Eating Disorders Among Queer and Trans Individuals: Implications for Conceptualization, Assessment, and Treatment

Abstract

Eating disorders (EDs) have been traditionally viewed as a disorder affecting cisgender, heterosexual women. Yet, the prevalence of EDs among queer and trans (QnT) individuals, coupled with the lack of interventions that attend to contextual factors related to sexual orientation and gender identity, underscore a critical health disparity issue requiring urgent attention. Here, we first review factors pertaining to QnT individuals’ minoritized sexual and gender identities that are important to consider in ED conceptualization for this population (e.g., minority stressors, identity-based body image standards). Next, we describe problematic assumptions present in existing ED assessment and propose more inclusive approaches. Lastly, we provide suggestions for practices that providers can implement within their treatment of EDs among QnT individuals.

I. Introduction

Eating disorders (EDs) are serious psychiatric illnesses that significantly impair individuals’ quality of life (de Vos et al., 2017), cause medical complications (Rome & Ammerman, 2003), and confer risk for premature death through physical illness or death by suicide (Chesney et al., 2014). EDs are characterized by behavioral (e.g., restriction of food intake, binge eating, compensatory behaviors) and cognitive-affective (e.g., overvaluation of weight and shape, fear of weight gain) symptoms (American Psychiatric Association, 2013). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013) recognizes several EDs. This review focuses on anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, and other specified feeding and eating disorders. Diagnostically, EDs are distinguished by body mass index, behavior type and frequency, and weight/shape disturbance. However, aside from avoidant/restrictive food intake disorder (characterized by a lack of weight/shape disturbance), all ED symptoms (e.g., weight/shape disturbance; restriction; binge/purge behaviors) may present across the spectrum of ED diagnoses (Melles & Jansen, 2023).

EDs are highly prevalent, such that over 28 million Americans will experience an ED during their lifetime (Deloitte Access Economics, 2020). Global prevalence rate range between 2–13.5%, which has more than doubled in recent decades (Galmiche et al., 2019). The severity of EDs has increased in the wake of COVID-19, such that more individuals with EDs are requiring inpatient hospitalization and longer durations of care (Asch et al., 2021). Importantly, COVID-19 may have further exacerbated existing health disparities among queer and trans individuals (Sampogna et al., 2022), which may explain increases in disordered eating behaviors within this population during this time (Hart et al., 2022). Additionally, COVID-19 may have increased ED risk through more exposure to diet culture content on social media platforms (Rodgers et al., 2020). Though individuals of all genders and sexual orientations may be harmed by the pervasive nature of diet culture, diet culture may have a layered meaning for QnT individuals, such that QnT folks experience pressure to have a body accepted by society in order to be more broadly accepted for their identity (Jordan, 2023). Among presumably cisgender individuals, the lifetime prevalence of meeting criteria for any ED among women is 8.4% and 2.2% for men, with other specified feeding and eating disorders being the most common (Table 1; Galmiche et al., 2019). Anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding and eating disorders usually onset in late teens to early 20’s (Kessler et al., 2013; Mustelin et al., 2016), while avoidant/restrictive food intake disorder typically onsets in childhood or adolescence (i.e., four to 13 years of age; Coglan & Otasowie, 2019). EDs co-occur with other mental disorders at high rates (i.e., up to 95%), with anxiety and depressive disorders being the most common co-occurring disorders (Hudson et al., 2007).

Table 1.

Eating Disorder (any diagnosis) Prevalence (%) by Gender Identity and Sexual Orientation

	Gender Identity
Sexual Orientation	Cisgender Men	Cisgender Women	Transgender Men	Transgender Women	Genderqueer or Non-Conforming Persons	Gender Expansive Persons
Heterosexual	<0.5–21	1–31	4.02	5.42	1.42	12.52
Gay/Lesbian	1.73–144	6.63–34.74	9.62	1.42	9.72	13.02
Bisexual	1.3–3.23	5.9–8.83	11.52	8.82	7.52	14.12
Queer	––	––	20.12	12.52	15.32	18.22
Another Sexual Orientation	2.93	2.4–3.73	11.52	5.62	8.52	8.82

Note. Gender Expansive refers to people who are agender, genderfluid, non-binary. Another Sexual Orientation refers to pansexual, asexual, and questioning.

