Individuals who identify as lesbian, gay, bisexual, transgender, queer, or another sexual or gender minority (LGBTQ+) face numerous health disparities compared to heterosexual and cisgender individuals. These include higher rates of chronic physical illness, substance use, and mental health disorders such as depression and anxiety.1 In addition, accumulating research has shown substantially elevated rates of disordered eating and body dissatisfaction in this population.
“Research suggests that as a whole, LGBTQ+ individuals – both adolescents and adults – are more likely to experience poor body image, disordered eating behaviors, and clinical eating disorders when compared to their heterosexual and cisgender counterparts,” according to Lacie Parker, PsyD, a clinical psychologist in private practice in Seattle, Washington, and co-author of a 2020 review on the topic.2
In a study published in June 2023 in the Journal of Eating Disorders, LGBTQ+ participants showed higher global scores on the Eating Disorder Examination Questionnaire (EDE-Q) as well as higher scores on the Eating Concern, Shape Concern, and Weight Concern subscales of the EDE-Q (all, P <.001), relative to cisgender and heterosexual participants. Additionally, sexual and gender minority participants had significantly lower Body Appreciation Scale (BAS-2) scores (P <.001).3 Notably, body image dissatisfaction was also influenced by higher scores on the Heterosexist Harassment, Rejection, and Discrimination Scale.
These higher rates of disordered eating and body dissatisfaction also carry over into pediatric LGBTQ+ individuals.4 In a retrospective study of data from 107,528 adolescents who had a Well Check at Kaiser Permanente Northern California in 2016, sexual minority adolescents had higher odds of disordered eating behaviors (adjusted odds ratio [aOR], 2.0; 95% CI, 1.9-2.2) and body image dissatisfaction (aOR, 3.8; 95% CI, 3.4-4.2), relative to heterosexual patients.5
“However, much of what we know conceptualizes sexual and gender minorities as a monolithic group, and because of this, our understanding of group differences within the LGBTQ+ community is still in its infancy,” cautioned Wesley R. Barnhart, MA, a PhD candidate in clinical psychology at Bowling Green State University in Ohio. “Preliminary research suggests meaningful differences within the LGBTQ+ community.”
A 2019 study found higher rates of “eating disorder proneness” (66.7% vs 47.6%) and weight-based self-worth (82.0% vs 63.0%) among lesbian women compared to gay men, and higher dissatisfaction with eating patterns among transgender and gender non-conforming adults compared to gay men (69.8% vs 47.7%).6
To further illustrate these nuances, Dr Barnhart explained that “In gay men, differences in disordered eating and body dissatisfaction exist by gender expression – such as self-reported endorsement of femininity or masculinity – and other subcultural appearance identifications, such as identifying as a ‘jock’’ or stereotypical masculine person with an overinvestment in muscularity.”7
Moreover, Dr Parker highlighted the unique role that gender dysphoria plays in body dissatisfaction, as evidenced by the experience of transgender and nonbinary individuals. These individuals are “more likely to engage in disordered eating behaviors or develop eating disorders as a way to help their body conform to their gender identity and minimize secondary sexual characteristics such as breast size or muscle mass, for example,” she said.2,8
Dr Barnhart added, “Other differences in identity – such as one’s age, race, ethnicity, ability status, weight, and more, also confer meaningful information about how disordered eating and body dissatisfaction may present in LGBTQ+ patients.”
In a 2022 study of 120,891 undergraduate and graduate students from the Healthy Minds Study, positive eating disorder screenings were 1.27 (95% CI, 1.25–1.30) more common among participants with lower self-reported family socioeconomic status (SES), with even higher rates (52%) observed among bisexual men and lesbian women of Latinx ethnicity with lower SES.9
“According to the Minority Stress Model, negative synergistic effects may occur when an individual affirms multiple marginalized identities, and thus LGBTQ+ individuals who are also members of other underrepresented, marginalized, and minoritized groups tend to have higher rates of body image concerns and disordered eating,” said Jameson K. Hirsch, PhD, professor and assistant chair of research in the department of psychiatry and behavioral sciences at Quillen College of Medicine at East Tennessee State University in Johnson City. Dr Hirsch co-authored the 2019 study on eating disorders proneness, described above.6
Research attuned to intersectionality represents a key area of investigation that will aid the development of culturally sensitive treatments for disordered eating and body dissatisfaction that are responsive to all LGBTQ+ peoples’ identities and lived experiences.
