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. 2025 Dec 8;34(3):663–675. doi: 10.1002/erv.70065

Age‐Related Trends in Eating‐Pathology Symptoms Among Sexual Minority Adults

Jason M Nagata 1,✉, Christopher D Otmar 1, Char Potes 1, Ken Murakami 1, Jason M Lavender 2,3, Emilio J Compte 4,5, Tiffany A Brown 6, Kelsie T Forbush 7, Annesa Flentje 8,9,10, Micah E Lubensky 8,11, Juno Obedin‐Maliver 10,11,12, Mitchell R Lunn 10,11,13
PMCID: PMC13048739  PMID: 41361934

ABSTRACT

Objective

To examine how eating‐disorder symptoms vary by chronological age and sexual orientation in sexual minority adults.

Method

Cross‐sectional data came from 2062 cisgender sexual minority participants (925 gay men, 573 lesbian women, 116 bi+ men, 448 bi+ women; age = 47.8 years, range = 18–96). Eight subscales from the Eating Pathology Symptoms Inventory were examined. A multivariate multivariable general linear model tested main and interaction effects of age and sexual orientation; significant multivariate multivariable findings were probed with false‐discovery‐rate‐adjusted univariate regressions.

Results

Older age was associated with lower body dissatisfaction, binge eating, and muscle‐building behaviours, but higher cognitive restraint and negative attitudes toward obesity. Age‐by‐group interactions indicated that body dissatisfaction and binge eating were higher among older cisgender bi+ women, whereas muscularity‐oriented behaviours were lower in lesbian and bi+ women compared to gay men. Associations remained after socioeconomic covariate adjustment.

Conclusions

Findings suggested that levels of eating pathology varied based on age and across sexual minority groups. Bi+ women showed increasing body dissatisfaction and binge eating with age, while lesbian and bi+ women reported lower muscularity‐oriented behaviours relative to gay men. Life‐course prevention and treatment strategies should address identity‐specific stress ecologies and the needs of adult sexual minority populations.

Keywords: age, eating disorders, LGBTQIA+, lifespan, sexual minority

Highlights

  • Older cisgender sexual minority adults showed negative associations between age and body dissatisfaction, binge eating, and muscle‐building behaviours, but positive associations between age and cognitive restraint and negative attitudes about obesity.

  • Cisgender lesbian and bi+ women were more likely to report greater body dissatisfaction compared to gay men, with stronger positive associations between age and both body dissatisfaction and binge eating specifically among bi+ women.

  • Muscle‐building behaviours were negatively associated with age overall and were lower among cisgender lesbian and bi+ women relative to gay men, with no evidence of steeper age‐related declines in gay men.

1. Introduction

The intersection of age and disordered eating in sexual minority adults, particularly those in later adulthood, remains largely unexplored, despite clear reasons for concern (Bulut et al. 2019; Lapid et al. 2010; Meneguzzo et al. 2018; Peat et al. 2008). Decades of research established that sexual minority adults face distinct health risks driven by stigma‐related stress and cumulative societal disadvantage over time (Flentje et al. 2025; Frost and Meyer 2023; Hoy‐Ellis 2023; Otmar and Merolla 2024). Yet, empirical work examining disordered eating in midlife and older sexual minority adults is scarce (Convertino et al. 2021; Feldman and Meyer 2007). This gap limits the field's understanding of how disordered eating patterns may differ across the lifespan in these populations (Brandsma 2007; Smith and Goldschmidt 2024; Smolak 2015), and hinders efforts to inform prevention, intervention, and policy for various age groups (Greenfield et al. 2019; Kinney et al. 2023).

This study is conceptually grounded in two major theories. The minority stress theory (Meyer 2003) posits that external and internal stressors experienced due to minority status can cause chronic stress leading to worse health outcomes. Similarly, the theory of allostatic load (McEwen 1998) addresses the adverse health consequences of chronic stress on the body. Drawing on these frameworks, we use age as a proxy for cumulative exposure to stigma‐related stress and its physiological and emotional toll. These frameworks inform our hypothesis that disordered‐eating symptoms in sexual minority adults may reflect downstream consequences of chronic regulatory strain, and that age and sexual orientation jointly shape patterns of vulnerability. Using cross‐sectional data from The PRIDE Study—a large, national cohort of sexual and gender minority people in the United States—we examined age‐related patterns and group differences in eating pathology symptoms (e.g., binge eating, purging, cognitive restraint). Although cross‐sectional, this study provides an essential foundation for identifying age‐related patterns that may reflect cumulative minority stress exposure over the adult life course. This work provides novel evidence on how disordered eating symptoms vary across adult age groups and sexual orientation subgroups, while also advancing an underexplored area in the epidemiology of eating pathology.

1.1. The Neglect of Older Sexual Minority Adults in Eating Pathology Research

The limited attention to older sexual minority adults in eating‐disorder research reflects a broader tendency to frame disordered eating as predominantly affecting adolescents and young adults (Pike et al. 2013; Treasure et al. 2020). A systematic review of 58 U.S.‐based eating‐disorder psychotherapeutic treatment randomised controlled trials found that none reported data on sexual minority individuals and most studies focused on young to mid‐life adults (Burnette et al. 2022). A review of more than 17,000 eating‐disorder publications between 2010 and 2021 found that fewer than one in three articles included any mention of diversity‐related terms (e.g., race, ethnicity, gender identity, sexual orientation), and noted this likely overrepresents actual engagement with diversity as a research focus because many mentions appeared only in passing (Halbeisen et al. 2022). Although recent work has broadened beyond cisgender women to address body dissatisfaction and muscularity concerns among cisgender adolescent boys and young men (Nagata et al. 2019), longitudinal studies have also documented eating pathology across midlife, particularly in cisgender heterosexual men (Brown et al. 2020), and a growing literature has examined disordered eating in middle‐aged and older men (Mangweth‐Matzek et al. 2016, 2022; Mangweth‐Matzek and Hoek 2017). Despite these advancements, prior studies have generally taken a youth‐centred focus.

