Gender Identity and Eating-Related Pathology

Transgender youth were at highest risk of developing an eating disorder.

Transgendered individuals are at increased risk of developing eating disorders and of using compensatory behaviors, according to the results of a large national survey of college students. The study, believed to include the largest number of transgender participants ever to be surveyed about eating disorders and compensatory behaviors, included 289,024 students from 223 US universities who were participants in the American College Health Association-National College Health Assessment II (J Adolesc Health.2015;doi.org/10.1016/jjadoleshealth2015.03003. [Epub before print].

As Dr. Elizabeth W. Diemer of Washington University School of Medicine, St. Louis, and her colleagues have reported earlier, qualitative research suggests that transgender individuals may experience greater-than-normal body dissatisfaction, and thus may be at greater risk of disordered eating (Int J Eat Disord. 2002; 32:473; Int J Eat Disord. 1998; 24:449). Despite this, the authors point out that results of empirical studies of associations between transgender and eating disorders have been inconsistent (Eat Weight Discord. 2013; 3:18).

To date, only one study has investigated associations between gender identity and disordered eating among transgender and cisgender groups derived from the same source population (cisgender is the opposite of transgender, or having a current sexual identify that matches one’s gender assigned at birth). That study, conducted among Finnish twins and their siblings, used “conflicted gender identity” rather than self-identified transgender status (Sex Roles. 2010; 63:118). The results indicated that women with “conflicted gender identity” had higher EAT scale scores than did their non-gender-conflicted counterparts.

The students participating in Dr. Diemer and colleagues’ study had a median age of 20 years and were surveyed between fall 2008 and fall 2011. Students in randomly selected classes were asked to complete the survey on paper or a link to the Web-based survey was sent to a random sample of enrolled students. The ACHA-NCHA questionnaire collected anonymous information about mental health, substance use, sexual behavior, and nutrition. In the demographic section of the questionnaire, students were asked several questions related to sexual orientation and gender identity.

For the current analysis, information on gender identity and sexual orientation was combined into a seven-level variable: transgender, cis-gender sexual minority (SM) men, cisgender unsure men, heterosexual men, cisgender SM women, cisgender unsure women, and cisgender heterosexual women. Cisgender heterosexual women served as the reference group, as most of the existing ED literature largely focuses on them. Due to a relatively low number of transgender respondents (n=479), they were analyzed as a single group.

A small number self-identified as being transgender

Of the nearly 300,000 participants 0.17%, or 479, identified themselves as transgender; 2.0% (n=5977) identified themselves as cisgender SM men; 0.58% (n=1662) identified themselves as cisgender unsure men; and 32% (n=91,599) viewed themselves as cisgender heterosexual men. Among the women, 3% (n=9445) identified themselves as cisgender SM women; 1% (n=3395) as cisgender unsure women; and 61% (n=176,467) as cisgender heterosexual women. The majority of participants were European Americans, and almost all were full-time students.

Approximately 2% of the sample had received an eating disorder diagnosis during the past year. In the last month use of vomiting or laxatives was reported by 3% (n=8054), while diet pills were used by 3%. The highest rate for self-reported eating disorder diagnosis and past-month use of diet pills and vomiting or laxative use was found among transgender students. Past-year ED diagnosis was more common in cisgender sexual minority men and cisgender sexual orientation unsure men and women than among heterosexual women.

Some possible reasons for higher risk among transgender patients

Several factors could help explain the findings, according to the authors. Transgender individuals may use disordered eating behaviors to suppress or to accentuate particular gendered features. Minority stress has also been identified as a potential factor in the association between transgender identity and disordered eating. Among lesbian, gay, and bisexual persons, a strong connection has been drawn between higher levels of minority stress and poorer mental health outcomes (Am J Public Health. 2001; 91:927). Transgender students who are uncertain of their sexual orientation may experience even more minority stress, and thus be more at risk for disordered eating. Finally, an earlier study showed that 75% of transgender participants had received counseling for their gender identity concerns (National Center for Transgender Equality and National Gay and Lesbian Task Force; Washington, DC, 2001). This level of contact with mental health clinicians would provide more opportunities to make an ED diagnosis.

Dr. Diemer and her colleagues feel their study findings can serve as “an important starting place for future investigations” into the increased risk of eating disorders among transgender individuals. The authors are correct that longitudinal studies with more comprehensive assessments will aid in the development of effective, targeted prevention and treatment approaches.