¹Reported by Hudson et al., 2007. Diagnoses obtained via the World Health Organization Composite International Diagnostic Interview. Sample comprised U.S. adults (N = 9282).

²Reported by Simone et al., 2022. Self-reported lifetime eating disorder diagnosis. Sample comprised U.S. college students (N = 5057).

³Reported by Simone et al., 2020. Self-reported lifetime eating disorder diagnosis. Sample comprised U.S. college students (N = 13584).

⁴Reported by Bell et al., 2019. Self-reported lifetime eating disorder diagnosis. Sample comprised U.S. queer and trans adults (N = 267).

I.a. EDs among Queer and Trans (QnT) Individuals

EDs present in individuals of all sexual orientations (Parker & Harriger, 2020) and genders (Diemer et al., 2018). However, white, cisgender, heterosexual women are overrepresented in the ED literature (Burnette et al., 2022). In recent years, more empirical work has examined EDs among samples with diverse sexual and gender identities. Collectively, this research suggests that queer and trans (QnT; i.e., individuals with minoritized sexual orientations and/or gender identities) individuals have EDs at disproportionately high rates compared to cisgender, heterosexual individuals (Table 1; Diemer et al., 2018; Simone et al., 2020), indicating that EDs are a health disparity issue that may be understood in the context of cis-heteronormativity. Specifically, among cisgender adults, queer individuals are at two to four times the odds of meeting criteria for an ED relative to heterosexual counterparts (Kamody et al., 2019), with similar disparities found among adolescents (Schvey et al., 2021). Among trans adults, over 10% of binary trans men, 6–8% of binary trans women, and 9–12% of nonbinary individuals self-report an ED diagnosis (Diemer et al., 2018; Simone et al., 2022). Though minimal research has examined ED prevalence at the intersection of sexual orientation and gender identity, ED risk may differ along these axes (e.g., queer trans men present greater ED risk than heterosexual trans men; Simone et al., 2022).

I.b. Purpose of the Current Review

The focus of this review concerns EDs among QnT individuals. While a comprehensive review is beyond the scope of the present paper, the current review aims to distill key findings from extant ED research among QnT individuals to better equip clinicians to deliver culturally responsive care. First, we review sexual orientation and gender identity considerations in the conceptualization of EDs. Second, we describe factors that should be included in ED assessment among QnT people. Lastly, we provide actionable steps clinicians can implement within their practice to center clients’ sexual orientation and gender identity within ED treatments.

II. Identity Considerations in Eating Disorder Conceptualization

QnT individuals may experience shared and unique factors pertinent to ED onset and maintenance in relation to their cisgender, heterosexual counterparts. For example, risk factors for development of EDs in QnT populations include depression, internalized cis-heterosexism, low sense of belongingness, and low self-compassion and are common across subgroups (Beccia, Reynolds, Agénor, Charlton, & Austin, 2023; Bell, Rieger, & Hirsch, 2019). Subgroups of QnT populations may face additional risk factors specific to their sexual orientation and gender identity (e.g., perceived stigma, discrimination). Minority stress theory (Brooks, 1981; Meyer, 2003) posits that QnT individuals are at increased risk of physical and mental health problems due to the experience of these added proximal (e.g., internalized cis-heterosexism) and distal (e.g., discrimination, harassment) stressors. Among queer individuals, proximal and distal minority stressors are associated with greater eating pathology (Brewster et al., 2014).

Discrimination-based trauma is a strong predictor of eating pathology, particularly for ongoing exposure to discrimination and oppression (Urban et al., 2023). Among cisgender queer adults, high compared to low exposure to identity-based systems of oppression and discrimination yielded five times the odds of being diagnosed with anorexia nervosa (Kamody et al., 2019). Such discrimination is also positively associated with ED pathology among trans men (Velez et al., 2016) and trans women (Brewster et al., 2019). This ongoing discrimination and internalization of messaging can create proximal stressors for QnT individuals, such as efforts to avoid rejection and violence through identity concealment (Castellini et al., 2023), which may be implicated in EDs (Brewster et al., 2019). QnT individuals may cope with proximal minority stressors through ED symptoms (e.g., reducing affective distress, self-punishment for their identity; Cusack, Iampieri, et al., 2022). Among trans populations, internalized cissexism mitigates improvements in body uneasiness even after pursuing medical transition and reduces perceived ability to respond to appearance pressures with resilience strengths (Castellini et al., 2023).