2. Age as a Lens for Understanding Minority Stress and Allostatic Load

Understanding how age may affect disordered‐eating risk among sexual minority adults requires attention to the cumulative effects of stress and resilience across the life course (Pearlin and Skaff 1996; Suglia et al. 2024, 2025). Age is often treated as a demographic covariate, yet it also reflects the layering of structural and interpersonal risks and resources over time and may offer a critical lens for understanding health disparities in sexual minority populations (Cohn‐Schwartz et al. 2025; Fredriksen‐Goldsen et al. 2013; Friend 1990). Two conceptual frameworks, minority stress theory (Meyer 2003) and the allostatic load (McEwen and Seeman 1999), are useful for considering how chronic stigma‐related stress may accumulate across the life course and heighten risk for disordered eating in adulthood.

Minority stress theory identifies the unique and chronic stressors that sexual minority individuals face—including interpersonal discrimination, structural stigma, and internalised societal devaluation of their identity—which persist over time and shape health vulnerability (Frost and Meyer 2023; Hoy‐Ellis 2023). Allostatic load provides a conceptual parallel, refers to the cumulative biological toll of repeated adaptation to these stressors, and is reflected in dysregulation across multiple systems, including immune function, metabolism, and cardiovascular health (McEwen and Seeman 1999). Population‐based studies suggest subgroup differences in allostatic load by sexual orientation, gender expression, and behaviour (Desjardins et al. 2022; Oi and Pollitt 2023). These frameworks point to plausible mechanisms by which cumulative stigma exposure across the life course may shape disordered eating.

Consistent with these frameworks, the mechanisms underlying eating pathology may shift across the course of development. For example, developmentally in adolescence and early adulthood, appearance and peer‐related pressures are especially salient risk processes for eating disorder symptoms (Nagata et al. 2024). In contrast, in midlife and beyond, disordered eating may be more likely to emerge as a maladaptive coping response to loneliness, anxiety, or major life transitions (e.g., bereavement, caregiving, or retirement) (Hawash et al. 2024; Levine 2012; Mason and Lewis 2015). Notably, accumulated stress exposure also may disrupt neurobiological systems and impair adaptive affect regulation, increasing vulnerability to maladaptive coping and behavioral responses, including disordered eating. Overall, attending to age as a marker of cumulative social experience is important for advancing a life course epidemiology of disordered eating in sexual minority populations.

2.1. Variation in Eating Pathology Risk Across Sexual Identity

Sexual minority adults are far from a homogeneous group, and their risk for eating pathology likely reflects distinct stress ecologies that are shaped by sexual identity and gender. Emerging evidence suggests that lesbian women may experience a cumulative burden of eating pathology over time, potentially driven by recurring exposure to weight stigma and body‐related stressors. Momentary assessment studies, for instance, show that weight stigma linked to higher body mass index (BMI) is associated with immediate increases in body image concerns and avoidance behaviours such as social avoidance and meal skipping, which align with disordered eating processes (Boehmer et al. 2007; Poon et al. 2024). Mid‐life body composition changes during menopausal transition may also erode body satisfaction and could reactivate or intensify pathology (Sharp et al. 2024), potentially compounded by the intersection of sexism and heterosexism in health‐care settings (Dore et al. 2024; Morrison and Dinkel 2012). By contrast, Soulliard et al. (2024) found that body image pressures within gay male communities—especially those promoting extreme leanness and muscularity—peak in early adulthood and tend to decline with age, suggesting a front‐loaded rather than cumulative risk trajectory for gay men.

Research has demonstrated that minority stress operates in distinct ways for bisexual and pansexual adults, referred to hereafter as bi+, compared to their gay, lesbian, or heterosexual peers. Bi+ adults face two forms of stigma—frequently perceived as ‘too straight’ for queer spaces and ‘too queer’ for straight ones—which generates chronic exposure to anti‐bisexual prejudice from an early age (Feinstein and Dyar 2017; Yost and Thomas 2012). On average, bisexual adults report at least one anti‐bisexual microaggression per day (Brewster and Moradi 2010). These stressors foster internalised binegativity and identity uncertainty, which, in turn, heighten anxiety and depression (Feinstein et al. 2020). Longitudinal evidence shows that week‐to‐week spikes in anti‐bisexual events among young adults (20–35 years) predict immediate increases in internalised binegativity, destabilise identity salience, and worsen mental health (Dyar and London 2018a, 2018b). Over time, recurrent stress exposures accumulate. Consistent with this notion, national data document higher lifetime mood and anxiety disorders in bisexual women and men than in their gay and lesbian counterparts (Bostwick et al. 2010). Such accumulation is aligned with weathering frameworks, which acknowledge the cumulative, accelerated wear‐and‐tear on physiological and psychosocial health resulting from persistent social stress exposure across the life course, which can manifest in earlier onset or greater severity of morbidity (Geronimus 1992; Geronimus et al. 2006). Internalised binegativity and mood dysregulation routinely precipitate maladaptive coping strategies (e.g., emotional eating, binge episodes, cyclic dietary restraint), which have the highest prevalence and severity in bisexual women across the adult lifespan (Calzo et al. 2017). Recurrent weight‐ and appearance‐based rejection in both queer and heterosexual contexts further reinforces body dissatisfaction, making bi+ individuals more likely than lesbian or gay peers to screen positive for binge‐eating disorder or bulimia nervosa in community surveys (Watson et al. 2017). It is, therefore, essential to model how age and disordered eating symptoms intersect rather than assuming shared trajectories or risks across sexual minority groups.

