Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Feb 1.
Published in final edited form as: Int J Eat Disord. 2023 Nov 21;57(2):303–315. doi: 10.1002/eat.24092

Bias-based bullying, self-esteem, queer identity pride, and disordered eating behaviors among sexually and gender diverse adolescents

Samantha E Lawrence 1,2,*, Ryan J Watson 3, Hana-May Eadeh 1, Camille Brown 4, Rebecca M Puhl 3,5, Marla E Eisenberg 1
PMCID: PMC10922269  NIHMSID: NIHMS1942880  PMID: 37990394

Abstract

Objective.

Limited research incorporates an intersectional approach when evaluating disordered eating behaviors among those holding minoritized social positions, such as lesbian, gay, bisexual, queer, questioning, and/or transgender/gender diverse (LGBTQ) adolescents. The current study assessed stigma experiences from peers at school, self-esteem, LGBTQ pride, and overlapping social positions as they relate to disordered eating behaviors among LGBTQ adolescents.

Method.

Participants included 11,083 adolescents (Mage=15.6, SD=1.3; 34.8% transgender/gender diverse) from a large national survey study of LGBTQ adolescents from 2017. Exhaustive Chi-square Automatic Interaction Detection analysis was used to identify bias-based bullying experiences (i.e., weight-based, identity-based), self-esteem, LGBTQ pride, and overlapping social positions (i.e., gender identity, sexual identity, race/ethnicity, body mass index (BMI) percentile) associated with the highest prevalence of unhealthy weight control behaviors, extreme unhealthy weight control behaviors, and past year binge eating.

Results.

Adolescents in the 28 identified groups with a high prevalence of disordered eating behavior held at least one structurally marginalized social position (e.g., high BMI), bias-based bullying experience, low self-esteem, or low LGBTQ pride in addition to being LGBTQ. Weight-based bullying was a salient risk-factor for disordered eating across social positions. Among adolescents with the same social positions, levels of self-esteem, LGBTQ pride, but no bias-based bullying experience, prevalence estimates of disordered eating were, on average, 23% lower.

Discussion.

LGBTQ adolescents with multiple marginalized social positions and related factors engage in disproportionately high prevalence disordered eating. Findings underscore the importance of addressing intersecting experiences of stigma to reduce disordered eating and promote health equity among adolescents.

Keywords: Disordered eating behaviors, stigma, intersectionality, adolescence, youth of color, minority stress

Introduction

Adolescence is a developmental period during which disordered eating behaviors—unhealthy behaviors such as fasting or purging—are prevalent (Neumark-Sztainer et al., 2011; Stice et al., 2009). However, adolescents with certain marginalized social positions are disproportionately affected by disordered eating due to stigma, discrimination, and other minority stressors (Brooks, 1981; Hendricks & Testa, 2012; Meyer, 1995, 2003). For instance, compared to their heterosexual and cisgender peers, adolescents who identify as lesbian, gay, bisexual, queer, or questioning their sexual identity and/or transgender, gender diverse, or questioning their gender identity (LGBTQ) engage in significantly higher rates of disordered eating than their cisgender and heterosexual peers (Austin et al., 2013; Guss et al., 2017; Parker & Harriger, 2020; Roberts et al., 2021, 2022; Watson et al., 2016).

Minority Stress and Intersectionality Theory

Interpersonal and structural stigma operate as key social determinants of health disparities faced by marginalized adolescents. Minority Stress Theory (Brooks, 1981; Hendricks & Testa, 2012; Meyer, 1995, 2003) posits that LGBTQ identities are stigmatized and, as a result, LGBTQ individuals endure chronic distal (e.g., bias-based bullying) and proximal (e.g., internalized LGBTQ stigma, low LGBTQ pride) stressors above and beyond those experienced by their heterosexual and cisgender peers. These minority stressors place LGBTQ adolescents at risk for poor health and well-being via multiple proposed pathways, including engagement in health risk behaviors as coping or avoidance strategies (Bockting et al., 2020; Eisenberg et al., 2022; McDonald, 2018; Meyer, 2003; Röder et al., 2018).

Importantly, LGBTQ adolescents are a heterogenous population and may experience co-occurring social and structural forces of privilege or oppression based on their social positions (e.g., a transgender person of color’s overlapping experiences of cissexism and racism) (Cyrus, 2017; Lett et al., 2020). Scholars increasingly call for attention to intersectionality—how individuals experience systems of oppression depending on their social identities—including in the context of eating disorders research (Burke et al., 2020). Intersectionality theory, developed from Black feminist scholarship and activism (Crenshaw, 1991), is a critical theoretical framework that posits that an individual’s social positions (e.g., sexual identity, gender identity, racial/ethnic identity, weight status) are mutually constitutive, such that they cannot be disentangled, and together create nuanced individual experiences. These individual experiences are also reflective of broader structural systems that disadvantage and privilege (e.g., via heterosexism, cissexism, racism, sizeism) (Conover & Israel, 2019; López & Gadsen, 2016; Parent et al., 2013). Intersectionality theory has important implications for health equity research. However, few studies to date consider LGBTQ adolescents’ multiple overlapping social positions as they relate to disordered eating and other health risk behaviors and, among those that do, many leverage analytic approaches that are limited in their ability to consider social positions as mutually constitutive (Bauer, 2014; Bauer et al., 2021; Burke et al., 2020).

Disparities in Disordered Eating Behaviors

Findings from population-based studies of adolescents in the United States (U.S.) highlight disordered eating disparities, primarily across singular marginalized social positions. For instance, rates of fasting to lose weight are nearly three times higher among sexually minoritized adolescents compared to their heterosexual peers, and rates of diet pill use or purging for weight loss are about five times higher among lesbian/gay adolescents compared to heterosexual adolescents (Watson et al., 2016). Transgender/gender diverse adolescents likewise had significantly elevated odds of fasting for more than 24 hours, using diet pills, and taking laxatives (adjusted odds ratios: 2.9-8.9 after adjusting for age, race/ethnicity, and body mass index) compared to cisgender adolescents (Guss et al., 2017). These and other health disparities can be tied to persistent identity-based stigma, discrimination, and oppression LGBTQ youth may face (Hendricks & Testa, 2012; Meyer, 2003).

Despite increasing research attention to heterogeneity of disordered eating behaviors within LGBTQ populations (Austin et al., 2013; Beccia et al., 2021; Hazzard et al., 2020; Roberts et al., 2021; Watson et al., 2016), many studies group LGBTQ youth into broad categories (Parker & Harriger, 2020), with little attention paid to LGBTQ adolescents’ other overlapping social positions which may operate in nuanced ways to impact disordered eating (Bowleg, 2008; Burke et al., 2020; McEntee et al., 2021). Indeed, evidence suggests that disordered eating behaviors may also vary by social positions such as racial and/or ethnic identity (Beccia et al., 2019; Smith et al., 2020) and body weight (Nagata et al., 2018; Rodgers et al., 2017), and that youth with certain marginalized social positions (e.g., Hispanic/Latinx ethnicity, high body weight) may disproportionately engage in disordered eating (Beccia et al., 2019; Nagata et al., 2018; Rodgers et al., 2017) as coping responses to minority stressors (Himmelstein et al., 2019a; Hunger et al., 2020; Hunger & Tomiyama, 2018). Disordered eating may be especially prevalent among adolescents with multiple marginalized social positions (e.g., high body weight and minoritized sexual identity) due to overlapping experiences of marginalization and minority stress (e.g., sizeism and heterosexism) (Beccia et al., 2019, 2021), though a dearth of studies consider more than two of adolescents’ overlapping social positions.