Bound with systems of oppression, individuals within QnT subgroups may differentially experience pressure to attain a body image ideal to align themselves with their identity and community (e.g., transnormativity; Johnson, 2016). For some QnT individuals, ED symptoms may function to achieve gender congruence or community belongingness. For example, cisgender queer women, may engage in ED behaviors to suppress sexualized body parts or to signal queerness (Simone et al., 2022). Cisgender queer men may use muscularity-oriented ED behaviors to align with specific appearance pressures in the gay community (Lavender et al., 2017). Trans women may experience thinness as affirming, consistent with societal expectations and regulations of women’s bodies (Cusack, Iampieri, et al., 2022). For nonbinary individuals, there is a pressure to be thin and attain a waifish, prepubescent ‘boy’ shape (Cusack, Iampieri, et al., 2022). Nonbinary individuals additionally report that shifts in gender expression may alleviate some sources of gender dysphoria while amplifying others, causing heightened gender-related distress (Galupo, Pulice-Farrow, et al., 2021). Notwithstanding these identity-based appearance pressures, it is critical that providers not over-pathologize some behaviors, especially in the context of increasingly barred access to gender affirming medical care. Common pitfalls that clinicians may encounter if they are not approaching ED treatment from this QnT-informed lens include, but are not limited to, encouraging acceptance of gendered body parts that do not align with clients’ identities (Hartman-Munick et al., 2021), removing opportunity to experience gender euphoria through mindful movement and/or gender expression, and inaccurate conceptualizations of the purpose behaviors serve in regulating emotions stemming from minority stressors (Cusack, Iampieri et al., 2021).

Despite the myriad of risk factors, QnT populations also have unique resilience strengths that present opportunities to prevent the development of EDs. Self-compassion has been shown to be protective against stigma and discrimination, yielding improved well-being in both cisgender gay men and gender diverse adults (Bell et al., 2019). Additionally, subverting traditional appearance norms may also serve as a protective factor against EDs (Bell et al., 2019). Awareness of stigmatizing or discriminatory experiences, self-advocacy skills, connection to community, and the understanding of sexual and gender identities as ever evolving and rightfully diverse have been shown to be protective for the mental health of trans youth of color (Singh, 2013). Further research is needed to better understand and leverage these resilience factors to buffer ED risk in QnT populations.

III. Identity Considerations in ED Assessment

A limitation of efforts to diminish psychological health disparities is the lack of psychometrically strong assessments for use with socially minoritized populations (Jones et al., 2019). Like other presentations of psychopathology, EDs occur within the biopsychosocial context (Burke et al., 2020). Yet, existing ED assessments make minimal reference to cultural and identity-based factors that may influence ED onset, maintenance, and/or symptom presentation, and in turn ignore the relevance of such constructs. It is important to consider that leading ED assessments were developed with the intention of assessing only anorexia nervosa and bulimia nervosa, with some consideration of binge eating behavior, in young (presumably cisgender) women (Cooper & Fairburn, 1987; Stice et al., 2000). Moreover, widely used instruments assessing ED pathology (e.g., the Eating Disorder Examination Questionnaire; Fairburn & Beglin, 1994) are grounded in assumptions that body image disturbance presents in the form of fear of weight gain and drive for thinness, which centers a white, cisgender viewpoint (Hartman-Munick et al., 2021). Though these factors may be relevant for some QnT individuals (Simone et al., 2023), failure to assess additional factors unique to an individual’s gender identity and sexual orientation may result in undetected cases and inaccurate ED conceptualizations, meaning that our estimates of EDs in these populations are likely an underestimate.