2.2. Current Study

Drawing from minority stress theory and the allostatic load framework, the present study has two overarching goals. First, we aim to test how eating pathology symptoms vary across adulthood among sexual minority adults, treating age as a proxy for cumulative psychosocial stress exposure (H1). Second, we aim to test whether age‐related trends in eating pathology differ across sexual identity groups (H2). Using cross‐sectional data from The PRIDE Study, we examine identity‐specific patterns of eating pathology across adulthood and thereby contributing to lifespan models of minority stress and disordered eating.

3. Method

3.1. Procedure and Participants

This cross‐sectional analysis used data from The PRIDE Study, a national cohort established to examine health trajectories among sexual and gender minority (SGM) adults in the United States and its territories. Participants were eligible if they were 18 years or older, identified as LGBTQIA+ or another SGM identity, lived in the United States or its territories, and were able to independently complete online surveys in English. Data were gathered through a secure online system designed to ensure broad participation while protecting confidentiality. Participants were enrolled using a multi‐pronged approach involving social media advertisements, outreach at community‐based events, collaboration with PRIDEnet, and peer referrals. Comprehensive information on community‐engaged study design and participant recruitment, enrolment, and retention is available in prior publications (Lunn et al. 2019; Obedin‐Maliver et al. 2024).

The analytic sample was derived from the Eating and Body Image 2023 survey, an ancillary data effort conducted from July 2023 through January 2024. Respondents could enter a raffle for one of fifty $40 gift cards upon survey completion. The study protocol was reviewed and approved by the IRBs at Stanford University (#63400), UCSF, and WIRB‐Copernicus Group. The analytic sample comprised 925 cisgender gay men (M = 52.80 years, SD = 15.60), 573 cisgender lesbian women (M = 48.20 years, SD = 17.04), 116 cisgender bi+ men (M = 49.20 years, SD = 15.16), and 448 cisgender bi+ women (M = 36.60 years, SD = 11.14). Most participants identified as White, either alone or in combination with another ethnoracial identity (range: 87.9%–94.8%). Smaller proportions identified as Black or African American (3.5%–8.6%), Hispanic/Latino (3.5%–7.4%), or Asian (2.3%–5.1%). Educational attainment was high overall, with the majority reporting a 4‐year college degree or higher across groups. Income distributions varied, with 22%–35% reporting annual incomes of $30,000 or less, and 5%–18% reporting incomes of $150,000 or more (see Table 1 for full participant sociodemographic information). Missing data were minimal (< 1% per item; Schafer and Graham 2002).

TABLE 1.

Sociodemographic characteristics.

Cisgender bi+ men Cisgender bi+ women Cisgender gay men Cisgender lesbian women p
N 116 448 925 573
Sociodemographic characteristics
Age Mean (SD) 49.16 (15.60) 36.49 (11.14) 52.76 (15.16) 48.21 (17.04) < 0.001
Race 0.005
American Indian/Alaska Native 1 (0.86%) 13 (2.90%) 27 (2.92%) 18 (3.14%)
Asian 5 (4.31%) 23 (5.13%) 37 (4.00%) 13 (2.27%)
Black/African American 10 (8.62%) 21 (4.69%) 40 (4.32%) 20 (3.49%)
Hispanic/Latino 7 (6.03%) 27 (6.03%) 68 (7.35%) 20 (3.49%)
Middle Eastern/North African 1 (0.86%) 3 (0.67%) 11 (1.19%) 3 (0.52%)
Native Hawaiian/Pacific Islander 1 (0.86%) 0 (0.00%) 5 (0.54%) 2 (0.35%)
White 102 (87.93%) 416 (92.86%) 826 (89.30%) 543 (94.76%)
Other/Unknown 2 (1.72%) 2 (0.45%) 9 (0.97%) 16 (2.79%)
Education
No schooling 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) < 0.001
Nursery to high school, no diploma 1 (0.9%) 0 (0.0%) 1 (0.1%) 5 (0.9%)
High school graduate or equivalent 3 (2.6%) 16 (3.6%) 37 (4.0%) 13 (2.3%)
Trade/technical/vocational training 2 (1.7%) 9 (2.0%) 14 (1.5%) 7 (1.2%)
Some college 16 (13.8%) 54 (12.1%) 104 (11.2%) 54 (9.4%)
2‐year college degree 4 (3.4%) 28 (6.2%) 47 (5.1%) 23 (4.0%)
4‐year college degree 36 (31.0%) 152 (33.9%) 290 (31.4%) 149 (26.0%)
Master's degree 32 (27.6%) 121 (27.0%) 255 (27.6%) 198 (34.6%)
Doctoral degree 11 (9.5%) 40 (8.9%) 77 (8.3%) 74 (12.9%)
Professional degree 11 (9.5%) 28 (6.2%) 100 (10.8%) 49 (8.6%)
Income < 0.001
$0–$30,000 26 (23.2%) 156 (34.8%) 200 (22.0%) 148 (26.3%)
$30,001–$60,000 31 (27.7%) 137 (30.6%) 219 (24.3%) 161 (28.4%)
$60,001–$100,000 25 (22.3%) 97 (21.6%) 209 (23.2%) 139 (24.5%)
$100,001–$150,000 14 (12.5%) 37 (8.3%) 190 (21.0%) 79 (13.9%)
$150,001+ 18 (16.1%) 24 (5.3%) 160 (17.8%) 44 (7.9%)
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Note: p values for continuous variables were calculated using one‐way ANOVA, and p values for categorical variables were derived from Chi‐square tests of independence. Participants were allowed to select more than one race/ethnicity, resulting in percentages that exceed 100%.

