Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2026 Apr 7.
Published in final edited form as: Int J Eat Disord. 2021 Feb 27;54(7):1135–1146. doi: 10.1002/eat.23494

Disparities in disordered eating between gender minority and cisgender adolescents

Savannah R Roberts 1,2, Rachel H Salk 3, Brian C Thoma 3, Madelaine Romito 2, Michele D Levine 3, Sophia Choukas-Bradley 1,2
PMCID: PMC13051521  NIHMSID: NIHMS2154000  PMID: 33638569

Abstract

Objective:

Adolescence is a developmental period of increased risk for disordered eating. Gender minority adolescents (GMAs), or those whose gender identity does not align with their sex assigned at birth, may experience body image concerns related to unique gender-related stressors. GMAs may use disordered eating to affirm a feminine, masculine, or nonbinary gender identity. However, little is known about differences in disordered eating between GMAs and cisgender adolescents. Therefore, this study had two primary goals: (a) to compare disordered eating between GMAs and cisgender adolescents by examining the role of gender identity and sex assigned at birth; and (b) within GMAs, to examine associations between gender identity congruence and disordered eating.

Method:

A large U.S. sample of GMAs and cisgender adolescents (n = 1,191 GMAs; 919 cisgender; Mage = 15.93 years) reported their disordered eating on an anonymous online survey.

Results:

A MANOVA revealed a significant interaction between gender identity and sex assigned at birth. Follow-up ANOVAs demonstrated that purging, caloric restriction, excessive exercise, and muscle building differed as a function of gender identity and sex assigned at birth. Among GMAs, a multiple multivariate regression model demonstrated that disordered eating was lower among participants who reported greater gender identity congruence.

Discussion:

GMAs should not be considered a homogenous group, as differences in gender identity may lead to the internalization of different appearance ideals and disparate eating disorder symptomatology. Results suggest that clinicians working with GMAs consider the unique body image concerns that could accompany a specific gender identity.

Keywords: adolescent, feeding and eating disorders, gender identity, sexual and gender minorities

1 |. INTRODUCTION

The adolescent developmental period is a transformative time of rapid psychological, physical, biological, and social changes that are associated with increased risk for disordered eating. Gender minority (i.e., transgender) youth, or youth whose gender identity does not align with their sex assigned at birth, experience unique gender-related stressors that leave them particularly vulnerable (Connolly, Zervos, Barone, Johnson, & Joseph, 2016; Donaldson et al., 2018; Guss, Williams, Reisner, Austin, & Katz-Wise, 2017). Gender minority youth may adopt various eating and weight control behaviors as a function of whether they desire a feminine, masculine, or androgynous appearance (Murray, 2017). Furthermore, these behaviors could change as they experience greater gender identity congruence (Romito et al., 2021). However, little research has examined the association between gender identity and disordered eating among subgroups of gender minority adolescents.

Extant literature demonstrates high rates of disordered eating among gender minority youth. In a study of Canadian gender minority adolescents, nearly half (48%) of those aged 14–18 endorsed binge eating, fasting, using diet pills, laxatives, or vomiting to lose weight (Watson, Veale, & Saewyc, 2017). In the United States, a large population-based study found that gender minority adolescents were more likely to engage in fasting, diet pill use, laxative use, and nonprescription steroid use than cisgender boys, and were equally likely to use diet pills or laxatives as cisgender girls (Guss et al., 2017). By adulthood, gender minority adults report greater rates of past eating disorder diagnoses than cisgender populations (Diemer, Grant, Munn-Chernoff, Patterson, & Duncan, 2015; Simone, Askew, Lust, Eisenberg, & Pisetsky, 2020). Given the severity of eating disorders, and the multitude of health disparities faced by gender minority youth (Connolly et al., 2016), it is imperative that we expand our understanding of the developmental and clinical features of disordered eating in this underserved population (Austin, 2015).