To date, ED assessment for QnT populations with strong psychometric properties is lacking (Hartman-Munick et al., 2021). ED assessment that attends to the nuance of QnT identity-based experiences may elucidate more accurate conceptualizations of the function that ED symptoms serve. This point is critical in providing more affirming, effective ED treatment and prevention efforts (Jones et al., 2019). Body image dissatisfaction is one of the most robust risk factors for EDs (Levine & Piran, 2004), yet body image norms are typically gendered. QnT individuals may transgress body image standards imposed by cisgender, heterosexual individuals (McGuire et al., 2016). This subversion is not necessarily pathological, and it may be affirming (Galupo, Cusack, et al., 2021). The risk is when any internalized body image ideal is unattainable without engaging in extreme eating, weight, and shape control behaviors. Thus, ED assessments may better measure ED risk and symptomology among QnT individuals by assessment of the internalization of any specific unattainable appearance ideal rather than centering thinness or any other one dimensional ideal (e.g., muscular ideal, androgynous ideal).

ED assessment among QnT individuals should include exploration of if and how one’s ED relates to a client’s feeling of identity-based affirmation and/or internalized stigma. For example, for QnT individuals, stereotypical body image pressures (e.g., thinness, muscularity; Convertino et al., 2022; Hazzard et al., 2019) and identity-specific factors (e.g., internalized cis-heterosexism) may explain variance in ED pathology (Brewster et al., 2019; Convertino et al., 2021). However, these findings are complicated by documented differences within QnT subgroups. For instance, for cisgender queer individuals, greater involvement within the queer community has been shown to be associated with greater ED symptoms (Convertino et al., 2021). Relatedly, gendered risk factors for EDs (e.g., sexual objectification) among bisexual and lesbian women (Brewster et al., 2014; Morrison et al., 2020) have been shown to be negatively associated with ED pathology for trans women (Brewster et al., 2019). These findings underscore that assessment should aim to capture ED-related risk and resilience factors for the individual client in context of their identities. For example, a more thorough ED assessment may include questions that gauge individuals’ historic and current experience with minority stressors (e.g., internalized cis-heterosexism, discrimination) and if/how they perceive these experiences relating to their ED. For example, if a patient admits to experiencing a lack of safety in their neighborhood, a clinician may follow up with questions about whether the patient alters their body size or gender expression to avoid anticipated safety concerns. This type of assessment may inform treatment aimed at improving healthier coping—rather than relying on ED symptoms—or capitalizing on internal strengths. This type of discussion on minority stressors could be integrated to tailor evidence-based treatments.

IV. Centering Identity in Evidence-Based Eating Disorder Treatment

QnT individuals often face significant structural barriers to accessing ED treatment (Hartman-Munick et al., 2021). When QnT individuals do receive ED treatment, they often report poor treatment quality relative to cisgender, heterosexual individuals (Penwell et al., 2023). Because EDs have been conceptualized from the experiences of cisgender, heterosexual women (Thapliyal et al., 2018), ED treatment reflects corresponding biases. For example, when asked about their experiences in ED treatment, many QnT individuals report that treatment pushed acceptance of gendered secondary sex characteristics, unpacking body image and desirability through a cis-heterosexual male gaze, and involved inappropriate acknowledgement of clients’ gender identity (Cusack, Levenson, et al., 2022; Hartman-Munick et al., 2021). To avoid continued harm of QnT individuals in ED treatment and to provide more culturally responsive care, below, we offer suggestions for centering client’s gender identity and sexual orientations, as relevant, within their ED treatment.

The American Psychological Association (APA) has created guidelines for providing competent psychological care for QnT individuals (APA, 2015, 2021), which are intended to be applied across presenting concerns, including EDs. APA guidelines state that therapists should seek to understand the experiences of QnT individuals, educate themselves on institutionalized cisheterosexism (e.g., minority stressors), and dismantle monosexual, heterosexual, and cisgender binary assumptions. Provider attention to systems of power and oppression is at the foundation of these guidelines (Budge & Moradi, 2018). For example, institutions grant privilege to certain genders and sexual orientations (i.e., heterosexual, cisgender individuals) that positions QnT individuals at a disadvantage, which may warrant the clinician validating QnT individuals’ experience and affirming their identity.