3.2. Measures

3.2.1. Sexual Orientation

Sexual orientation was assessed using a single self‐report item asking participants to select the term that best described their current sexual orientation. Response options included asexual/demisexual/gray‐ace, bisexual/pansexual, gay/lesbian, queer, straight/heterosexual, and another sexual orientation. Gender identity was assessed via a separate self‐report item with response options for cisgender man, cisgender woman, transgender man, transgender woman, non‐binary, and another gender identity. The analytic sample was restricted to participants identifying as cisgender men (n = 1041) or cisgender women (n = 1021). Among these cisgender participants, 1498 identified as gay or lesbian (gay men: n = 925; lesbian women: n = 573), and 564 identified as bisexual or pansexual (bi+ men: n = 116; bi+ women: n = 448). Participants identifying as gender‐diverse (n = 1006; 21.3%) were excluded from the present analysis because age‐related eating pathology patterns in transgender and gender‐diverse populations are addressed in a separate manuscript. Participants identifying with other sexual orientations (n = 1661; 35.1%) were excluded, including queer (n = 1025), asexual/demisexual/gray‐ace (n = 419), straight/heterosexual (n = 76), and another orientation (n = 22).

Queer participants were on average younger (M = 35.2 years, SD = 11.0) than those in the analytic sample (M = 47.8 years, SD = 16.2), with nearly three‐quarters under age 38, consistent with cohort‐based shifts in the adoption of the label (Worthen 2022; Zosky and Alberts 2016). The analytic sample focused on cisgender gay men, lesbian women, and bi+ men and women, which are the populations most consistently represented in prior research on sexual minority eating pathology and thus provide established benchmarks for interpreting age‐related patterns. Participants who identified with orientations outside of these categories (e.g., queer, asexual, heterosexual) or who did not provide a sexual orientation response (n = 119; 2.5%) were not included in the present analyses. Our decision reflects an analytic scope rather than a judgement of legitimacy. Queer identity, in particular, encompasses a wide range of experiences (from exclusive same‐gender attraction to multi‐gender attraction to the rejection of categorical labels) that cannot be meaningfully collapsed into a single group for age‐patterned comparisons. This scope does not diminish the importance of examining eating pathology among queer‐identified or other groups, which warrants dedicated study in its own right.

3.2.2. Eating Pathology Symptoms Inventory (EPSI)

The Eating Pathology Symptoms Inventory (EPSI; Forbush et al. 2013) is a 45‐item self‐administered scale designed to quantify disordered eating behaviours across eight separate symptoms: Body Dissatisfaction, Binge Eating, Cognitive Restraint, Purging, Restricting, Excessive Exercise, Muscle Building, and Negative Attitudes Toward Obesity. Respondents rate each item in reference to the previous 4 weeks using a 5‐point scale ranging from 0 (never) to 4 (very often). Item responses were summed to generate subscale scores, with higher values reflecting greater symptom severity. The scale demonstrated strong internal consistency, convergent and discriminant validity, and factorial invariance across sex and weight status (Coniglio et al. 2018; Forbush et al. 2014). Recent work showed that the EPSI structure held for cisgender gay men and lesbian women and met strict measurement invariance criteria, which supports unbiased group comparisons (Nagata et al. 2025). All subscales demonstrated satisfactory internal consistency in the current sample (Cronbach's αs = 0.76–0.90). EPSI subscale scores were standardised using z‐score transformation. This placed all outcomes on a common scale and allowed direct comparison of effect estimates across models.

3.2.3. Age

Participants reported their age in years. Age was modelled as a continuous variable and was mean‐centred. In the analytic sample, the mean age was 47.78 years (SD = 12.3; range = 18–96).

3.3. Analytic Strategy

Prior to modelling, data were screened for missingness, normality, and multicollinearity. Visual inspection and descriptive statistics indicated minimal missingness, and no imputation procedures were necessary. Generalised variance inflation factors (GVIFs) were computed, and all adjusted GVIFs were below the recommended threshold of 2 (age = 1.99; group = 1.11; age x group = 1.50). Assumptions of linearity, homoscedasticity, and multivariate normality were assessed through residual diagnostics and were judged to be adequately met. We fit a multivariate general linear model (GLM) with eight z‐standardised EPSI subscales as outcomes. Independent variables included mean‐centred age, sexual orientation/gender identity group (cisgender gay men [reference], lesbian women, bi+ men, bi+ women), and an age‐by‐group interaction term. Multivariable associations were tested using Pillai's trace with Type III sums of squares.

When significant multivariable effects were detected, we conducted follow‐up univariate linear regressions for each subscale. For significant age × group interactions, we probed the effects by estimating the simple slope of age within each sexual orientation group and comparing these slopes against those among gay men. To aid interpretation, we also generated interaction plots with bootstrapped 95% confidence intervals. p values from univariate regressions and pairwise simple‐slope contrasts were adjusted for multiple comparisons using the Benjamini–Hochberg false discovery rate procedure.

We reported b and β coefficients, standard errors, t statistics, 95% confidence intervals, and model R 2 values. All analyses were conducted using R version 4.5.0 (R Core Team 2024). Cisgender gay men were selected as the reference group because they represented the largest subgroup in the analytic sample, thereby promoting model stability and yielding more precise estimates of group contrasts (Ranganathan et al. 2017). This choice also aligned with recommendations to make reference group selection an intentional decision that facilitates clear interpretation of results, rather than relying on software defaults or conventional hierarchies (Johfre and Freese 2021).