Psychosocial factors, such as low self-esteem and low LGBTQ pride (i.e., negative affect about LGBTQ identity), have also been implicated in disordered eating in adolescence (Espinoza et al., 2019; Parker & Harriger, 2020; Roberts et al., 2022). LGBTQ adolescents with low LGBTQ pride and/or low self-esteem may engage in disordered eating to cope with these proximal stressors and may be particularly vulnerable to poor health sequalae of distal stressors, such as bias-based bullying. Bullying victimization is likewise associated with disordered eating (Himmelstein et al., 2019a; Lee & Vaillancourt, 2018, 2019), and bias-based bullying (i.e., bullying that targets specific characteristics, such as racial and/or ethnic identity; sexual identity; gender identity or gender expression; or body weight) may be especially harmful for LGBTQ adolescents’ health (Russell et al., 2012). Despite extant evidence of the relevance of these psychosocial factors and bias-based bullying experiences to disordered eating, it is unclear whether these factors may be differentially relevant to disordered eating when examined in conjunction with one another and multiple overlapping social positions. For instance, Roberts et al.’s (2022) findings from the same dataset as the present study underscore the relevance of self-esteem to disordered eating behaviors (i.e., self-esteem associated with decreased odds of disordered eating). The present analysis examines the relevance of self-esteem as part of a confluence of other factors for LGBTQ+ youth reporting the highest prevalence of disordered eating. Elucidating these nuances may inform intervention and prevention efforts.

The Current Study

The present study builds on prior research (Austin et al., 2013; Beccia et al., 2019, 2021), including previous work with this dataset that identified general- and LGBTQ-specific psychosocial factors related to disordered eating (Roberts et al., 2022), to identify characteristics of adolescents with the highest prevalence of disordered eating behaviors. Specifically, the present analysis uses a novel quantitative approach to intersectional research (Bauer et al., 2021; Shaw et al., 2011) to examine adolescents’ experiences with three categories of disordered eating behaviors (i.e., unhealthy weight control behaviors, extreme unhealthy weight control behaviors, binge eating). Indicators include stigma from peers at school (i.e., weight- and identity-based bullying), self-esteem, LGBTQ pride, and overlapping social positions (i.e., gender identity, sexual identity, racial/ethnic identity, body mass index (BMI) percentile).

Method

Participants and Procedures

Participants in the present analysis were a subsample of adolescents (n=11,083) drawn from a large national study of LGBTQ adolescents who participated in the LGBTQ National Teen Survey (N=17,112). The LGBTQ National Teen Survey, an anonymous, cross-sectional survey of LGBTQ adolescents’ health and interpersonal experiences, was hosted online by Qualtrics.com from April to December 2017 in collaboration with the Human Rights Campaign (HRC). Recruitment consisted of both paid advertisements and free posts on social media platforms (e.g., Twitter, Facebook, Instagram), partnerships with community-based organizations affiliated with HRC (e.g., Youth Link) who shared the study opportunity with their members, and school-based organizations (e.g., gender sexuality alliances). Inclusion criteria for the broader study were that adolescents identified as LGBTQ; were 13-17 years old; resided in the United States; and spoke English. Participants in the analytic sample lived in all 50 states, ranging from 13 participants in Wyoming to 1,085 in California. Study procedures, including a waiver of parental consent, were approved by the University of Connecticut Institutional Review Board. Adolescents provided informed assent and received a small gift. Additional details on recruitment, data collection, and screening are reported elsewhere (Watson et al., 2020).

Measures

Gender Identity

Participants reported their sex assigned at birth (“What sex were you assigned at birth?”; response options: male, female) and current gender identity (“What is your current gender identity? Please select all that apply.”; response options: male, female, trans male/trans boy, trans female/trans girl, non-binary, gender queer/gender nonconforming, or different identity). Participants who selected “different identity” could then describe their current gender identity in a text box; these responses were reviewed and categorized as applicable with matching response options previously provided (e.g., trans female/trans girl), or left as “other.”

Based on participants’ responses to these two items, a 6-option gender identity variable was created. Specifically, adolescents for whom sex assigned at birth and current gender identity were concordant were coded as “cisgender girls” or “cisgender boys.” Adolescents assigned female at birth who identified their gender as “male” and/or “trans male/trans boy” were coded as “transgender boys,” and adolescents assigned male at birth who identified their gender as “female” and/or “trans female/trans girl” were coded as “transgender girls.” Adolescents assigned female at birth who identified as “non-binary” and/or “gender queer/gender nonconforming” were coded as “transmasculine/non-binary,” and adolescents assigned male at birth who selected either of these identities were coded as “transfeminine/non-binary.” For this gender identity variable, non-binary and gender queer/gender nonconforming identities superseded any binary identities participants may have also selected.

Sexual Identity

Participants reported their sexual identity in response to the survey item: “How do you describe your sexual identity?” Response options were: “gay or lesbian,” “bisexual,” “straight, that is, not gay,” or “something else.” If participants selected “something else,” they were presented with five additional response options: “queer,” “pansexual,” “asexual,” “questioning,” and “other.” Participants who selected “other” could then describe their sexual identity in a text box; these responses were reviewed and categorized as applicable with matching response options previously provided (e.g., queer), or left as “other.”

Racial/ethnic identity

Participants reported their racial/ethnic identity in response to the survey item: “How would you describe yourself? (Select all that apply).” Response options were: “White, non-Hispanic,” “Non-Latino Black or African American,” “American Indian or Alaska Native,” “Asian or Pacific Islander,” “Latino, Hispanic, or Mexican American,” and “other.” Participants who selected only one racial or ethnic identity were coded as that identity label. Participants who selected more than one racial and/or ethnic identity were coded as “bi/multiracial.” Participants who selected “other” could then describe their current racial and/or ethnic identity in a text box; these responses were reviewed and categorized as applicable with corresponding response options previously provided (e.g., German was reclassified as White), or left as “other.”

Body Mass Index (BMI) Percentile

BMI percentiles were tabulated using the Centers for Disease Control and Prevention growth charts (Kuczmarski et al., 2002) and participants’ self-reported height (in feet/inches), weight (in pounds), age, and sex assigned at birth. BMI percentiles were categorized as follows: <5th percentile, ≥5th <85th percentile, 85th-95th percentile, and ≥95th percentile for age and assigned sex.(Kuczmarski et al., 2002)

Bias-based Bullying Victimization

Participants reported the frequency with which they experienced several forms of bias-based bullying from peers. Specifically, respondents answered the following items: “How often have you been teased or treated badly by other students at your school because of your…” 1) body weight, 2) gender, 3) race/ethnicity, 4) sexuality, and 5) masculinity or femininity. Participants responded to each item on a 5-point scale ranging from Never to Very often. Experiences of bias-based bullying were collapsed into two dichotomous variables: weight-based bullying victimization (item 1 above; having ever experienced weight-based bullying=1, having never experienced weight-based bullying=0) and identity-based bullying victimization (items 2-5 above; having ever experienced any of the above forms of identity-based bullying=1, having never experienced any of the above forms of identity-based bullying=0).

General Self-esteem

Participants responded to the 10-item Rosenberg Self-Esteem Scale (Rosenberg, 1965), a measure validated with adolescents (Bagley & Mallick, 2001) (current sample α=.90) which poses positive and negative self-statements assessing adolescents’ general self-esteem (e.g., “I feel that I am a person of worth, at least on an equal plane with others.”) on a 4-point scale where 0=Strongly disagree and 3=Strongly agree. Five negative self-statements were reverse-coded and a mean score was computed; higher scores indicate higher general self-esteem. For the present analysis, general self-esteem was dichotomized as high (=1) if participants scored at or above the 75th percentile (i.e., a mean score of at least 1.90), or low (=0) if they scored below the 75th percentile.

LGBTQ+ Pride

Participants responded to four positive and negative statements about their LGBTQ+ pride (e.g., “I am proud to be part of the LGBTQ community”) on a 4-point scale where 0=Strongly disagree and 3=Strongly agree. The three negative statements were reverse-coded and a mean score was computed; higher scores indicate more pride in adolescents’ LGBTQ+ identity (current sample α=.78). For the present analysis, LGBTQ+ pride was dichotomized as high (=1) if participants scored at or above the 75th percentile (i.e., a mean score of at least 2.75), or low (=0) if they scored below the 75th percentile.

Disordered Eating

Participants reported the frequency with which they engaged in nine unhealthy weight control behaviors on a 4-point scale, from 0=Never to 3=On a regular basis in the past year. As has been done in prior work with adolescents (Didericksen et al., 20180201; Neumark-Sztainer et al., 2010), these behaviors were collapsed into two categories: 1) unhealthy weight control behaviors (e.g., skipping meals; using food substitutes, such as powders or drinks) and 2) extreme unhealthy weight control behaviors (i.e., using diet pills, laxatives, or diuretics; self-induced vomiting). Responses were dichotomized; having engaged in one or more unhealthy weight control behaviors at least “sometimes” (versus “never” or “rarely”) and having engaged in one or more extreme unhealthy weight control behaviors at least “rarely” (versus “never”) were indicators of disordered eating in the present analyses (see Supplemental Table 1 for prevalence of specific unhealthy and extreme unhealthy weight control behaviors). Whereas engaging in extreme unhealthy weight control behaviors even rarely may be indicative of disordered eating, rarely engaging in unhealthy weight control behaviors (e.g., using a meal replacement), may not be. Indeed, most participants (73.9%) reported engaging in unhealthy weight control behaviors at least “rarely” (compared to 57.8% who did so at least “sometimes”).