Several factors may contribute to disordered eating among gender minority youth. These adolescents may experience elevated rates of body dissatisfaction due to incongruence between their physical bodies and felt sense of gender (Guss et al., 2017; Romito et al., 2021). Dissatisfaction could arise from gender incongruent body parts, such as secondary sexual characteristics, in addition to weight and general appearance concerns (Bockting & Allen, 2012). Further, these youth may engage in excessive body surveillance, scrutinizing their appearance while concerned over whether they “pass” as their desired gender to others (Brewster, Velez, Breslow, & Geiger, 2019; Gordon, Austin, Krieger, White Hughto, & Reisner, 2016). Potentially caused by gender incongruence and passing concerns, body dissatisfaction may confer risk for disordered eating behaviors (Jones, Haycraft, Murjan, & Arcelus, 2016). Furthermore, victimization and stigmatization may exacerbate body image concerns. Nationally representative data from the United States demonstrate that gender minority youth face consistently high rates of discrimination, harassment, and assault (Greytak, Kosciw, & Diaz, 2009; Institute of Medicine, 2011), and may use caloric restriction as a coping mechanism for managing this victimization (Watson et al., 2017). Gender minority adolescents may also feel their body is developing in the “wrong” direction during puberty (Bockting & Allen, 2012), and might use restrictive or compensatory behaviors to slow pubertal development or obtain the body characteristics of their congruent gender (Coelho et al., 2019; Donaldson et al., 2018; Romito et al., 2021).

Prior research has primarily assessed “transgender” people in a single analytic group, failing to acknowledge the variability in gender identities that could be related to different presentations of disordered eating. With gender identity occurring on a spectrum, gender minority adolescents may wish to appear more feminine, masculine, nonbinary or androgynous, resulting in considerable variations in disordered eating. For example, transmasculine adolescents (those assigned female at birth who identify with a masculine gender identity) may engage in greater muscle-building behaviors in pursuit of the masculine ideal, whereas transfeminine adolescents (those assigned male at birth who identify with a feminine gender identity) may engage in restrictive practices to obtain the feminine ideal, a pattern supported by case studies with gender minority youth (Couturier, Pindiprolu, Findlay, & Johnson, 2015; Hepp & Milos, 2002; Romito et al., 2021).

Extant research suggests that when gender minority youth feel a greater sense of comfort with their external appearance and gender identity (i.e., greater gender congruence), they are less likely to engage in disordered eating. Indeed, gender-affirming care has been associated with decreased disordered eating behaviors (Becker et al., 2018; Jones et al., 2016). Body dissatisfaction is believed to be central to the distress gender minority individuals experience (Jones et al., 2016), perhaps indicating that reduced gender identity concerns may be associated with lower levels of disordered eating. Data that assess the association between gender identity congruence and disordered eating are critical to addressing the needs of gender minority youth.

The current study, therefore, has two goals. First, we compare disordered eating between GMAs and cisgender adolescents by examining the role of gender identity and sex assigned at birth. We predict that groups endorsing a feminine gender identity (transfeminine adolescents and cisgender girls) will be more likely to engage in restrictive practices, whereas those with a masculine gender identity (transmasculine adolescents and cisgender boys) will be more likely to endorse muscle-building behaviors. Second, among gender minority adolescents, we examine how gender identity congruence is associated with disordered eating, with the expectation that higher gender identity congruence will be associated with lower levels of eating disorder symptomatology.

2 |. METHOD

2.1 |. Procedure

Participants in the current study are a subsample from a larger, online, cross-sectional survey of gender minority and cisgender adolescents aged 14–18 in the United States (Salk, Thoma, & Choukas-Bradley, 2020). The purpose of the broader study was to examine mental health disparities between gender minority and cisgender youth. Participants were recruited via two sets of paid advertisements on Facebook and Instagram from July to October 2018. One set of advertisements targeted cisgender adolescents using the text: “Teenagers needed for online health study! Click now to participate in research!” In order to oversample gender minority youth, the second advertisement set targeted gender minority adolescents using the text: “Are you transgender or genderqueer? Click now to participate in research!” In addition, the gender minority advertisement was targeted to gender minority youth using “Interests” labels such as Gender Identity, Genderqueer, and Transgender Activism. Clicking either ad opened the survey webpage, where participants provided assent and then completed anonymous questionnaires hosted on a secure server using their own devices. Within the assent form, participants were informed that the study was voluntary, they could stop participating at any time, and they could skip any question. To ensure that participation did not place gender minority adolescents at risk for discrimination or parental rejection, a waiver of parental permission was obtained. As an additional safety measure, participants viewed a message regarding safety and security before starting the survey. Participants who completed the study were eligible to enter a drawing for a $50 gift card. The University of Pittsburgh Human Research Protection Office approved this study.

