new insights into the mental health issues of the SGM individual in the Covid-19 context. The outcome of the review focused on five aspects: (a) depression and anxiety symptoms related to Covid-19 symptoms; (b) perceived social support and Covid-19 stress; (c) family support and psychological distress related to Covid-19; (d) Covid-19 stress and disordered eating, and (e) problem drinking and substance abuse associated with Covid-19 stress.

Discussion

The present review indicated a negative association between Covid-19 stress and psychological distress among sexual and gender minority individuals. The findings have important implications for psychologists and social workers working with this population and policymakers around the globe.

Caregiver and adolescent intuitive eating behavior: associations with weight change during family-based treatment for anorexia nervosa

PURPOSE

Intuitive eating (IE) is an adaptive eating construct for which little research exists in eating disorder (ED) samples. IE is negatively correlated with disordered eating behaviors in healthy adolescents and adults, and similar associations have been found in adults with EDs. This study aims to examine IE in a treatment seeking sample of adolescents and their caregivers to understand the role of IE in weight gain during FBT.

METHODS

Descriptive statistics and bivariate correlations were calculated in a sample of 47 pairs of adolescent patients and their caregivers who initiated outpatient FBT at a large academic medical center. Analyses examined associations between caregiver and adolescent IE on the Intuitive Eating Scale (IES), change in percent expected body weight (%EBW) by session 4 and end of treatment (EOT), clinical impairment, and ED pathology.

RESULTS

Significant correlations were found between aspects of adolescent IE, ED symptoms, and clinical impairment. Caregiver IES scores (Reliance on Hunger and Satiety Cues, Body-Food Choice Congruence, IES Total) were negatively related to adolescent ED symptoms (EDE-Q Weight Concerns, EDE-Q Shape Concerns, EDE-Q Global) at baseline. Caregiver IE (Eating for Physical Rather than Emotional Reasons) was positively associated with adolescent weight gain at FBT session 4 and EOT, even when statistically adjusting for gender and initial level of care.

CONCLUSION

Study results were consistent with past research indicating adolescent IE is negatively associated with ED behaviors, cognitions, and impairment. This study is the first to provide evidence that caregiver IE is positively associated with adolescent weight gain in FBT and is the first to provide evidence that caregiver IE is negatively related to adolescent ED symptoms. Future research should examine adolescent and caregiver IE throughout FBT to understand the role of IE in treatment response.

LEVEL OF EVIDENCE

Level III: Evidence obtained from cohort or case-control analytic studies.

Clinical aspects of binge eating disorder: A cross-sectional mixed-methods study of binge eating disorder experts' perspectives

Introduction

Research on binge eating disorder continues to evolve and advance our understanding of recurrent binge eating.

Methods

This mixed-methods, cross-sectional survey aimed to collect information from experts in the field about clinical aspects of adult binge eating disorder pathology. Fourteen experts in binge eating disorder research and clinical care were identified based on receipt of relevant federal funding, PubMed-indexed publications, active practice in the field, leadership in relevant societies, and/or clinical and popular press distinction. Anonymously recorded semi-structured interviews were analyzed by ≥2 investigators using reflexive thematic analysis and quantification.

Results

Identified themes included: (1) obesity (100%); (2) intentional/voluntary or unintentional/involuntary food/eating restriction (100%); (3) negative affect, emotional dysregulation, and negative urgency (100%); (4) diagnostic heterogeneity and validity (71%); (5) paradigm shifts in understanding binge eating disorder (29%); and (6) research gaps/future directives (29%).

Discussion

Overall, experts call for a better understanding of the relationship between binge eating disorder and obesity, including a need for clarification around the extent to which the two health issues are separate vs. related/overlapping. Experts also commonly endorse food/eating restriction and emotion dysregulation as important components of binge eating disorder pathology, which aligns with two common models of binge eating disorder conceptualization (e.g., dietary restraint theory and emotion/affect regulation theory). A few experts spontaneously identified several paradigm shifts in our understanding of who can have an eating disorder (beyond the anorexi-centric "thin, White, affluent, cis-gendered neurotypical female" stereotype), and the various factors that can drive binge eating. Experts also identified several areas where classification issues may warrant future research. Overall, these results highlight the continual advancement of the field to better understand adult binge eating disorder as an autonomous eating disorder diagnosis.

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.

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.

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.

What next for eating disorder genetics? Replacing myths with facts to sharpen our understanding

Substantial progress has been made in the understanding of anorexia nervosa (AN) and eating disorder (ED) genetics through the efforts of large-scale collaborative consortia, yielding the first genome-wide significant loci, AN-associated genes, and insights into metabo-psychiatric underpinnings of the disorders. However, the translatability, generalizability, and reach of these insights are hampered by an overly narrow focus in our research. In particular, stereotypes, myths, assumptions and misconceptions have resulted in incomplete or incorrect understandings of ED presentations and trajectories, and exclusion of certain patient groups from our studies. In this review, we aim to counteract these historical imbalances. Taking as our starting point the Academy for Eating Disorders (AED) Truth #5 "Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses", we discuss what we do and do not know about the genetic underpinnings of EDs among people in each of these groups, and suggest strategies to design more inclusive studies. In the second half of our review, we outline broad strategic goals whereby ED researchers can expand the diversity, insights, and clinical translatability of their studies.

Factors that drive mental health disparities and promote well-being in transgender and nonbinary people

Transgender (or trans) is an umbrella term for individuals who experience their gender differently from what is associated with the sex they were assigned at birth. Individuals who are nonbinary experience their gender outside binary conceptions of gender. Although research has predominantly focused on negative mental health outcomes for transgender and non-binary (TNB) individuals, an emergent literature has begun to explore protective and health-promoting factors and dimensions of psychological well-being. In this Review, we discuss the sociocultural context for TNB people, beginning with a brief history of TNB identity before highlighting frameworks for understanding the higher prevalence of certain mental health concerns among TNB individuals. Next, we summarize the predictive factors associated with higher rates of depression, anxiety, suicidality, trauma-related concerns, disordered eating behaviours and substance use. We also review TNB coping, resilience and resistance to anti-trans stigma, as well as psychological well-being, flourishing and gender euphoria. Tying these topics together, we discuss affirming interventions for reducing mental health disparities and promoting psychological health in TNB individuals and communities. We conclude by discussing future research directions.

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.