4. Results

4.1. Multivariate Omnibus Test

Descriptive statistics for each EPSI subscale by sexual orientation group are presented in Supporting Information S1: Table S1 and age distributions are presented in Supporting Information S1: Figure S1. Bivariate correlations among the eight subscales (Supporting Information S1: Table S2) indicated significant associations across all pairs, with the strongest associations observed between body dissatisfaction and binge eating (r = 0.57) and between cognitive restraint and excessive exercise (r = 0.45). Multivariable regression analyses revealed a significant main effect of age (Pillai's trace V = 0.076, F(8, 2046) = 21.08, p < 0.001) and of sexual orientation (V = 0.198, F(24, 6144) = 18.09, p < 0.001). The interaction between age and group was statistically significant (V = 0.026, F(24, 6144) = 2.24, p < 0.001).

4.2. Follow‐Up Univariate Regressions

Multivariable regression analyses examined associations between age, sexual orientation, and their interaction in predicting EPSI subscale scores, with cisgender gay men serving as the reference group (Table 2). Age was significantly associated with multiple forms of eating pathology. Specifically, older age was linked to lower body dissatisfaction (b = −0.01, 95% CI [−0.01, 0.00], β = −0.13), binge eating (b = −0.01, 95% CI [−0.01, 0.00], β = −0.12), and muscle building (b = −0.02, 95% CI [−0.02, −0.01], β = −0.25), but higher cognitive restraint (b = 0.01, 95% CI [0.00, 0.01], β = 0.10) and negative attitudes toward obesity (b = 0.01, 95% CI [0.01, 0.01], β = 0.16).

TABLE 2.

Multivariable regression predicting EPSI scales by age and sexual orientation.

Outcome Predictor b β SE t p 95% CI R 2
Body dissatisfaction (Intercept) −0.17 0.03 −5.24 0.00 [−0.24, −0.11] 0.08
Age −0.01 −0.13 0.00 −3.79 0.00 [−0.01, 0.00]
Lesbian women 0.32 0.14 0.05 6.12 0.00 [0.22, 0.42]
Bi+ men −0.23 −0.05 0.10 −2.37 0.02 [−0.41, −0.04]
Bi+ women 0.66 0.27 0.07 9.07 0.00 [0.52, 0.81]
Age × lesbian women 0.00 0.03 0.00 0.90 0.37 [0.00, 0.01]
Age × Bi+ men 0.01 0.03 0.01 1.27 0.23 [0.00, 0.02]
Age × Bi+ women 0.02 0.13 0.00 4.07 0.00 [0.01, 0.03]
Binge eating (Intercept) −0.04 0.03 −1.20 0.29 [−0.11, 0.03] 0.02
Age −0.01 −0.12 0.00 −3.56 0.00 [−0.01, 0.00]
Lesbian women 0.04 0.02 0.05 0.74 0.46 [−0.07, 0.14]
Bi+ men −0.12 −0.03 0.10 −1.24 0.29 [−0.32, 0.07]
Bi+ women 0.31 0.13 0.08 4.14 0.00 [0.16, 0.46]
Age × lesbian women 0.00 0.03 0.00 1.15 0.29 [0.00, 0.01]
Age × Bi+ men 0.01 0.04 0.01 1.51 0.26 [0.00, 0.02]
Age × Bi+ women 0.01 0.09 0.00 2.72 0.02 [0.00, 0.02]
Cognitive restraint (Intercept) 0.06 0.03 1.69 0.24 [−0.01, 0.12] 0.04
Age 0.01 0.10 0.00 2.89 0.03 [0.00, 0.01]
Lesbian women −0.07 −0.03 0.05 −1.27 0.27 [−0.17, 0.04]
Bi+ men −0.04 −0.01 0.10 −0.38 0.70 [−0.23, 0.15]
Bi+ women −0.11 −0.04 0.07 −1.42 0.27 [−0.25, 0.04]
Age × lesbian women 0.01 0.08 0.00 2.73 0.03 [0.00, 0.02]
Age × Bi+ men 0.01 0.02 0.01 1.07 0.33 [−0.01, 0.02]
Age × Bi+ women 0.01 0.04 0.00 1.32 0.27 [0.00, 0.02]
Purging (Intercept) 0.03 0.03 0.91 0.58 [−0.04, 0.10] 0.01
Age −0.01 −0.09 0.00 −2.61 0.07 [−0.01, 0.00]
Lesbian women −0.06 −0.03 0.05 −1.04 0.58 [−0.16, 0.05]
Bi+ men −0.10 −0.02 0.10 −1.02 0.58 [−0.3, 0.09]
Bi+ women 0.05 0.02 0.08 0.63 0.70 [−0.10, 0.20]
Age × lesbian women 0.00 −0.02 0.00 −0.51 0.70 [−0.01, 0.00]
Age × Bi+ men 0.00 0.00 0.01 0.13 0.90 [−0.01, 0.01]
Age × Bi+ women 0.01 0.06 0.00 1.73 0.34 [0.00, 0.02]
Restricting (Intercept) −0.06 0.03 −1.60 0.37 [−0.12, 0.01] 0.01
Age 0.00 −0.02 0.00 −0.63 0.58 [−0.01, 0.00]
Lesbian women 0.07 0.03 0.05 1.34 0.37 [−0.03, 0.18]
Bi+ men −0.13 −0.03 0.10 −1.33 0.37 [−0.33, 0.06]
Bi+ women 0.15 0.06 0.08 2.04 0.33 [0.01, 0.30]
Age × lesbian women 0.00 −0.03 0.00 −0.90 0.58 [−0.01, 0.00]
Age × Bi+ men 0.00 0.01 0.01 0.56 0.58 [−0.01, 0.02]
Age × Bi+ women 0.00 −0.03 0.00 −0.78 0.58 [−0.01, 0.01]
Excessive exercise (Intercept) 0.14 0.03 4.12 0.00 [0.07, 0.21] 0.02
Age 0.00 −0.07 0.00 −2.05 0.07 [−0.01, 0.00]
Lesbian women −0.23 −0.10 0.05 −4.23 0.00 [−0.33, −0.12]
Bi+ men −0.01 0.00 0.10 −0.08 0.94 [−0.20, 0.19]
Bi+ women −0.30 −0.13 0.08 −4.03 0.00 [−0.45, −0.16]
Age × lesbian women 0.01 0.08 0.00 2.83 0.01 [0.00, 0.02]
Age × Bi+ men 0.00 0.02 0.01 0.77 0.50 [−0.01, 0.02]
Age × Bi+ women 0.01 0.04 0.00 1.16 0.33 [0.00, 0.01]
Negative attitudes toward obesity (Intercept) 0.15 0.03 4.50 0.00 [0.08, 0.22] 0.07
Age 0.01 0.16 0.00 4.80 0.00 [0.01, 0.01]
Lesbian women −0.29 −0.13 0.05 −5.51 0.00 [−0.39, −0.19]
Bi+ men −0.22 −0.05 0.10 −2.33 0.03 [−0.41, −0.04]
Bi+ women −0.20 −0.08 0.07 −2.74 0.01 [−0.35, −0.06]
Age × lesbian women 0.00 0.02 0.00 0.71 0.48 [0.00, 0.01]
Age × Bi+ men 0.00 0.02 0.01 0.73 0.48 [−0.01, 0.02]
Age × Bi+ women 0.01 0.04 0.00 1.27 0.27 [0.00, 0.02]
Muscle building (Intercept) 0.39 0.03 11.84 0.00 [0.32, 0.45] 0.11
Age −0.02 −0.25 0.00 −7.55 0.00 [−0.02, −0.01]
Lesbian women −0.68 −0.31 0.05 −13.39 0.00 [−0.78, −0.58]
Bi+ men −0.28 −0.06 0.09 −2.94 0.00 [−0.46, −0.09]
Bi+ women −0.63 −0.26 0.07 −8.80 0.00 [−0.77, −0.49]
Age × lesbian women 0.01 0.10 0.00 3.48 0.00 [0.00, 0.02]
Age × Bi+ men 0.00 0.01 0.01 0.40 0.69 [−0.01, 0.01]
Age × Bi+ women 0.02 0.13 0.00 4.11 0.00 [0.01, 0.03]
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Note: Cisgender gay men served as the reference group. Coefficients represent unstandardised (b) and standardised (β) estimates. p values are Benjamini–Hochberg adjusted to control the false discovery rate. Confidence intervals are presented as [lower, upper]. Bold coefficients indicate predictors that were statistically significant after Benjamini–Hochberg correction.