2.2 |. Participants

Table 1 displays demographic information for the full sample. A total of 3,318 adolescents participated in the larger study. Of these, 2,110 (cisgender: n = 919; gender minority: n = 1,191) participants who completed at least one subscale of the measure of disordered eating and provided demographic information were included in analyses. Participants were recruited in the United States, and lived in all 50 states, the District of Columbia, and Puerto Rico. Compared to the full sample, these 2,110 participants were older, and more likely to be assigned female at birth and to identify as a sexual minority. No other differences in demographics between those who did or did not complete the measure of disordered eating were observed.

TABLE 1.

Demographic characteristics for total sample

Full sample Trans masculine Transfeminine Nonbinary/questioning AFAB Nonbinary/questioning AMAB Cisgender male Cisgender female
N (%) 2,110 (100) 635 (30.1) 64 (3.0) 441 (20.9) 51 (0.02) 231 (10.9) 688 (32.6)
Age M (SD) 15.9 (1.2) 16.0 (1.2) 16.2 (1.2) 15.9 (1.2) 16.14 (1.0) 15.9 (1.1) 15.8 (1.1)
N (%) n (%) n (%) n (%) n (%) n (%) n (%)
Race/ethnicity
 White 1.381 (65.5) 429 (67.6) 47 (73.4) 302 (68.5) 30 (58.8) 142 (61.5) 431 (62.6)
 Black 102 (4.8) 15 (2.4) 2 (3.1) 19 (4.3) 2 (3.9) 10 (4.3) 54 (7.8)
 Hispanic 192 (9.1) 56 (8.8) 3 (4.7) 32 (7.3) 4 (7.8) 23 (10.0) 74 (10.8)
 Asian/Pacific islander 82 (3.9) 15 (2.4) 3 (4.7) 10 (2.3) 0 (0.0) 15 (6.5) 39 (5.7)
 Native American 24 (1.1) 5 (0.8) 2 (3.1) 9 (2.0) 0 (0.0) 2 (0.9) 6 (0.9)
 Mixed race 319 (15.1) 112 (17.7) 7 (10.9) 68 (15.4) 14 (27.4) 37 (16.1) 81 (11.8)
 Other race 10 (.5) 3 (0.5) 0 (0.0) 1 (0.2) 1 (2.0) 2 (0.9) 3 (0.4)
Sexual orientation
 Straight/heterosexual 446 (21.1) 29 (4.6) 1 (1.4) 4 (0.9) 1 (2.0) 129 (55.8) 282 (41.0)
 Gay/lesbian 324 (15.4) 129 (20.4) 15 (23.5) 58 (13.2) 14 (27.4) 49 (21.2) 59 (8.6)
 Bisexual/pansexual 902 (42.7) 296 (46.6) 35 (54.7) 229 (52.0) 19 (37.2) 48 (20.8) 275 (40.0)
 Queer/other 291 (13.8) 134 (21.1) 9 (14.1) 101 (22.9) 10 (19.6) 2 (0.9) 35 (5.1)
 Asexual 114 (5.4) 38 (6.0) 2 (3.1) 47 (10.7) 7 (13.7) 2 (0.9) 18 (2.6)
 Questioning 15 (0.7) 5 (0.8) 1 (1.4) 2 (0.5) 0 (0.0) 1 (0.4) 6 (0.9)
 Missing 18 (0.9) 4 (0.6) 1 (1.4) 0 (0.0) 0 (0.0) 0 (0.0) 13 (1.9)
Educational status
 High school 1855 (87.9) 550 (86.6) 53 (82.8) 373 (84.6) 44 (86.3) 205 (88.7) 630 (91.6)
 College 168 (8.0) 46 (7.2) 7 (10.9) 43 (9.8) 5 (9.8) 20 (8.7) 47 (6.8)
 Not in school 85 (4.0) 38 (6.0) 4 (6.3) 25 (5.7) 2 (3.9) 5 (2.2) 11 (1.6)
 Missing 2 (0.1) 1 (0.2) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.4) 0 (0.0)
Open in a new tab

Abbreviations: AFAB, assigned female at birth: AMAB. assigned male at birth.