Participants also responded to a series of questions related to their binge eating in the past year. First, participants responded to the following dichotomous (yes/no) item: “In the past year, have you ever eaten so much food in a short period of time that you would be embarrassed if others saw you (binge eating)?” Participants who responded “yes” that they had “binge eaten” were presented with a dichotomous (yes/no) follow-up item: “During the times when you ate this way, did you feel you couldn’t stop eating or control what or how much you were eating?” Participants who reported “yes” to this item then responded to a third and final item assessing frequency of binge eating with loss of control; response options were 1=Less than once a month, 2=A few times a month, 3=A few times a week, 4=Nearly every day. Responses to this third and final item were dichotomized, and binge eating at least monthly (versus never or less than once a month) was an indicator of disordered eating in the present analyses.

Statistical Analysis

Descriptive analyses were conducted for social position, bias-based bullying victimization, self-esteem, LGBTQ pride, and disordered eating behavior variables. Next, exhaustive Chi-square Automatic Interaction Detection (CHAID) analyses were conducted (with ten-fold cross-validation and a Bonferroni correction to avoid overfitting) to identify bias-based bullying experiences, levels of self-esteem and LGBTQ pride, and overlapping social positions associated with the highest prevalence of disordered eating. A separate exhaustive CHAID model was conducted for each of our three dependent variables of interest. Of note, there is not an agreed upon method for incorporating an intersectional framework in quantitative analysis (Else-Quest & Hyde, 2016; Weber & Castellow, 2012). However, CHAID has been recommended as a quantitative method for intersectional analyses with moderate to large samples (Mahendran et al., 2022), and has a number of advantages, including its ability to run numerous interaction tests concurrently, compared to regression models which may not be powered to do so. Another advantage of exhaustive CHAID is that it retains missing data for each independent variable in a “missing” category.

Exhaustive CHAID is a data-driven, nonparametric, decision-tree approach used to identify which intersecting categorical independent variables have the strongest associations with dependent variables (Kass, 1980; Shaw et al., 2011). This approach systematically cycles through all categorical independent variables (i.e., social positions, bias-based bullying experiences, self-esteem, and LGBTQ pride), splitting between categories where significant differences are detected in the prevalence of dependent variables (i.e., disordered eating behaviors). This process of testing every intersection of every independent variable with respect to the dependent variable is repeated until no further statistically significant splits can be made given the established p-value (p < .05) and minimum node size (40). These final groups in the decision tree, called “terminal nodes,” do not differ significantly with respect to the dependent variable.

As an example, the first significant split in the decision tree for extreme weight control behaviors was weight-based bullying. From there, the tree further branched separately within each weight-based bullying response category (ever experienced in the last 30 days, never experienced in the last 30 days, missing). Among participants who experienced weight-based bullying, for instance, independent variables were assessed and the categories with the most significant difference in prevalence of extreme weight control behaviors were identified (i.e., self-esteem level), resulting in further branching of the tree by that categorical variable. This procedure occurred separately for each weight-based bullying category and continued until terminal nodes were reached. In doing so, the branches highlight unique patterns of bias-based bullying experiences, self-esteem levels, LGBTQ+ pride levels, and overlapping social positions that are associated with the prevalence of extreme weight control behaviors (see the decision trees in Supplemental Figures 1-3).

The ten terminal nodes with the highest prevalence of each disordered eating behavior category (except for binge eating, where there were only eight terminal nodes with prevalence above the overall sample average) are presented in Tables 2-4; in total, we report on 28 high prevalence groups across the three disordered eating behavior categories of interest. Index scores were calculated for each terminal node to demonstrate the proportion of adolescents with those bullying experiences, psychosocial factors, and social positions engaging in disordered eating behaviors relative to the overall sample same mean (index score=prevalence of disordered eating behavior in a given terminal node/prevalence of disordered eating behavior in overall sample*100). Follow-up Chi-square analyses were conducted with comparison groups with the same social positions, self-esteem, and LGBTQ pride, but no weight- or identity-based bullying victimization to determine the contributions of these stigmatizing experiences.

Table 2.

Groups with highest prevalence of unhealthy weight control behaviors at least ‘sometimes’ in last year (overall=58.3%)

Sample
size		 Racial
and/or
ethnic
identity		 Gender
identity		 BMI
percentile		 Weight-
based
bullying		 Identity-
based
bullying		 Self-
esteem		 LGBTQ
pride		 Prevalence
(%)		 Index
score (%)		 Prevalence
without
BBB (%)
898 — Trans boy, Transmasc/NB 3, 4 Yes, missing Yes, missing Low — 85.7 147.0 54.5
846 — Cis girl 3, 4 Yes, missing Yes, missing Low — 80.7 138.4 56.6
124 — Cis girl, trans boy — Yes — Missing — 79.8 136.9 42.9
1,781 — Cis girl, trans boy, transmasc/NB, trans girl 2, missing Yes, missing Yes Low — 73.5 126.0 44.1
405 — Cis boy, trans girl, transfem/NB 3, 4 Yes, missing Yes, missing Low — 73.3 125.8 36.0
233 Bi/multiracial, Middle Eastern/Arab, Hispanic/Latina/x/o, Native American, Black, Other — — Missing — Missing — 67.4 115.6 N/A
137 — — 3, 4 Yes, missing No Low — 65.7 112.7 52.4
154 — — 4 Yes, missing — High Low 65.6 112.5 35.7
209 — Cis girl, trans boy, trans girl, transmas/NB 2, missing Yes, missing No, missing Low — 62.7 107.5 44.1
404 — Cis boy, transfem/NB 2, missing Yes, missing — Low — 59.9 102.7 32.5
Open in a new tab

Note. Ten highest prevalence nodes included. A cell with a “—” in the table indicates that the branch in the decision tree that terminated in the node reported on did not split by that variable. In other words, a “—” represents all categories for that variable.

None of the decision trees that terminated in these ten nodes split by sexual identity and, thus, this predictor has been omitted from the exhaustive CHAID tables. An example of how to interpret the first row in the table: 85.7% of transgender boys and transmaculine/nonbinary youth with a BMI ≥85th percentile who experienced weight- and identity-based bullying (or were missing for these items) and had low self-esteem—across racial/ethnic identities, sexual identities, and levels of LGBTQ+ pride—reported using unhealthy weight control behaviors at least “sometimes” in the past year. BMI=body mass index. LGBTQ=lesbian, gay, bisexual, transgender, gender diverse, queer, and/or questioning. BBB=bias-based bullying. Cis=cisgender. Trans=transgender. Transmasc/NB=transmasculine/non-binary. Transfem/NB=transfeminine/non-binary. N/A=not applicable. BMI Percentiles: 1=<5th, 2=≥5th-<85th, 3=85th-95th, and 4=95th+.

Table 4.

Groups with highest prevalence of binge eating with loss of control at least monthly in the past year (overall=30.4%)

Sample
size		 Racial
and/or
ethnic
identity		 Gender
identity		 BMI
percentile		 Weight-
based
bullying		 Identity-
based
bullying		 Self-
esteem		 LGBTQ
pride		 Prevalence
(%)		 Index
score (%)		 Prevalence
without
BBB (%)
1,286 — — 4 Yes — Low — 54.9 180.8 35.0
61 — Transgirl, transfem/NB 2 Yes — Low, missing — 54.1 178.1 11.1
841 — — 3, missing Yes — Low, missing Low 48.6 160.1 25.3
300 — — 3, missing Yes — Low, missing High, missing 40.0 131.7 28.6
283 — — 3, 4 Missing — — — 39.6 130.3 N/A
335 — — 4 Yes — High, missing — 36.1 118.9 13.9
2,077 — Cis girl, trans boy, transmasc/NB, cis boy 2 Yes — Low, missing — 33.4 110.0 17.9
586 — — 3, 4 No — Low, missing — 32.9 108.4 N/A
Open in a new tab

Note. Top 8 highest prevalence nodes included (only 8 nodes had a disordered eating prevalence above the sample mean). Sexual identity did not emerge in any of the high prevalence nodes and, thus, this predictor has been omitted from the exhaustive CHAID tables. BMI=body mass index. LGBTQ=lesbian, gay, bisexual, transgender, gender diverse, queer, and/or questioning. BBB=bias-based bullying. Cis=cisgender. Trans=transgender. Transmasc/NB=transmasculine/non-binary. Transfem/NB=transfeminine/non-binary. N/A=not applicable. BMI Percentiles: 1=<5th, 2=≥5th-<85th, 3=85th-95th, and 4=95th+.