Clear sexual orientation differences were apparent. Lesbian women and bi+ women consistently demonstrated elevated scores on multiple EPSI subscales. For body dissatisfaction, both lesbian women (b = 0.32, 95% CI [0.22, 0.42], β = 0.14) and bi+ women (b = 0.66, 95% CI [0.52, 0.81], β = 0.27) reported higher levels compared to gay men. Bi+ women also reported higher binge eating (b = 0.31, 95% CI [0.16, 0.46], β = 0.13). In contrast, lesbian women (b = −0.23, 95% CI [−0.33, −0.12], β = −0.10) and bi+ women (b = −0.30, 95% CI [−0.45, −0.16], β = −0.13) reported lower excessive exercise. Similarly, these groups showed lower muscle‐building behaviours (lesbian women: b = −0.68, 95% CI [−0.78, −0.58], β = −0.31; bi+ women: b = −0.63, 95% CI [−0.77, −0.49], β = −0.26). Bi+ men exhibited generally lower or comparable levels of eating pathology relative to gay men, including lower body dissatisfaction (b = −0.23, 95% CI [−0.41, −0.04], β = −0.05), negative attitudes toward obesity (b = −0.22, 95% CI [−0.41, −0.04], β = −0.05), and muscle building (b = −0.28, 95% CI [−0.46, −0.09], β = −0.06).

There was limited evidence for age‐by‐sexual orientation interactions, but several significant interactions emerged (see Figure 1). For bi+ women, age interacted with body dissatisfaction (b = 0.02, 95% CI [0.01, 0.03], β = 0.13) and binge eating (b = 0.01, 95% CI [0.00, 0.02], β = 0.09), indicating that the age‐related declines in these outcomes observed among gay men were less pronounced among bi+ women. For muscle building, significant age interactions were also observed for lesbian women (b = 0.01, 95% CI [0.00, 0.02], β = 0.10) and bi+ women (b = 0.02, 95% CI [0.01, 0.03], β = 0.13), such that decreases in muscle‐building behaviours with age were weaker for lesbian and bi+ women than for gay men. In addition, significant interactions emerged for cognitive restraint and excessive exercise among lesbian women. For cognitive restraint, the positive association with age was steeper for lesbian women compared to gay men (b = 0.01, 95% CI [0.00, 0.02], β = 0.08). For excessive exercise, lesbian women showed a flatter age slope than gay men, indicating less decline across age (b = 0.01, 95% CI [0.00, 0.02], β = 0.08).

FIGURE 1.

FIGURE 1

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Associations between age and disordered eating behaviours and attitudes by sexual orientation. Associations between age and disordered eating behaviours and attitudes by sexual orientation. Age was negatively associated with body dissatisfaction (A), binge eating (B), excessive exercise (D), and muscle building (F), and positively associated with cognitive restraint (C) and negative attitudes toward obesity (E). Significant age × group interactions indicated differential patterns for bi+ women (A, B, F) and lesbian women (F), such that age‐related decreases observed among gay men were attenuated or absent in these groups.