2.3 |. Measures

2.3.1 |. Gender identity

Participants first reported their sex assigned at birth. Participants then selected all gender identities with which they identified: “male,” “female,” “transgender,” “female-to-male transgender/FTM,” “male-to-female transgender/MTF,” “trans male/transmasculine,” “trans female/transfeminine,” “genderqueer,” “gender expansive,” “intersex,” “androgynous,” “nonbinary,” “two-spirited,” “third gender,” “agender,” “not sure,” and “other.” For the purposes of the current study, adolescents were categorized by their gender identity and sex assigned at birth. A 6-category variable was created, including: transmasculine (those assigned female at birth who identify with a masculine gender identity), transfeminine (those assigned male at birth who identify with a feminine gender identity), nonbinary/questioning assigned female at birth (AFAB; does not identify as feminine or masculine, or is unsure of their gender identity), nonbinary/questioning assigned male at birth (AMAB; does not identify as feminine or masculine, or is unsure of their gender identity), cisgender boy, and cisgender girl. Adolescents were categorized as nonbinary if they selected genderqueer, gender expansive, intersex, androgynous, nonbinary, two-spirited, third gender, or agender but did not select any binary gender identities. Adolescents who selected they were “not sure” of their gender identity were categorized as questioning. For the current study, nonbinary and questioning adolescents were included in the same group, as they did not identify with a binary (masculine or feminine) gender identity.

2.3.2 |. Disordered eating

The Eating Pathology Symptoms Inventory (EPSI; Forbush et al., 2013) was used to assess disordered eating behaviors and attitudes. The 45-item measure has demonstrated excellent validity, internal consistency, and reliability (Forbush et al., 2013; Forbush, Wildes, & Hunt, 2014). For the current study, six of the eight subscales most rele-vant to the research questions were administered: binge eating, cognitive restraint, purging, caloric restriction, excessive exercise, and muscle building. Participants indicated how frequently, over the past 4 weeks, they endorsed a disordered eating behavior or cognition on a 5-point Likert scale, ranging from Never (0) to Very often (4). Within each subscale, items were summed, with a higher score indicating higher levels of eating pathology. High internal consistency was demonstrated for each subscale (αs ranged from .71–.89), consistent with prior research (αs= .67–.91; Christian et al., 2020, Forbush et al., 2013).

2.3.3 |. Gender identity congruence

The Transgender Congruence Scale (TCS; Kozee, Tylka, & Bauerband, 2012) was used to assess gender minority adolescents’ comfort with their gender identity and external appearance. The TCS is a psychometrically sound measure validated for use with gender minority individuals (Kozee et al., 2012). The measure consists of 12 items that assess gender minority individuals’ congruence between their gender identity and appearance over the past 6 months on a 5-point Likert scale, ranging from Strongly disagree (1) to Strongly agree (5). An example item includes “My outward appearance represents my gender identity.” The TCS can be scored with either a total score or two subscales (Kozee et al., 2012); we elected to use the total score in order to assess gender identity congruence broadly. The mean of all items was calculated, with a higher score indicating greater gender identity congruence. Internal consistency for this measure was excellent (α = .86), as has been found in prior studies with gender-nonconforming populations (αs = .79–.94; van den Brink, Vollmann, & van Weelie, 2020).

2.4 |. Statistical analyses

Analyses were conducted with SPSS Version 26 and R Version 3.6.1. To examine subgroup differences in disordered eating, a multivariate analysis of variance (MANOVA) was completed. Disordered eating was measured by combining six dependent variables: binge eating, cognitive restraint, purging, caloric restriction, excessive exercise, and muscle building. Two independent variables, sex assigned at birth (male or female) and gender identity (masculine, feminine, or nonbinary/questioning) were examined as predictors of group differences. The MANOVA examined the interaction of sex assigned at birth and gender identity, allowing us to separately assess the function of these variables on disordered eating outcomes. Follow-up analyses of variance (ANOVAs) were used to probe a significant interaction. Bonferroni corrections were used to adjust for multiple comparisons. To examine the study’s second aim, a multiple multivariate analysis was conducted to examine the association between gender identity congruence and disordered eating among gender minority adolescents. The same dependent variables were combined to measure disordered eating (binge eating, cognitive restraint, purging, caloric restriction, excessive exercise, and muscle building). Five predictor variables (gender identity congruence, race/ethnicity, sexual orientation, age, and BMI) were used to examine associations between gender identity congruence and disordered eating while controlling for important demographic characteristics. These covariates were included based on theory (i.e., they had been linked to disordered eating in prior work), and because each was significantly associated at the bivariate level with at least one dimension of disordered eating and gender identity congruence.