Provider affirmation of a client’s identities is critical. When therapy affirms a client’s gender identity and sexual orientation and attends to systems of power and oppression, QnT individuals evidence reductions in internalizing symptoms (Tebbe & Budge, 2022). Concerningly, some trans and nonbinary individuals report that providers never asked about their gender identity (Hartman-Munick et al., 2021), and approximately 40% of trans and nonbinary individuals seeking ED treatment conceal their trans identity with their provider (Duffy et al., 2016). When trans and nonbinary clients have disclosed their gender identity in ED treatment, some individuals reported that their gender identity was ignored, or they were put in a position to have to educate their provider on gender (Cusack, Levenson, et al., 2022; Hartman-Munick et al., 2021). Affirming QnT identities is an ongoing process that can be implemented as early as initial phone calls and intake questions (Pachankis et al., 2022). For example, staff can be trained not to assume gender from the sound of a voice on a phone and intake sheets can include inclusive language asking about QnT identities and experiences with minority stressors (Pachankis et al., 2022). Providers can affirm clients by acknowledging the harm of cis-heteronormativity (e.g., individual and systemic prejudice, discrimination, and assumptions that all individuals are and should be cisgender and/or heterosexual; Budge & Moradi, 2018) and disrupting it in the therapy room (Anzani et al., 2019). In an ED therapeutic context, cis-heteronormativity may look like assuming that QnT’s body image concerns function similarly to cisgender heterosexual women without exploration. At the structural level, providers can affirm QnT clients through engagement in advocacy that addresses systemic issues implicated in ED prevalence and treatment disparities experienced among QnT individuals (Horne, 2020).

Affirming the lived experience of QnT individuals in ED treatment also requires attending to gender identity and sexual orientation when relevant, while not overemphasizing identity-factors when not applicable (Cusack, Levenson, et al., 2022). When relevant to the client, ED treatments may benefit from addressing the role of stigma and self-compassion (Bell et al., 2019). This approach may be especially helpful for when ED symptoms function as a means of managing internalized cis-heterosexism (e.g., self-punishment for one’s identity). More specifically, for queer and trans people who seek medical transition, interventions that address internalized cis-sexism, in combination with gender-affirming treatment, may be particularly helpful in reducing feelings of shame and guilt (Castellini et al., 2023), which are core to ED pathology (Williams & Levinson, 2022). Indeed, prior research shows that addressing internalized stigma among QnT clients may reduce shame associated with internalized cis-heterosexism (Skerven et al., 2019).

More research is needed on how to adapt existing interventions (e.g., mirror exposure) for QnT clients before concrete recommendations can be provided as to avoid harm (e.g., focus on acceptance of body characteristics inducing gender dysphoria; Hartman-Munick et al., 2021). In cognitive-behavioral therapy enhanced (Fairburn, 2008) and exposure therapy for EDs (Butler & Heimberg, 2020), patients perform behavioral experiments or exposures to approach feared and avoided foods, clothes, physical sensations, situations, etc. When ED symptoms intersect with QnT identity, clinicians should assess the risk of invalidation or compromised safety in these treatments. For example, if a trans person restricts their food intake to associate themselves with gendered ideals, a clinician may consider exploring coordination with gender affirming care, if desired, accessing gender-affirming supplies, connecting with social supports and community, and engaging in other activities that align with one’s gender expression and identity. Additionally, it can be useful to work with patients to co-create understanding about the origins of appearance ideals, the cost of pursuing such ideals, and the natural size and shape diversity among both cisgender and transgender people. In cases where ED symptoms function as punishment or to regulate emotions, clinicians may consider interventions focused on experiencing, tolerating, and effectively responding to distress or interventions that promote self-compassion, while acknowledging how systems of oppression may be the catalyst or context in which these emotions and symptoms emerged. The examples here, though not exhaustive of all of the ED symptoms or functions ED symptoms may serve, are intended to be starting places to help clinicians conceptualize and treat EDs through a QnT-informed lens to promote ED recovery.