The proportion of variance explained by the models was modest (R 2 values ranging from 0.01 for purging and restricting to 0.11 for muscle building). Supporting Information S1: Table S3 demonstrates that additional covariate adjustment for educational attainment, income, and ethnoracial identity had minimal impact on the overall pattern of associations. Because outcomes were standardised, coefficients can be compared directly across EPSI subscales. This makes clear that some effects, while statistically significant, were trivial in size (e.g., standardised β of 0.05), whereas others reflected more meaningful differences, particularly the larger group contrasts observed for body dissatisfaction and muscle building (βs > 0.25). Thus, although age and group interactions reached significance in several of the symptoms, their substantive impact varied considerably in magnitude.

5. Discussion

The present study extends the limited literature on eating pathology in sexual minorities across the lifespan by systematically examining age effects, identity group differences, and their interaction in cisgender sexual minority adults. Guided by minority‐stress (Meyer 2003) and allostatic‐load (McEwen and Seeman 1999) models, we first found that chronological age carried mixed implications: older age was associated with higher cognitive restraint and stronger negative attitudes toward obesity, as well as lower body dissatisfaction, binge eating, and muscle‐building behaviours, and these associations were generally small in magnitude, with a small‐to‐moderate association for muscle building. Population‐based work showed comparable age‐linked increases in weight‐control cognitions among mid‐life adults (Peat et al. 2008); the current findings echo that pattern in a sexual minority cohort, suggesting that chronic weight‐related vigilance may persist independently of eating disorder behaviours that may wane, although the effects observed here were modest in size.

Second, we observed clear sexual identity differences, with cisgender sexual minority women, especially bi+ women, reporting higher body dissatisfaction, and bi+ women additionally reporting higher binge eating, relative to gay men; these group differences were nominal among lesbian women (e.g., body dissatisfaction) and small among bi+ women (e.g., binge eating). At the same time, body dissatisfaction and muscle‐focused practices decreased with age across the sample, consistent with longitudinal evidence that appearance preoccupation in cisgender gay men peaks in early adulthood and declines thereafter (Soulliard et al. 2024). Such trajectories fit the premise that community‐driven appearance norms lose salience with age while stress‐imbued cognitions might endure. Sexual‐orientation contrasts added a second layer of risk stratification. Across the lifespan, cisgender sexual minority women reported higher body dissatisfaction than cisgender gay men, and the age‐related increase in binge eating was limited to bi+ cisgender women and was small in magnitude. Third, although age‐by‐identity interactions were more limited, significant interactions indicated that bi+ women exhibited increasing vulnerability with age, particularly in body dissatisfaction and binge eating, and that lesbian and bi+ women showed slightly less pronounced age‐related decreases in muscle‐building behaviours compared to gay men. Prior panel studies linked internalised binegativity and identity ambiguity to escalating eating‐pathology risk from young adulthood into midlife (Calzo et al. 2017; Dyar and London 2018b). The present data are consistent with those patterns, but the small interaction effects suggest gradual rather than dramatic divergence across age. Given the cross‐sectional nature of the current study, contextualising the findings requires attention to generational cohort effects (Keyes et al. 2010). Older sexual minority adults in our sample matured during decades when diet culture and stigma were even more pervasive and affirming care scarce (Crandall and Martinez 1996; Marks 2019; Stearns 2022). National data indicate that anti‐fat attitudes remain stable into late adulthood, even as overt restrictive behaviours decline (Andreyeva et al. 2008). Our findings align with this pattern, suggesting that weight stigma and cognitive restraint in the older adults in our sample may reflect earlier sociocultural climates. Qualitative studies further support this interpretation: older gay men who came of age during the 1970s and 1980s reported internalisation of thin‐lean body ideals shaped by community‐specific appearance norms and a cultural context largely devoid of body‐positivity discourse (Drummond 2005; Hennen 2008). By contrast, younger sexual minority adults—particularly Gen Z individuals—navigated a more body‐diverse cultural landscape, yet one still shaped by social media platforms that amplify and homogenise physique ideals (Bacaj et al. 2025; Charmaraman et al. 2021; Park et al. 2025). It is crucial to attend to these cohort effects to minimise conflation of impacts of biological ageing with influences from generational sociocultural norms. Together, these patterns suggest that age differences in eating pathology may reflect cohort‐specific sociocultural contexts as much as, or more than, cumulative minority stress exposure. While descriptive aspects of these data can still inform clinical treatment of eating disorders, future prospective studies are needed to disentangle longitudinal versus generational effects and to more directly assess the experience of sexual minority stigma to characterise its impacts across historical and developmental contexts (van der Star 2024).

These findings have several potential clinical implications. Prevention and treatment strategies for eating disorders may need to be responsive to both developmental stage and sexual orientation. In considering clinical applications, the generally small standardised effects suggest that these patterns are meaningful at the population level but should not be overinterpreted for any one individual, whereas the relatively larger differences in body dissatisfaction and muscularity‐oriented behaviours may merit particular attention in assessment and intervention for sexual minority adults. For example, clinicians should be attentive to the potential for body dissatisfaction to increase among bi+ women as they age, as well as to developmental shifts in the severity of muscularity‐oriented behaviours among gay men. Importantly, eating pathology in midlife and older adults should not be overlooked, and incorporation of minority stress frameworks may enhance the relevance and effectiveness of interventions for sexual minority populations across the life course.