3 |. RESULTS

Adolescents most frequently endorsed binge eating (M = 12.67; SD = 7.58) and caloric restriction (M = 9.70; SD = 6.46). The mean scores obtained on the EPSI were within one standard deviation of those obtained in the original scale validation with cisgender collegeaged men and women (Forbush et al., 2014). Descriptive statistics are presented, by gender identity, in Table 2.

TABLE 2.

Disordered eating among gender identity subgroups

Transmasculine Transfeminine Nonbinary/questioning AFAB Nonbinary/questioning AMAB Cisgender male Cisgender female
Behavior or cognition M SD M SD M SD M SD M SD M SD
Binge eating 12.62 7.73 12.33 8.53 13.32 7.39 13.94 7.99 10.52 6.79 12.94 7.58
Cognitive restraint 4.73 3.32 3.S4 3.22 4.44 3.35 4.14 3.81 4.12 2.83 5.06 3.31
Purging 2.55 4.40 2.28 4.47 2.57 4.05 2.61 5.28 0.97 2.35 2.75 4.57
Caloric restriction 10.47 6.39 10.11 6.00 10.86 6.78 8.84 7.40 7.06 6.22 9.17 6.05
Excessive exercise 5.95 5.19 4.62 4.37 5.47 4.82 525 5.46 7.62 5.25 6.68 5.32
Muscle building 4.67 3.59 1.14 1.49 3.08 2.75 3.41 3.73 3.87 3.24 2.31 2.46
Open in a new tab

Abbreviations: AFAB, assigned female at birth; AMAB, assigned male at birth.

3.1 |. Associations between gender identity, sex assigned at birth, and disordered eating

A two-way MANOVA was used to examine the associations between gender identity, sex assigned at birth, and six dimensions of disordered eating: binge eating, cognitive restraint, purging, caloric restriction, excessive exercise, and muscle building. Full results of multivariate and follow-up univariate models are presented in Table 3. Full results from simple main effects analyses are presented in Table 4. Full results of simple comparisons are presented in Table 5. Otherwise, only significant results are presented in text.

TABLE 3.

Results of the MANOVA

Effect Pillai's trace F df p Part.η2
Multivariate model
 Intercept .73 930.73 6, 2099 < .001 .73
 Sex assigned at birth .01 3.97 6, 2099 .001 .01
 Gender identity .09 15.90 12, 4,200 < .001 .04
 Sex assigned at birth * gender identity .04 6.57 12, 4,200 < .001 .02
Folow-up univariate models
Binge eating
 Intercept 2.245.38 1, 2,104 < .001 .52
 Sex assigned at birth 1.77 1, 2,104 .184 .00
 Gender identity 6.01 2, 2,104 .002 .01
 Sex assigned at birth * gender identity 2.75 2, 2,104 .064 .00
Cognitive restraint
 Intercept 1,43613 1, 2,104 < .001 .41
 Sex assigned at birth 9.18 1, 2,104 .002 .00
 Gender identity 0.15 2, 2,104 .857 .00
 Sex assigned at birth * gender identity 1.15 2, 2,104 .317 .00
Purging
 Intercept 234.31 1, 2,104 < .001 .10
 Sex assigned at birth 5.06 1, 2,104 .025 .00
 Gender identity 4.44 2, 2,104 .012 .00
 Sex assigned at birth * gender identity 3.46 2, 2,104 .032 .00
Caloric restriction
 Intercept 1761.94 1, 2,104 < .001 .46
 Sex assigned at birth 10.65 1, 2,104 .001 .01
 Gender identity 2.89 2, 2,104 .056 .00
 Sex assigned at birth * gender identity 9.75 2, 2,104 < .001 .01
Excessive exercise
 Intercept 1.064.69 1, 2,104 < .001 .34
 Sex assigned at birth 0.31 1, 2,104 .579 .00
 Gender identity 7.86 2, 2,104 < .001 .01
 Sex assigned at birth * gender identity 11.95 2, 2,104 < .001 .01
Muscle building
 Intercept 849.59 1, 2,104 < .001 29
 Sex assigned at birth 6.78 1, 2,104 .009 .00
 Gender identity 64.29 2, 2,104 < .001 .06
 Sex assigned at birth * gender identity 3.51 2, 2,104 .030 .00
Open in a new tab

TABLE 4.