Results

Characteristics of the Sample

Overall, 11,083 adolescents (64.8% of full sample) responded to at least one survey item related to disordered eating and were included in the analytic sample. Most participants excluded from the analytic subsample responded only to demographic items and were excluded from this analysis using listwise deletion. Participants in the analytic subsample with missing data for independent variables were retained in analyses and rates of missingness for dependent variables were low (≤1.4%).

Compared to participants excluded from the analytic sample, participants in the analytic sample did not significantly differ in terms of age, but were more likely to be cisgender girls, transgender boys, and transmasculine/non-binary (and less likely to be cisgender boys or transfeminine/non-binary; X2 (5, N=17,112)=183.43, p<0.001); more likely to be non-Hispanic/Latina/x/o White (and less likely to be any other race and/or ethnicity; X2 (7, N=16,521)=250.30, p<0.001); more likely to identify as queer, pansexual, or asexual (and less likely to identify as gay, lesbian, or bisexual; X2 (7, N=17,112)=77.26, p<0.001); more likely to have a BMI percentile <85 (and less likely to have a BMI percentile ≥95; X2 (7, N=15,390)=18.05, p<0.001); less likely to have experienced weight-based bullying (X2 (1, N=11,447)=14.66, p<0.001) or identity-based bullying (X2 (1, N=11,434)=5.13, p<0.5); had lower self-esteem (X2 (1, N=11,505)=16.29, p<0.001); and had higher LGBTQ pride (X2 (1, N=11,198)=4.03, p<0.5). See Table 1 for information on participants’ social positions, experiences of bias-based bullying, self-esteem, and LGBTQ pride.

Table 1.

Characteristics of the analytic sample (N=11,083 adolescents)

M (SD)
Age 15.57(1.27)
N %
Social Positions
Gender identity
 Cisgender boy 2,336 21.1
 Cisgender girl 4,878 44.0
 Transgender boy 958 8.6
 Transgender girl 126 1.1
 Transmasculine/non-binary 2,521 22.7
 Transfeminine/non-binary 264 2.4
Sexual identity
 Gay or lesbian 4,051 36.6
 Bisexual 3,759 33.9
 Straight 180 1.6
 Queer 499 4.5
 Pansexual 1,541 13.9
 Asexual 543 4.9
 Questioning 263 2.4
 Other 247 2.2
Race and/or ethnicity
 NH White 7,265 65.6
 Bi/Multiracial 1,596 14.4
 Latina/x/o, Hispanic, or Mexican American 1,141 10.3
 NH Black or African American 502 4.5
 Asian or Pacific Islander 437 3.9
 American Indian or Alaska Native 49 0.4
 Middle Eastern/Arab 38 0.3
 Other 37 0.3
 Missing 18 0.2
BMI percentile categories
 <5th 460 4.2
 ≥5th-<85th 6,210 56.0
 85th-95th 1,847 16.7
 ≥95th 2,100 18.9
 Missing 466 4.2
Risk/protective Factors
Experienced weight-based bullying
 Yes 5,943 53.6
 No 4,225 38.1
 Missing 915 8.3
Experienced identity-based bullying (about racial/ethnic identity, sexual identity, gender identity/expression)
 Yes 8,900 80.3
 No 1,256 11.3
 Missing 927 8.4
Self-esteem
 ≥75th percentile 2,650 23.9
 <75th percentile 7,536 68.0
 Missing 897 8.1
LGBTQ pride
 ≥75th percentile 2,898 26.1
 <75th percentile 7,092 64.0
 Missing 1,093 9.9
Disordered Eating Behaviors
Unhealthy weight control behaviors (in last year)
 Never/rarely 4,583 41.7
 Sometimes/On a regular basis 6,411 58.3
Extreme unhealthy weight control behaviors (in last year)
 Never 8,138 74.4
 Ever 2,794 25.6
Binge eating with loss of control (in last year)
 Never/Less than once a month 7,616 69.6
 At least once a month 3,322 30.4
Open in a new tab

Note. M=mean. SD=standard deviation. N=sample size. NH=non-Hispanic. LGBTQ=lesbian, gay, bisexual, transgender, gender diverse, queer, and/or questioning.

Disordered eating behaviors were prevalent (see Table 1). Over half the sample (57.8%) reported engaging in unhealthy weight control behaviors at least sometimes in the past year, 25.2% reported engaging in extreme unhealthy weight control behaviors in the past year, and 30.0% reported engaging in binge eating with a loss of control at least monthly in the past year.

Stigma Experiences, Self-Esteem, LGBTQ Pride, and Overlapping social positions Associated with Highest Prevalence of Disordered Eating

Several patterns were observed with respect to bullying experiences, psychosocial factors, and overlapping social positions consistently associated with high prevalence of disordered eating behaviors (see Tables 2-4 and Supplemental Figures 1-3). First, multiply marginalized adolescents (i.e., adolescents who reported at least one marginalized social position in addition to being LGBTQ) were a part of all 28 high prevalence groups across all three categories of disordered eating behaviors, and most also reported an experience of bias-based bullying, low self-esteem, and/or low LGBTQ pride. For example, 85.7% of transgender boys and transmasculine/non-binary adolescents with a BMI ≥ 85th percentile, who experienced weight- and identity-based bullying, and had low self-esteem, engaged in unhealthy weight control behaviors—a prevalence nearly one-and-a-half times the sample average. Similarly, 45.7% of LGBTQ adolescents with a BMI ≥ 95th percentile, who experienced weight- and identity-based bullying, and had low self-esteem and LGBTQ pride, engaged in extreme unhealthy weight control behaviors—a prevalence nearly double the overall sample average.

Second, weight-based bullying emerged in 22 of the 28 high prevalence groups across all three categories of disordered eating behaviors—more often than any other individual social position, psychosocial factor, or bias-based bullying experience included in these models. Participants in five high prevalence groups reported experiencing both weight- and identity-based bullying. In comparison groups of adolescents with the same social positions, level of self-esteem, and level of LGBTQ pride but no bias-based bullying experience, prevalence of disordered eating was 6.0-43.0% lower (average difference: −22.7%). For example, whereas 73.3% of cisgender boys, transgender girls, or transfeminine/non-binary adolescents with BMIs ≥85th percentile, low self-esteem, and who experienced weight- and identity-based bullying (or were missing for bias-based bullying) engaged in unhealthy weight control behaviors, only 36.0% of adolescents with these same social positions but no bias-based bullying experience reported unhealthy weight control behaviors (more than 20% lower than the overall sample average prevalence). Likewise, the prevalence of binge-eating with loss of control was approximately five times higher among transgender girls and transfeminine/non-binary adolescents with BMIs ≥5th-<85th percentile and low self-esteem (or who were missing for self-esteem) who experienced weight-based bullying (54.1%) compared to those who did not experience weight-based bullying (11.1%).

Third, weight-based bullying, low self-esteem, low LGBTQ pride, and six social positions (i.e., transgender boys, cisgender girls, transmasculine/non-binary adolescents, transfeminine non-binary adolescents, and those participants with BMIs in the 85-95th percentiles or BMIs ≥ 95th percentile) were associated with high prevalence of all three categories of disordered eating behaviors. Weight-based bullying (78.6% of high-risk groups), BMIs ≥ 85th percentile (71.4% of high-risk groups), low self-esteem (71.4% of high-risk groups), and transgender/gender diverse identities (35.7% of high-risk groups) most commonly emerged in these high prevalence groups, often concurrently. Notably, across exhaustive CHAID models, the decision tree branches that terminated in high prevalence disordered eating nodes only split by racial/ethnic identity once, and did not split by sexual identity at all.