In addition, ED treatments should identify and draw on clients’ identity-based strengths. Providers can leverage clients’ resources across individual, interpersonal, and community levels to alleviate distress and promote wellbeing (Tebbe & Budge, 2022). Indeed, internal strengths (e.g., eschewing binary gender roles), social supports, and involvement in QnT advocacy can function as protective factors against ED pathology (Parker & Harriger, 2020). Further, gender euphoria (i.e., feeling joy in one’s gender) is a protective factor for psychopathology among QnT individuals (Tebbe & Budge, 2022). Providers can work with QnT clients to promote resiliency factors within ED treatment through locating affirming community resources, practicing affirming self-talk, and increasing authenticity and gender euphoria (e.g., modifying hair and clothing style, accessing gender affirming medical treatments; Beischel et al., 2022; Cusack, Iampieri, et al., 2022).

V. Conclusion

EDs among QnT individuals are alarmingly common. As leading conceptualizations and treatments of EDs are largely informed by the experiences of cisgender, heterosexual women, extant tools may be inadequate in meeting the needs of QnT individuals seeking ED treatment. Overall, there is consensus in the need for providers to educate themselves on the lived experiences of QnT individuals and assess clients’ experiences in context of minority stressors (Parker & Harriger, 2020; Tebbe & Budge, 2022). However, caution is needed as QnT individuals’ gender identity and sexual orientation may not be implicated in their ED (Cusack, Levenson, et al., 2022; Hartman-Munick et al., 2021). For example, if a client indicates that their QnT identity is not related to their ED during the assessment, the clinician should explore other potential maintenance factors rather than continually raising the client’s identity as a point of focus in treatment. As such, providers must unpack their potential biases, prioritize understanding the client’s experience, and educate themselves on how gender and sexual orientation may be relevant for addressing EDs among QnT individuals.

This review has several notable limitations. First, this paper is narrowly focused on QnT individuals without attention to intersecting identities. Eating, weight, and shape concerns (and gender euphoria) are influenced by and negotiated through factors beyond gender identity and sexual orientation (e.g., race; Beischel et al., 2022; Burke et al., 2020, 2022). For example, body image satisfaction may vary by racial identity, and include facets of body image that are not related to weight or shape (e.g., skin tone, privilege granted to white and lighter skin tones; Tran et al., 2020; Winter et al., 2019). Qualitative work on body image among gay and bisexual cisgender men has found participants differentiate body image ideals by race (e.g., “White bears” and “Black bears”), people of color compared their bodies to dominant ideals (e.g., White, lean muscularity), and queer men commonly report appearance-based stigma based on race and/or weight-status (Tran et al., 2020). QnT individuals of color may experience race-, gender-, and sexual orientation-based discrimination and prejudice that together exacerbate body image and eating concerns (Gonzales & Blashill, 2021) and should be considered in future ED research and treatment, especially as these intersecting identities position individuals at social locations with varying degrees of access to ED treatment (Penwell et al., 2023). Second, ED research (including the work cited in this review) has predominantly recruited samples with anorexia nervosa and bulimia nervosa. Future research should investigate the function, assessment, and treatment of binge eating disorder, other specified feeding and eating disorders, and avoidant/restrictive food intake disorder among QnT individuals to inform more effective, culturally responsive interventions. Lastly, though this review attempted to highlight QnT strengths and resilience, most QnT ED research to date has focused on determining prevalence and risk (Burke et al., 2020). This focus makes sense given the dearth of literature among QnT individuals, yet an important next step is understanding resilience factors that can inform ED prevention and intervention efforts for QnT individuals. This direction aligns with calls for strength-based approaches rather than deficit approaches to ED treatment, specifically for clients with marginalized identities (Burke et al., 2020).

The field is long overdue in its need to expand ED conceptualizations and treatments to reflect the lived experience of QnT individuals. It is essential for providers to assess the function that EDs serve, in light of potential minority stressors or identity-based appearance ideals. Though gender identity and sexual orientation may not be relevant to ED symptoms for all QnT individuals, this initial step, along with affirming identities (e.g., asking about identities, using correct pronouns) is needed in providing more culturally responsive ED treatment. Lastly, we suggest that providers adopt a strengths-based approach that draws from and builds upon the unique internal, social, and community resources associated with QnT individuals’ identities.