Results of simple main effects analysis

Simple main effects of gender identity
Dependent variable Sex assigned at birth F 2, 2,104 p Part. η2
Binge eating Male 5.01 .007 .01
Female 1.07 .342 .00
Cognitive restraint Male 0.21 .812 .00
Female 4.92 .007 .01
Purging Male 4.66 .010 .00
Female 0.39 .675 .00
Caloric restriction Male 6.10 .002 .01
Female 11.40 <.001 .01
Excessive exercise Male 10.85 <.001 .01
Female 7.89 <.001 .01
Muscle building Male 20.89 <.001 .02
Female 105.35 <.001 .09
Simple main effects of sex assigned at birth
Dependent variable Gender identity F 1, 2,104 p Part. η2
Binge eating Masculine 13.59 <.001 .01
Feminine 0.38 .535 .00
Nonbinary/questioning 0.31 .579 .00
Cognitive restraint Masculine 5.41 .020 .00
Feminine 8.03 .005 .00
Nonbinary/questioning 0.39 .530 .00
Purging Masculine 24.08 <.001 .01
Feminine 0.71 .401 .00
Nonbinary/questioning 0.00 .949 .00
Caloric restriction Masculine 46.24 <.001 .02
Feminine 1.27 .260 .00
Nonbinary/questioning 4.60 .032 .00
Excessive exercise Masculine 17.80 <.001 .01
Feminine 9.25 .002 .00
Nonbinary/questioning 0.09 .770 .00
Muscle building Masculine 12.37 <.001 .01
Feminine 8.94 .003 .00
Nonbinary/questioning 0.54 .462 .00
Open in a new tab

TABLE 5.

Simple comparisons analyses

Purging
 Caloric restriction
Comparison groups M difference p 95% CI LL 95% CI UL M difference p 95% CI LL 95% CI UL
Transmascuine
 Nonbinary/questioning AFAB −0.01 1.000 −0.64 0.62 −0.41 .887 −1.36 0.53
 Cisgender boys 1.59 < .001 0.96 2.23 3.32 <.001 2.36 4.27
 Cisgender girls −0.19 1.000 −0.75 0.37 1.28 .001 0.44 2.12
Transfeminine
 Nonbinary/questioning AMAB −0.33 1.000 −2.23 1.58 1.27 .868 −1.60 4.13
 Cisgender boys 1.32 .084 −0.12 2.75 2.98 .003 0.82 5.13
 Cisgender girls −0.47 .401 −1.55 0.62 0.94 2.60 −0.69 2.57
Nonbinary/questioning AFAB
 Transmasculine 0.01 1.000 −0.62 0.64 0.41 .887 −0.53 1.36
 Nonbinary/questioning AMAB −0.04 .949 −1.27 1.19 2.02 .032 0.17 3.87
 Cisgender girls −0.18 1.000 −0.80 0.44 1.69 <.001 0.76 2.62
Nonbinary/questioning AMAB
 Transfeminine 0.33 1.000 −1.58 2.23 −1.27 .868 −4.13 1.60
 Nonbinary/questioning AFAB 0.04 .949 −1.19 1.27 −2.02 .032 −3.87 −0.17
 Cisgender boys 1.64 .037 0.07 3.21 1.71 .247 −0.65 4.07
Excessive exercise
 Muscle building
Comparison groups M difference p 95% CI LL 95% CI UL M difference p 95% CI LL 95% CI UL
Transmascuine
 Nonbinary/questioning AFAB 0.48 .405 −0.29 1.24 1.60 <.001 1.15 2.04
 Cisgender boys −1.67 < .001 0.89 2.44 0.81 <.001 0.36 1.26
 Cisgender girls −0.73 .031 −1.41 −0.05 2.37 <.001 1.97 2.76
Transfeminine
 Nonbinary/questioning AMAB −0.62 1.000 −2.93 1.70 −2.27 <.001 −3.61 −0.92
 Cisgender boys −2.98 < .001 −4.72 −1.24 −2.73 <.001 −3.74 −1.72
 Cisgender girls −2.05 .002 −3.37 −0.73 −1.17 .003 −1.94 −0.40
Nonbinary/questioning AFAB
 Transmasculine −0.48 .405 −1.24 0.29 −1.60 <.001 −2.04 −1.15
 Nonbinary/questioning AMAB 0.22 .770 −1.27 1.72 −0.33 .462 −1.20 .54
 Cisgender girls −1.21 < .001 −1.96 −0.45 0.77 <.001 0.33 1.21
Nonbinary/questioning AMAB
 Transfeminine 0.62 1.000 −1.70 2.93 2.27 <.001 0.92 3.61
 Nonbinary/questioning AFAB −0.22 .770 −1.72 1.27 0.33 .462 −0.54 1.20
 Cisgender boys −2.37 .009 −4.27 −0.46 −0.46 .949 −1.57 0.65
Open in a new tab