In sexual and gender minority groups, minority stress includes discrimination based on LGBTQ+ status, concealment of sexual orientation and gender identity, and self-directed negative beliefs about being LGBTQ+, Dr Barnhart explained.10 “Minority stress may reinforce disordered eating and body dissatisfaction in sexual and gender minorities as a tool to help them fit in. Considering that physical appearance is often a robust source of teasing and harassment for these individuals, for example, they may engage in disordered eating to try to reach thin and muscular body image ideals and reduce the potential for harassment.”11
Screening and Treatment
Dr Parker offered the following recommendations regarding screening, treatment, and referrals for disordered eating and body image concerns among LGBTQ+ patients:
- Clinicians might first assess patients for the presence of specific disordered eating behaviors such as restricting calories, dieting, following a specific “lifestyle,” purging and other compensatory behaviors, and binge eating. She also asks about their “relationship to their body, since this tends to go above and beyond one’s eating patterns.”
- For treatment, a multidisciplinary approach is recommended. Incorporating medical doctors, psychiatrists, and dieticians who are Health at Every Size/HAES aligned and practice Intuitive Eating can help support a wide range of patient needs. In therapy, psychoeducation about Intuitive Eating, HAES principles, and disordered eating would be especially helpful if supplementary care with a dietician is not accessible.
- Aim to address the patient’s “relationship with food and their body and their core wounds and relationship with themself, as disordered eating and eating disorders are often a coping mechanism to help deal with a larger pain, and getting at the root of that pain is needed for long-lasting and deep change,” she explained. “It is important that clinicians are mindful about how the LGBTQ+ identity has contributed to their core pain and relationship with their body, and it is equally important for clinicians not to assume that this core pain exists just because of the LGBTQ+ identity.”
- To increase cultural competency, clinicians should seek continuing education programs for working with LGBTQ+ patients, consult with clinicians who specialize in working with this population, and stay up to date on the latest research in this area. Consuming media created by LGBTQ+ individuals – such as The Body is Not an Apology, by Sonya Renee Taylor – can also be a great way to increase competency.
- Treatment centers should ideally have at least one therapist on staff who specializes in working with LGBTQ+ individuals.
- Clinicians in private practice should promptly refer out if needed. “I have heard so many horror stories from my LGBTQ+ clients from past experiences with therapists who did not know how to work with these individuals,” Dr Parker shared. “If you don’t feel competent yet in this area, it is better to refer out so that they can get the care they need from someone who really specializes in this.”
Results of additional analyses by Dr Hirsch and colleagues suggested that “lack of belongingness and perceptions of stigma are associated with greater depression and less self-compassion and, in turn, to greater likelihood of developing an eating disorder.”6 To help reduce the influence of these factors and promote healthier perspectives on eating behaviors and body image, he suggests that clinicians could help patients with strategies to improve relationships, counteract stigma, and enhance strengths-based characteristics such as self-compassion. However, further research is needed to assess the effectiveness of these approaches in improving physical and mental health in LGBTQ+ patients.
“Given the growing number of policies restricting LGBTQ+ health services and other societal factors that are deleteriously impacting the health of LGBTQ+ persons, it seems critical for clinicians to be able to provide affirming care,” Dr Hirsch stated. “Competency-focused trainings may be effective in improving knowledge and skills needed to better work with LGBTQ+ groups,” citing a recent meta-analysis demonstrating that LGBTQ+-focused competency trainings led to improvements in knowledge of LGBTQ+ culture and health, attitudes toward LGBTQ+ individuals, and behaviors toward LGBTQ+-affirming practices.12
Among other needs, “It is our hope that clinicians consider sexual and gender minority stress in case conceptualization and treatment planning with LGBTQ+ patients presenting with disordered eating and body dissatisfaction,” Dr Barnhart said. “Clinicians with competency in this domain will be better positioned to understand their patients and deliver culturally sensitive therapeutic services that validate the lived experiences of their LGBTQ+ patients.”
Despite the progress made in recent years towards supporting LGBTQ+ patients, there are calls for further research into the complexities of and treatment strategies for the prevalent body image dissatisfaction and disordered eating behaviors in this population. Dr Parker points to the need for studies focused on adolescents, lesbians, and transgender individuals, as well as research investigating the impact of intersectional identities on eating disorders in LGBTQ+ individuals.
“Research attuned to intersectionality represents a key area of investigation that will aid the development of culturally sensitive treatments for disordered eating and body dissatisfaction that are responsive to all LGBTQ+ peoples’ identities and lived experiences,” Dr Barnhart stated. White, educated, middle and upper class, and Western LGBTQ+ individuals are overrepresented in the current body of research, which limits the generalizability of the available findings on these issues, he noted.
Additionally, “As a researcher interested in positive health psychology, my view is that there is still much to learn about the potential role of protective characteristics for eating disorders and other forms of psychopathology and health within LGBTQ+ communities,” Dr Hirsch said. “Given the many layers of systemic and structural discrimination that LGBTQ+ persons experience, it is imperative that clinicians and researchers promote and investigate adaptive psychosocial resources that have the potential to buffer against oppression and discrimination.”
This article originally appeared on Psychiatry Advisor