Discussion

Ample evidence highlights disparities in disordered eating behaviors among LGBTQ adolescents (Guss et al., 2017; Panza et al., 20200806; Parker & Harriger, 2020; Roberts et al., 2021, 2022; Watson et al., 2016) and youth with other marginalized social positions (Beccia et al., 2019; Nagata et al., 2018; Smith et al., 2020), yet disordered eating remains understudied from an intersectional perspective (Burke et al., 2020; McEntee et al., 2021). Using exhaustive CHAID, a novel approach to intersectional quantitative research (Bauer et al., 2021; Shaw et al., 2011), and a large national sample of LGBTQ youth, the current study examined experiences of bias-based bullying, self-esteem, LGBTQ pride, and four overlapping social positions as they relate to three categories of disordered eating. Consistent with extant literature (Calzo et al., 2018; Hadland et al., 2014; Miller & Luk, 2019), disordered eating was highly prevalent among LGBTQ adolescents in the present sample. However, disordered eating prevalence varied depending on adolescents’ stigma experiences from peers at school, self-esteem, LGBTQ pride, and overlapping social positions. Findings provide insight into intersecting experiences of stigma that may elevate disordered eating risk for LGBTQ adolescents and highlight potential points of intervention.

In line with prior research on disordered eating using an intersectional approach (Beccia et al., 2021), LGBTQ+ adolescents who reported two or more marginalized social positions were part of all the highest prevalence groups in the present study. Multiply marginalized adolescents may face compounding pressures and stressors related to their gender identity (e.g., socially reinforced ideas about gendered body shape and size ideals, gender dysphoria (Calzo et al., 2016; Romito et al., 2021)) and weight (e.g., weight-based bullying (Himmelstein et al., 2019a)), among other social positions, that may intersect in unique ways to exacerbate disordered eating risk. For example, gender identity was most salient in high prevalence groups where adolescents had a BMI in the 5th-85th percentiles. Adolescents in high prevalence groups who had BMIs in the 5th-85th percentiles were typically cisgender girls or transgender/gender diverse.

Compared to cisgender men, cisgender women and transgender/gender diverse individuals experience more body-related distress—including internalization of “thin ideals,” body monitoring and shame, and appearance comparison—regardless of weight (Strübel et al., 2020). These internal processes may be compounded by distal minority stressors, such as the current political climate regarding LGBTQ identities (e.g., anti-trans legislation), which may further heighten LGBTQ adolescents’ vulnerability to disordered eating as a coping mechanism. Accordingly, cisgender girls and transgender/gender diverse adolescents with BMIs in the 5th-85th percentiles may engage in more disordered eating behaviors than cisgender boys in the same BMI category (Romito et al., 2021). Cultivating more weight- (e.g., school wellness programs that emphasize health rather than weight) and gender-inclusive school norms (e.g., using adolescents’ chosen name and correct pronouns regardless of how a person’s body conforms to gender expectations) may help mitigate these disparities (Lessard & Lawrence, 2022; Pollitt et al., 2021; Russell et al., 2018; Vantieghem & Van Houtte, 2020). To illustrate, evidence suggests that some transgender/gender diverse adolescents engage in disordered eating behaviors to prevent or delay pubertal development and/or cope with gender-related distress (e.g., gender dysphoria) (Coelho et al., 2019; Roberts et al., 2021; Romito et al., 2021), but that body image and disordered eating may improve when their gender identity is affirmed consistently (Roberts et al., 2021; Testa et al., 20170403). Future research should further explore the potentially buffering role of gender affirmation, and other inclusive school practices, in disordered eating behaviors.

Findings from this study not only highlight the need for further intersectional research in this area, but for disordered eating intervention and prevention efforts to attend to gender identity, BMI, bias-based bullying, self-esteem, and LGBTQ pride. For example, adolescents in most high prevalence groups experienced weight-based bullying (sometimes in conjunction with identity-based bullying), indicating that weight-based bullying is a salient risk-factor for disordered eating across social positions. Indeed, among groups of adolescents with the same social positions and risk factors, but no bias-based bullying, prevalence of disordered eating was as much as 43% lower—in most cases at or below the overall sample prevalence. Findings are consistent with prior work implicating bias-based bullying in disordered eating and other health risk behaviors (Himmelstein et al., 2019a; Reisner et al., 2014; Russell et al., 2012), and highlight the importance of school-based efforts to reduce bias-based bullying by peers. Enumerating characteristics that can heighten adolescents’ vulnerability to victimization (e.g., LGBTQ identity, high body weight) in anti-bullying policies (Kull et al., 2015; Lessard & Lawrence, 2022; Saewyc et al., 2014) and establishing gender and sexuality alliances (Gower et al., 2020; Lessard et al., 2020) are two low-cost strategies found to reduce bias-based bullying, and may help mitigate disordered eating disparities among singly and multiply marginalized youth.

Results of the present study also have important implications for practice and assessment, particularly for those that are multiply marginalized and/or transgender/gender diverse. First, youth experiencing weight-related bullying, high body weight, and/or who are gender diverse would likely benefit from regular screenings of disordered eating during primary care or mental health visits (Duffy et al., 2021; Pham et al., 2022). Further, specifically for gender diverse youth, there is an added layer of the overlap of gender dysphoria and weight-related concerns that may differentially impact disordered eating behaviors compared to cisgender youth (e.g., restrictive eating or overeating to change body shape related to looking more like an affirmed gender presentation). Using body neutrality approaches for transgender/gender diverse youth may be particularly important given the multifaceted sources of potential distress (Perry et al., 2019). Transgender/gender diverse youth require additional support from affirming and specially trained mental and physical health care providers that understand both gender dysphoria and weight stigma-related concerns.

Despite evidence of sexual identity-based disparities in disordered eating among adolescents (Calzo et al., 2018; Parker & Harriger, 2020), sexual identity did not emerge in any high risk prevalence groups in the present study. It may be that, among a predominantly LGBQ sample of adolescents with an overall high prevalence of disordered eating, sexual identity was not the most salient disordered eating risk factor. Adolescents who are stigmatized for their more visible identities and characteristics, such as gender identity and body weight, may be especially likely to engage in disordered eating behaviors aimed at conforming to socially reinforced gender expectations for body weight, shape, and size (Coelho et al., 2019; Himmelstein et al., 2019b; Romito et al., 2021). Future longitudinal intersectional research should examine whether sexual identity becomes increasingly salient for disordered eating risk across adolescence and into young adulthood (Hazzard et al., 2020), and/or in the context of relationships when expectations for how one “should” look to a partner may impact eating behaviors.

Limitations and Future Directions

Using a large, racially/ethnically diverse national sample of LGBTQ adolescents and a novel quantitative approach recommended for intersectional research (Bauer et al., 2021; Shaw et al., 2011), the current study extends the literature base by examining bias-based bullying experiences, psychosocial factors, and four overlapping social positions as they relate to disordered eating behaviors. Despite this study’s strengths, findings should be interpreted in the context of several limitations. First, these cross-sectional, self-reported data are subject to response bias and causality cannot be examined. Longitudinal research is needed to understand how bullying experiences, psychosocial factors, and overlapping social positions impact disordered eating behaviors over time. In particular, research is needed to further elucidate the specific social and structural factors (beyond weight- and identity-based bullying) underlying disparities in disordered eating, as dismantling oppressive systems is imperative to promoting health equity. Indeed, individuals’ identities themselves are not “risk factors” for disordered eating; rather, oppressive (e.g., cissexist, sizeist) systems need to be dismantled to eliminate disordered eating disparities.

Second, the measure of LGBTQ pride used in the current study was developed for the LGBTQ National Teen Survey (Watson et al., 2020); future validation of this measure is needed to determine its effectiveness. Third, although gender identity was considered in the present study, specific levels of gender dysphoria and associated harms were not captured—an important avenue for future research. Fourth, some disordered eating items (e.g., “using food substitutes”) are vague, and collapsing items into unhealthy versus extreme unhealthy weight control behaviors—which is a common approach in related studies—may obscure patterns by specific behaviors. Similarly, collapsing participants who selected two or more racial/ethnic identities into a bi/multiracial group is reductionist and may obscure important intragroup variation. Future research should explore these nuances. Fifth, despite the advantages of exhaustive CHAID retaining participants with missing data for independent variables in the analytic sample, it can be challenging to interpret nodes characterized by missing data.