Note: p-values reflect Bonferroni correction.

Abbreviations: AFAB, assigned female at birth; AMAB, assigned male at birth; CI, confidence interval; LL, lower level; UL, upper level.

There was a statistically significant interaction effect between sex assigned at birth and gender identity on the combined dependent variables [F(12, 4,200) = 6.57, p < .001, Pillai’s Trace = .037, partial η2 = .02]. Follow-up univariate two-way ANOVAs were run to explore this interaction further, and showed a statistically significant interaction effect between sex assigned at birth and gender identity on purging [F(2, 2,104) = 3.46, p = .032, partial η2 = .00], caloric restriction [F(2, 2,104) = 9.75, p < .001, partial η2 = .01], muscle building [F(2, 2,104) = 3.51, p = .030, partial η2 = .00], and excessive exercise [F(2, 2,104) = 11.95, p < .001, partial η2 = .01], but not binge eating (p = .064) or cognitive restraint (p = .317). After a Bonferroni correction, analyses regarding caloric restriction and excessive exercise remained significant (p < .008), while purging and muscle building were marginally significant (p < .05).

3.1.1 |. Simple main effects of gender identity

Among adolescents assigned male at birth, purging [F(2, 2,104) = 4.66, p = .010, partial η2 = .00], caloric restriction [F(2, 2,104) = 6.10, p = .002, partial η2 = .01], excessive exercise [F(2, 2,104) = 10.85, p < .001, partial η2 = .01], and muscle building differed as a function of gender identity [F(2, 2,104) = 20.89, p < .001, partial η2 = .02]. Among adolescents assigned female at birth, caloric restriction [F(2, 2,104) = 11.40, p < .001, partial η2 = .01] and muscle building [F(2, 2,104) = 105.35, p < .001, partial η2 = .09] differed as a function of gender identity.

3.1.2 |. Simple main effects of sex assigned at birth

For adolescents with a masculine gender identity, purging [F(1, 2,104) = 24.08, p < .001, partial η2 = .01], caloric restriction [F(1,2,104) = 46.24, p < .001, partial η2 = .02], excessive exercise [F (1, 2,104) = 17.80, p < .001, partial η2 = .01], and muscle building [F(1, 2,104) = 12.37, p < .001, partial η2 = .01] differed as a function of sex assigned at birth. For adolescents with a feminine gender identity, excessive exercise [F(1, 2,104) = 9.25, p = .002, partial η2 = .00] and muscle building [F(1, 2,104) = 8.94, p = .003, partial η2 = .00] differed as a function of sex assigned at birth.

Transmasculine adolescents

Transmasculine adolescents engaged in significantly greater purging than cisgender boys (p < .001), greater caloric restriction than cisgender girls (p = .001), and greater muscle building than cisgender boys, girls, and nonbinary AFAB adolescents (ps < .001). Transmasculine adolescents engaged in significantly less excessive exercise than cisgender girls (p = .031).