5.1. Limitations and Future Directions

Several limitations are worth noting. First, the cross‐sectional design prevents causal and temporal inferences; longitudinal replication is needed to disentangle developmental change from cohort effects (Hoffman and Stawski 2009; Wang and Maxwell 2015). Second, the predominantly White and highly educated nature of the sample may limit external validity; eating pathology and access to care vary systematically by ethnoracial identity and socioeconomic position (Burke et al. 2020). Additionally, our study did not directly measure stigma exposures or physiological dysregulation associated with stress. Moreover, our single‐level regression models did not incorporate an explicitly intersectional framework that considers how multiple social identities (e.g., race/ethnicity, income) and systems of oppression may jointly shape eating pathology. Multilevel approaches, such as those outlined by Evans et al. (2018), provide a way to model intersectional health inequities by treating each social stratum as a unit of analysis, allowing for more precise estimation of both additive and non‐additive identity effects. Future prospective research using these methods could yield richer insights into how multiple marginalised identities intersect to shape risk trajectories.

Future work should incorporate biomarker panels, as recent findings demonstrated elevated allostatic‐load composites among sexual minority women with non‐heterosexual behavior or attraction (Desjardins et al. 2025; Oi and Pollitt 2023). Additionally, future research should adopt longitudinal designs to track within‐person trajectories and to examine whether sociocultural shifts (e.g., body‐positivity/body‐neutrality movements) impact the manifestation and/or maintenance of eating pathology. Mixed‐methods approaches could clarify how health‐care access, provider competence, and community resources interact with age and orientation to modify risk. By grounding age and sexual orientation interactions in empirical minority‐stress and life‐course frameworks, this study provides the evidence base for developing age‐ and identity‐responsive prevention and treatment strategies for sexual minority populations.

Author Contributions

Jason M. Nagata: conceptualization, formal analysis, methodology, writing – original draft, writing – review and editing, funding. Christopher D. Otmar: formal analysis, methodology, writing – original draft, writing – review and editing. Char Potes: writing – original draft, writing – review and editing. Ken Murakami: writing – original draft, writing – review and editing. Jason M. Lavender: conceptualization, writing – review and editing. Emilio J. Compte: formal analysis, methodology, writing – review and editing. Tiffany A. Brown: conceptualization, writing – review and editing. Kelsie T. Forbush: conceptualization, methodology, writing – review and editing. Annesa Flentje: conceptualization, methodology, writing – review and editing. Micah E. Lubensky: conceptualization, methodology, writing – review and editing. Juno Obedin‐Maliver: conceptualization, methodology, writing – review and editing, funding. Mitchell R. Lunn: conceptualization, methodology, writing – review and editing, funding. All authors read and approved the final manuscript.

Funding

E.J.C. was supported by the Chilean National Agency for Research and Development (FONDECYT N° 11240740). Research reported in this article was partially funded through a Patient‐Centred Outcomes Research Institute (PPRN‐1501‐26848) to M.R.L.. The statements in this article are solely the responsibility of the authors and do not necessarily represent the views of Patient‐Centred Outcomes Research Institute, its Board of Governors or Methodology Committee, the Uniformed Services University, the Department of Defence, or the National Institutes of Health.

Ethics Statement

The Institutional Review Boards of Stanford University School of Medicine (#63400), the University of California, San Francisco, and WIRB‐Copernicus Group (WCG) approved this study, and oversight was provided by The PRIDE Study's Research Advisory Committee and Participant Advisory Committee. All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Boards and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent

Informed consent was obtained from all participants.

Conflicts of Interest

Dr. Obedin‐Maliver has received consulting fees from Sage Therapeutics, Ibis Reproductive Health, Folx Health Inc., Hims and Hers Health Inc., and Upstream Inc. Dr. Lunn received consultation fees from Hims and Hers Health Inc., Folx Health Inc., Otsuka Pharmaceutical Development and Commercialisation Inc., and the American Dental Association on topics unrelated to this work. None of these roles present a conflict of interest with this work as described here. The other authors have no conflicts of interest to report.

Supporting information

Supporting Information S1

ERV-34-663-s001.docx (286.3KB, docx)

Acknowledgements

We thank Anthony Kung for editorial assistance. The PRIDE Study is a community‐engaged research project that serves and is made possible by LGBTQIA+ community involvement at multiple points in the research process, including the dissemination of findings. We acknowledge the courage and dedication of The PRIDE Study participants for sharing their stories, the careful attention of the PRIDEnet Participant Advisory Committee (PAC) members for reviewing and improving every study application, and the enthusiastic engagement of the PRIDEnet Ambassadors and Community Partners for bringing thoughtful perspectives as well as promoting enrolment and disseminating findings. For more information, please visit https://pridestudy.org/pridenet. This study includes items from the ‘Development and validation of the Eating Pathology Symptoms Inventory’, by Forbush et al. 2013, Psychological Assessment, 25, 859–878. Copyright 2011 by Kelsie T. Forbush. Reproduced with permission. No further reproduction, modification, or distribution of the Eating Pathology Symptoms Inventory, derivative versions, or translated versions is permitted without advance, written permission from the copyright holder (Dr. Kelsie Forbush).

Nagata, Jason M. , Otmar Christopher D., Potes Char, et al. 2026. “Age‐Related Trends in Eating‐Pathology Symptoms Among Sexual Minority Adults,” European Eating Disorders Review: 34. no. 3), 663–675. 10.1002/erv.70065.

Handling Editor: Nadia Micali

Data Availability Statement

Data from The PRIDE Study may be accessed through an Ancillary Study application (details at pridestudy.org/collaborate).

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Associated Data

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

Data Citations

  1. R Core Team 2024. “R: A Language and Environment for Statistical Computing.” [Computer software] R Foundation for Statistical Computing. http://www.r‐project.org/.

Supplementary Materials

Supporting Information S1

ERV-34-663-s001.docx (286.3KB, docx)

Data Availability Statement

Data from The PRIDE Study may be accessed through an Ancillary Study application (details at pridestudy.org/collaborate).

Articles from European Eating Disorders Review are provided here courtesy of Wiley

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