Conclusion

Multiply marginalized adolescents—especially adolescents who experienced weight-based bullying, had high body weight, had low self-esteem, and/or identified as transgender/gender diverse—were consistently represented in the high prevalence disordered eating groups. These findings highlight the need to better understand and address stigma and psychosocial correlates among adolescents with multiple intersecting marginalized social positions in order to reduce disordered eating. Future intersectional research is needed to elucidate additional social and structural factors across contexts (e.g., in schools, healthcare settings) that may underlie disordered eating disparities. In the meantime, efforts to combat bias-based bullying and promote more inclusive school climates (e.g., inclusive of weight and gender diversity) are essential to dismantle systems of oppression that foster disordered eating disparities.

Supplementary Material

Supinfo2
Supinfo1

Table 3.

Groups with highest prevalence of any extreme weight control behaviors in the last year (overall=25.6%)

Sample
size		 Racial
and/or
ethnic
identity		 Gender
identity		 BMI
percentile		 Weight-
based
bullying		 Identity-
based
bullying		 Self-
esteem		 LGBTQ
pride		 Prevalence
(%)		 Index
score (%)		 Prevalence
without
BBB (%)
897 — — 4 Yes Yes Low Low 49.1 191.9 22.0
328 — Trans boy, trans girl 2, 3, missing Yes — Low — 45.7 178.9 16.1
178 — — 4 Missing — — — 42.7 167.1 N/A
2,363 — Cis girl, transmasc/NB, transfem/NB 2, 3, missing Yes — Low — 34.5 134.9 14.8
317 — — 4 Yes — Low High, missing 34.4 134.5 23.5
204 — — 1, 2, 3, missing Missing — Low — 32.4 126.6 N/A
280 — — 4 Yes — High — 29.6 116.0 10.0
62 — — 4 Yes No, missing Low Low 27.4 107.3 21.4
201 — — — Yes — Missing — 27.2 107.1 14.8
184 — — 4 No — Low, missing — 26.8 106.3 N/A
Open in a new tab

Note. Top 10 highest prevalence nodes included. Sexual identity did not emerge in any of the high prevalence nodes and, thus, this predictor has been omitted from the exhaustive CHAID tables. BMI=body mass index. LGBTQ=lesbian, gay, bisexual, transgender, gender diverse, queer, and/or questioning. BBB=bias-based bullying. Cis=cisgender. Trans=transgender. Transmasc/NB=transmasculine/non-binary. Transfem/NB=transfeminine/non-binary. N/A=not applicable. BMI Percentiles: 1=<5th, 2=≥5th-<85th, 3=85th-95th, and 4=95th+.

Public Significance Statement:

Multiply marginalized LGBTQ+ adolescents, most of whom also reported experiencing bias-based bullying from peers at school, reported disproportionately high prevalence disordered eating. In comparison groups of adolescents with no bias-based bullying experience, prevalence of disordered eating was, on average, 24% lower. Findings underscore the importance of addressing intersecting experiences of stigma to reduce disordered eating and promote health equity among adolescents.

Acknowledgements:

This research uses data from the LGBTQ National Teen Study, designed by Ryan J. Watson and Rebecca M. Puhl in collaboration with the Human Rights Campaign, and supported by the Office for Vice President of Research at the University of Connecticut. The authors acknowledge the important contributions of Ellen Kahn, Gabe Murchison, and Liam Miranda in their support, conceptualization, and management related to the 2017 LGBTQ Teen Study. PIQTOC (Protection at the Intersections for Queer Teens of Color) coinvestigators, including Dr. Lisa Bowleg, Dr. Ana María del Río-González, Dr. Nic Rider, and Dr. Stephen T. Russell, contributed to the overall study from which this manuscript is derived.

Funding Sources:

Research reported in this publication was in part funded by the Office of Vice President for Research at the University of Connecticut (PIs: R.J.W., R.M.P.) and was supported by the National Institute on Minority Health and Health Disparities under Award Number R01MD015722 (PI: M.E.E.). R.J.W. acknowledges support from the National Institute on Drug Abuse grant K01DA047918. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Sponsors had no role in the study design; collection, analysis, and interpretation of data; writing of the report; or decision to submit the manuscript for publication.

Footnotes

Conflict of Interest Statement: No competing financial interests exist.

Data Availability Statement:

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

  1. Austin SB, Nelson LA, Birkett MA, Calzo JP, & Everett B (2013). Eating disorder symptoms and obesity at the intersections of gender, ethnicity, and sexual orientation in US high school students. American Journal of Public Health, 103(2), e16–e22. 10.2105/AJPH.2012.301150 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Bagley C, & Mallick K (2001). Normative data and mental health construct validity for the Rosenberg Self-Esteem Scale in British adolescents. International Journal of Adolescence and Youth, 9(2–3), 117–126. 10.1080/02673843.2001.9747871 [DOI] [Google Scholar]
  3. Bauer GR (2014). Incorporating intersectionality theory into population health research methodology: Challenges and the potential to advance health equity. Social Science & Medicine, 110, 10–17. 10.1016/J.SOCSCIMED.2014.03.022 [DOI] [PubMed] [Google Scholar]
  4. Bauer GR, Churchill SM, Mahendran M, Walwyn C, Lizotte D, & Villa-Rueda AA (2021). Intersectionality in quantitative research: A systematic review of its emergence and applications of theory and methods. SSM - Population Health, 14, 100798. 10.1016/J.SSMPH.2021.100798 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Beccia AL, Baek J, Austin SB, Jesdale WM, & Lapane KL (2021). Eating-related pathology at the intersection of gender identity and expression, sexual orientation, and weight status: An intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) of the Growing Up Today Study cohorts. Social Science & Medicine, 281, 114092. 10.1016/j.socscimed.2021.114092 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Beccia AL, Baek J, Jesdale WM, Austin SB, Forrester S, Curtin C, & Lapane KL (2019). Risk of disordered eating at the intersection of gender and racial/ethnic identity among U.S. high school students. Eating Behaviors, 34, 101299. 10.1016/J.EATBEH.2019.05.002 [DOI] [PubMed] [Google Scholar]
  7. Bockting WO, Miner MH, Romine RES, Dolezal C, Robinson B. “Bean” E., Rosser BRS, & Coleman E (2020). The Transgender Identity Survey: A measure of internalized transphobia. LGBT Health, 7(1), 15–27. 10.1089/LGBT.2018.0265 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Bowleg L. (2008). When Black + Lesbian + Woman ≠ Black Lesbian Woman: The methodological challenges of qualitative and quantitative intersectionality research. Sex Roles, 59(5–6), 312–325. 10.1007/s11199-008-9400-z [DOI] [Google Scholar]
  9. Brooks VR (1981). The theory of minority stress. Minority Stress and Lesbian Women, 77–85. [Google Scholar]
  10. Burke NL, Schaefer LM, Hazzard VM, & Rodgers RF (2020). Where identities converge: The importance of intersectionality in eating disorders research. International Journal of Eating Disorders, 53(10), 1605–1609. 10.1002/eat.23371 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Calzo JP, Austin SB, & Micali N (2018). Sexual orientation disparities in eating disorder symptoms among adolescent boys and girls in the United Kingdom. European Child & Adolescent Psychiatry, 27(11), 1483–1490. 10.1007/s00787-018-1145-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Calzo JP, Sonneville KR, Scherer EA, Jackson B, & Austin SB (2016). Gender conformity and use of laxatives and muscle-building products in adolescents and young adults. Pediatrics, 138(2), e20154073. 10.1542/peds.2015-4073 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Coelho JS, Suen J, Clark BA, Marshall SK, Geller J, & Lam P-Y (2019). Eating disorder diagnoses and symptom presentation in transgender youth: A scoping review. Current Psychiatry Reports, 21(11), 107. 10.1007/s11920-019-1097-x [DOI] [PubMed] [Google Scholar]
  14. Conover KJ, & Israel T (2019). Microaggressions and social support among sexual minorities with physical disabilities. Rehabilitation Psychology, 64(2), 167–178. 10.1037/rep0000250 [DOI] [PubMed] [Google Scholar]
  15. Crenshaw KW (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Rev, 43(6), 1241–1299. 10.2307/1229039 [DOI] [Google Scholar]
  16. Cyrus K. (2017). Multiple minorities as multiply marginalized: Applying the minority stress theory to LGBTQ people of color. Journal of Gay & Lesbian Mental Health, 21(3), 194–202. 10.1080/19359705.2017.1320739 [DOI] [Google Scholar]
  17. Didericksen KW, Berge JM, Hannan PJ, Harris SM, MacLehose RF, & Neumark-Sztainer D (2018February01). Mother-father-adolescent triadic concordance and discordance on home environment factors and adolescent disordered eating behaviors. Families, Systems, & Health, 36(3), 338. 10.1037/fsh0000325 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Duffy ME, Calzo JP, Lopez E, Silverstein S, Joiner TE, & Gordon AR (2021). Measurement and construct validity of the Eating Disorder Examination Questionnaire Short Form in a transgender and gender diverse community sample. Psychological Assessment, 33(5), 459–463. 10.1037/pas0000996 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Eisenberg ME, Gower AL, Watson RJ, Rider GN, Thomas D, & Russell ST (2022). Substance use behaviors among LGBTQ+ youth of color: Identification of the populations bearing the greatest burden in three large samples. Journal of Adolescent Health. 10.1016/J.JADOHEALTH.2022.04.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Else-Quest NM, & Hyde JS (2016). Intersectionality in quantitative psychological research: II. Methods and techniques. Psychology of Women Quarterly, 40(3), 319–336. 10.1177/0361684316647953 [DOI] [Google Scholar]
  21. Espinoza P, Penelo E, Mora M, Francisco R, González ML, & Raich RM (2019). Bidirectional relations between disordered eating, internalization of beauty ideals, and self-esteem: A longitudinal study with adolescents. The Journal of Early Adolescence, 39(9), 1244–1260. 10.1177/0272431618812734 [DOI] [Google Scholar]
  22. Gower AL, Watson RJ, Erickson DJ, Saewyc EM, & Eisenberg ME (2020). LGBQ youth’s experiences of general and bias-based bullying victimization: The buffering role of supportive school and community environments. International Journal of Bullying Prevention 2020 3:2, 3(2), 91–101. 10.1007/S42380-020-00065-4 [DOI] [Google Scholar]
  23. Guss CE, Williams DN, Reisner SL, Austin SB, & Katz-Wise SL (2017). Disordered weight management behaviors, nonprescription steroid use, and weight perception in transgender youth. Journal of Adolescent Health, 60(1), 17–22. 10.1016/J.JADOHEALTH.2016.08.027 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hadland SE, Austin SB, Goodenow CS, & Calzo JP (2014). Weight misperception and unhealthy weight control behaviors among sexual minorities in the general adolescent population. Journal of Adolescent Health, 54(3), 296–303. 10.1016/j.jadohealth.2013.08.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Hazzard VM, Simone M, Borg SL, Borton KA, Sonneville KR, Calzo JP, & Lipson SK (2020). Disparities in eating disorder risk and diagnosis among sexual minority college students: Findings from the national Healthy Minds Study. International Journal of Eating Disorders, 53(9), 1563–1568. 10.1002/eat.23304 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Hendricks ML, & Testa RJ (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43(5), 460–467. 10.1037/A0029597 [DOI] [Google Scholar]
  27. Himmelstein MS, Puhl RM, & Watson RJ (2019a). Weight-based victimization, eating behaviors, and weight-related health in Sexual and Gender Minority Adolescents. Appetite, 141, 104321. 10.1016/j.appet.2019.104321 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Himmelstein MS, Puhl RM, & Watson RJ (2019b). Weight-based victimization, eating behaviors, and weight-related health in Sexual and Gender Minority Adolescents. Appetite, 141. 10.1016/j.appet.2019.104321 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Hunger JM, Dodd DR, & Smith AR (2020). Weight discrimination, anticipated weight stigma, and disordered eating. Eating Behaviors, 37, 101383. 10.1016/j.eatbeh.2020.101383 [DOI] [PubMed] [Google Scholar]
  30. Hunger JM, & Tomiyama AJ (2018). Weight labeling and disordered eating among adolescent girls: Longitudinal evidence from the national heart, lung, and blood institute growth and health study. Journal of Adolescent Health, 63(3), 360–362. 10.1016/j.jadohealth.2017.12.016 [DOI] [PubMed] [Google Scholar]
  31. Kass GV (1980). An Exploratory Technique for Investigating Large Quantities of Categorical Data. Journal of the Royal Statistical Society: Series C (Applied Statistics), 29(2), 119–127. 10.2307/2986296 [DOI] [Google Scholar]
  32. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, & Johnson CL (2002). 2000 CDC Growth Charts for the United States: Methods and development. Vital and Health Statistics. Series 11, Data from the National Health Survey, 246, 1–190. [PubMed] [Google Scholar]
  33. Kull RM, Kosciw JG, & Greytak EA (2015). From statehouse to schoolhouse: Anti-bullying policy efforts in U.S. states and school districts. New York: GLSEN. www.glsen.org [Google Scholar]
  34. Lee KS, & Vaillancourt T (2018). Longitudinal Associations Among Bullying by Peers, Disordered Eating Behavior, and Symptoms of Depression During Adolescence. JAMA Psychiatry, 75(6), 605–612. 10.1001/jamapsychiatry.2018.0284 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Lee KS, & Vaillancourt T (2019). A Four-Year Prospective Study of Bullying, Anxiety, and Disordered Eating Behavior Across Early Adolescence. Child Psychiatry & Human Development, 50(5), 815–825. 10.1007/s10578-019-00884-7 [DOI] [PubMed] [Google Scholar]
  36. Lessard LM, & Lawrence SE (2022). Weight-Based Disparities in Youth Mental Health: Scope, Social Underpinnings, and Policy Implications. Policy Insights from the Behavioral and Brain Sciences, 9(1), 49–56. 10.1177/23727322211068018 [DOI] [Google Scholar]
  37. Lessard LM, Watson RJ, & Puhl RM (2020). Bias-Based Bullying and School Adjustment among Sexual and Gender Minority Adolescents: The Role of Gay-Straight Alliances. Journal of Youth and Adolescence, 49(5), 1094–1109. 10.1007/s10964-020-01205-1 [DOI] [PubMed] [Google Scholar]
  38. Lett E, Dowshen NL, & Baker KE (2020). Intersectionality and Health Inequities for Gender Minority Blacks in the U.S. American Journal of Preventive Medicine, 59(5), 639–647. 10.1016/J.AMEPRE.2020.04.013 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. López N, & Gadsen VL (2016). Health Inequities, Social Determinants, and Intersectionality Health Disparities, Inequity, and Social Determinants: A Brief Context. NAM Perspectives. [Google Scholar]
  40. Mahendran M, Lizotte D, & Bauer GR (2022). Quantitative methods for descriptive intersectional analysis with binary health outcomes. SSM - Population Health, 17, 101032. 10.1016/j.ssmph.2022.101032 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. McDonald K. (2018). Social Support and Mental Health in LGBTQ Adolescents: A review of the literature. 10.1080/01612840.2017.1398283, 39(1), 16–29. 10.1080/01612840.2017.1398283 [DOI] [PubMed] [Google Scholar]
  42. McEntee ML, Serier KN, Smith JM, & Smith JE (2021). The Sum Is Greater than its Parts: Intersectionality and Measurement Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in Latinx Undergraduates in the United States. Sex Roles, 84(1–2), 102–111. 10.1007/s11199-020-01149-7 [DOI] [Google Scholar]
  43. Meyer IH (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36(1), 38–56. 10.2307/2137286 [DOI] [PubMed] [Google Scholar]
  44. Meyer IH (2003). Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychological Bulletin, 129(5), 674–697. 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Miller JM, & Luk JW (2019). A Systematic Review of Sexual Orientation Disparities in Disordered Eating and Weight-Related Behaviors Among Adolescents and Young Adults: Toward a Developmental Model. Adolescent Research Review, 4(2), 187–208. 10.1007/s40894-018-0079-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Nagata JM, Garber AK, Tabler JL, Murray SB, & Bibbins-Domingo K (2018). Prevalence and Correlates of Disordered Eating Behaviors Among Young Adults with Overweight or Obesity. Journal of General Internal Medicine, 33(8), 1337–1343. 10.1007/s11606-018-4465-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Neumark-Sztainer D, Bauer KW, Friend S, Hannan PJ, Story M, & Berge JM (2010). Family weight talk and dieting: How much do they matter for body dissatisfaction and disordered eating behaviors in adolescent girls? Journal of Adolescent Health, 47(3), 270–276. 10.1016/j.jadohealth.2010.02.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Neumark-Sztainer D, Wall M, Larson NI, Eisenberg ME, & Loth K (2011). Dieting and disordered eating behaviors from adolescence to young adulthood: Findings from a 10-year longitudinal study. Journal of the American Dietetic Association, 111(7), 1004–1011. 10.1016/j.jada.2011.04.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Panza E, Fehling KB, Pantalone DW, Dodson S, & Selby EA (2020August06). Multiply marginalized: Linking minority stress due to sexual orientation, gender, and weight to dysregulated eating among sexual minority women of higher body weight. Psychology of Sexual Orientation and Gender Diversity, 8(4), 420. 10.1037/sgd0000431 [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Parent MC, DeBlaere C, & Moradi B (2013). Approaches to Research on Intersectionality: Perspectives on Gender, LGBT, and Racial/Ethnic Identities. Sex Roles 2013 68:11, 68(11), 639–645. 10.1007/S11199-013-0283-2 [DOI] [Google Scholar]
  51. Parker LL, & Harriger JA (2020). Eating disorders and disordered eating behaviors in the LGBT population: A review of the literature. Journal of Eating Disorders 2020 8:1, 8(1), 1–20. 10.1186/S40337-020-00327-Y [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Perry M, Watson L, Hayden L, & Inwards-Breland D (2019). Using body neutrality to inform eating disorder management in a gender diverse world. The Lancet. Child & Adolescent Health, 3(9), 597–598. 10.1016/S2352-4642(19)30237-8 [DOI] [PubMed] [Google Scholar]
  53. Pham AH, Eadeh H-M, Garrison MM, & Ahrens KR (2022). A Longitudinal Study on Disordered Eating in Transgender and Nonbinary Adolescents. Academic Pediatrics, S1876-2859(22)00639–8. 10.1016/j.acap.2022.12.013 [DOI] [PubMed] [Google Scholar]
  54. Pollitt AM, Ioverno S, Russell ST, Li G, & Grossman AH (2021). Predictors and Mental Health Benefits of Chosen Name Use Among Transgender Youth. Youth & Society, 53(2), 320–341. 10.1177/0044118X19855898 [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Reisner SL, Greytak EA, Parsons JT, & Ybarra ML (2014). Gender Minority Social Stress in Adolescence: Disparities in Adolescent Bullying and Substance Use by Gender Identity. 10.1080/00224499.2014.886321, 52(3), 243–256. 10.1080/00224499.2014.886321 [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Roberts SR, Maheux AJ, Watson RJ, Puhl RM, & Choukas-Bradley S (2022). Sexual and gender minority (SGM) adolescents’ disordered eating: Exploring general and SGM-specific factors. International Journal of Eating Disorders, 55(7), 933–946. 10.1002/EAT.23727 [DOI] [PubMed] [Google Scholar]
  57. Roberts SR, Salk RH, Thoma BC, Romito M, Levine MD, & Choukas-Bradley S (2021). Disparities in disordered eating between gender minority and cisgender adolescents. International Journal of Eating Disorders, 54(7), 1135–1146. 10.1002/eat.23494 [DOI] [PubMed] [Google Scholar]
  58. Röder M, Barkmann C, Richter-Appelt H, Schulte-Markwort M, Ravens-Sieberer U, & Becker I (2018). Health-related quality of life in transgender adolescents: Associations with body image and emotional and behavioral problems. International Journal of Transgenderism, 19(1), 78–91. 10.1080/15532739.2018.1425649 [DOI] [Google Scholar]
  59. Rodgers RF, Watts AW, Austin SB, Haines J, & Neumark-Sztainer D (2017). Disordered eating in ethnic minority adolescents with overweight. International Journal of Eating Disorders, 50(6), 665–671. 10.1002/eat.22652 [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Romito M, Salk RH, Roberts SR, Thoma BC, Levine MD, & Choukas-Bradley S (2021). Exploring transgender adolescents’ body image concerns and disordered eating: Semi-structured interviews with nine gender minority youth. Body Image, 37, 50–62. 10.1016/j.bodyim.2021.01.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Rosenberg M. (1965). Rosenberg self-esteem scale (RSE). Acceptance and Commitment Therapy. Measures Package, 61(52), 18. [Google Scholar]
  62. Russell ST, Pollitt AM, Li G, & Grossman AH (2018). Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. Journal of Adolescent Health, 63(4), 503–505. 10.1016/j.jadohealth.2018.02.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  63. Russell ST, Sinclair KO, Poteat PV, & Koenig BW (2012). Adolescent harassment based on discriminatory bias. American Journal of Public Health, 102(3), 493–495. 10.2105/AJPH.2011.300430 [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Saewyc EM, Konishi C, Rose HA, & Homma Y (2014). School-Based Strategies to Reduce Suicidal Ideation, Suicide Attempts, and Discrimination among Sexual Minority and Heterosexual Adolescents in Western Canada. International Journal of Child, Youth & Family Studies : IJCYFS, 5(1), 89. [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Shaw LR, Chan F, & McMahon BT (2011). Intersectionality and Disability Harassment: The Interactive Effects of Disability, Race, Age, and Gender. Rehabilitation Counseling Bulletin, 55(2), 82–91. 10.1177/0034355211431167 [DOI] [Google Scholar]
  66. Smith JM, Smith JE, McLaughlin EA, Belon KE, Serier KN, Simmons JD, Kelton K, Arroyo C, & Delaney HD (2020). Body dissatisfaction and disordered eating in Native American, Hispanic, and White College Women. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, 25(2), 347–355. 10.1007/s40519-018-0597-8 [DOI] [PubMed] [Google Scholar]
  67. Stice E, Marti CN, Shaw H, & Jaconis M (2009). An 8-Year Longitudinal Study of the Natural History of Threshold, Subthreshold, and Partial Eating Disorders From a Community Sample of Adolescents. Journal of Abnormal Psychology, 118(3), 587–597. 10.1037/A0016481 [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Strübel J, Sabik NJ, & Tylka TL (2020). Body image and depressive symptoms among transgender and cisgender adults: Examining a model integrating the tripartite influence model and objectification theory. Body Image, 35, 53–62. 10.1016/j.bodyim.2020.08.004 [DOI] [PubMed] [Google Scholar]
  69. Testa RJ, Rider GN, Haug NA, & Balsam KF (2017April03). Gender confirming medical interventions and eating disorder symptoms among transgender individuals. Health Psychology, 36(10), 927. 10.1037/hea0000497 [DOI] [PubMed] [Google Scholar]
  70. Vantieghem W, & Van Houtte M (2020). The Impact of Gender Variance on Adolescents’ Wellbeing: Does the School Context Matter? Journal of Homosexuality, 67(1), 1–34. 10.1080/00918369.2018.1522813 [DOI] [PubMed] [Google Scholar]
  71. Watson RJ, Adjei J, Saewyc E, Homma Y, & Goodenow C (2016). Trends and Disparities in Disordered Eating Among Heterosexual and Sexual Minority Adolescents. International Journal of Eating Disorders, 50(1), 22–31. 10.1002/eat.22576 [DOI] [PMC free article] [PubMed] [Google Scholar]
  72. Watson RJ, Wheldon CW, & Puhl RM (2020). Evidence of Diverse Identities in a Large National Sample of Sexual and Gender Minority Adolescents. Journal of Research on Adolescence : The Official Journal of the Society for Research on Adolescence, 30 Suppl 2(S2), 431–442. 10.1111/JORA.12488 [DOI] [PubMed] [Google Scholar]
  73. Weber L, & Castellow J (2012). Feminist Research and Activism to Promote Health Equity. [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supinfo2
NIHMS1942880-supplement-Supinfo2.docx (13.7KB, docx)
Supinfo1
NIHMS1942880-supplement-Supinfo1.docx (166.4KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

RESOURCES