Transfeminine adolescents

Transfeminine adolescents engaged in significantly greater caloric restriction than cisgender boys (p = .003). They engaged in significantly less excessive exercise than cisgender girls (p = .002) and boys (p < .001), as well as less muscle building than cisgender girls (p = .003), boys (p < .001), and nonbinary/questioning AMAB adolescents (p < .001).

Nonbinary/questioning AFAB adolescents

Nonbinary/questioning AFAB adolescents engaged in significantly greater caloric restriction (p < .001) and muscle building (p < .001) than cisgender girls. However, they endorsed significantly less excessive exercise than cisgender girls (p < .001).

Nonbinary/questioning AMAB adolescents

Nonbinary/questioning AMAB adolescents endorsed significantly greater purging (p = .037) but significantly less excessive exercise (p = .009) than cisgender boys.

3.2 |. Association between gender identity congruence and disordered eating

In the multiple multivariate regression model, gender identity congruence was significantly associated with the combined dependent variables [Pillai’s lambda = .03, p < .001]. Subsequently, separate models were examined. Full results are presented in Table 6. Gender identity congruence was significantly, negatively associated with binge eating (β = −.26, p < .001), cognitive restraint (β = −.10, p = .001), purging (β = −.16, p < .001), caloric restriction (β = −.13, p = .02), and muscle building (β = −.09, p = .002). Gender identity congruence was not a significant predictor of excessive exercise (p = .063).

TABLE 6.

Association between gender identity congruence and disordered eating

Multivariate tests
 Univariate tests (β)
Effect Pillai’s λ F 6, 1,135 Binge eating Cognitive restraint Purging Caloric restriction Excessive exercise Muscle building
Gender identity congruence .03 6.03*** −.26*** −.10** −.16*** −.13* −.08 −.09**
Race/ethnicity .01 1.86 .08 .00 .07* .06 .03 .00
Sexual orientation .03 5.05*** .02 −.01 .02 .02 −.02 −.07***
Age .02 3.09** .03 .00 −.01 −.10* −.08** .01
BMI .17 38.47*** .61*** .12*** .20*** −.49*** .03 .00
Adjusted R2 .09 .02 .04 .07 .01 .02
F 5, 1,140 22.92*** 5.69*** 11.43*** 19.14*** 2.48* 5.65***
Open in a new tab
*

p < .05;

**

p < .01;

***

p < .001.

4 |. DISCUSSION

In a large sample of U.S. adolescents, significant differences in disordered eating were found between gender minority and cisgender youth. Specifically, purging, caloric restriction, excessive exercise, and muscle building differed as a function of gender identity and sex assigned at birth. Among gender minority participants, adolescents who experienced greater gender identity congruence reported lower levels of binge eating, cognitive restraint, purging, caloric restriction, and muscle building. Findings indicate that there are important differences to consider in the presentation of disordered eating between subgroups of gender minority and cisgender adolescents, underscoring the need for more research into the factors that increase gender minority adolescents’ risk for disordered eating.

Our study’s first aim involved examining the function of gender identity and sex assigned at birth on six dimensions of disordered eating, an approach that allowed for comparisons between subgroups of gender minority adolescents. We hypothesized that adolescents with feminine gender identities (transfeminine adolescents and cisgender girls) would endorse higher levels of caloric restriction, a behavior typically associated with femininity, than those with masculine gender identities. Results partially supported this hypothesis, with transfeminine adolescents reporting greater caloric restriction than cisgender boys. However, nonbinary/questioning AFAB adolescents endorsed higher caloric restriction than cisgender girls, and transmasculine adolescents engaged in greater caloric restriction than cisgender girls and boys. These results are consistent with the suggestion that, among gender minority youth, caloric restriction may be motivated by relieving gender-related distress regardless of gender identity or sex assigned at birth (Ålgars, Alanko, Santtila, & Sandnabba, 2012; Avila, Golden, & Aye, 2019; Coelho et al., 2019).

Our hypothesis that adolescents with masculine gender identities would engage in greater muscle building was partially supported. Transmasculine adolescents engaged in greater muscle building than cisgender boys, girls, and nonbinary AFAB adolescents. Furthermore, transfeminine adolescents reported less muscle building than nonbinary/questioning AMAB adolescents, cisgender boys, and cisgender girls. These findings suggest that desiring a masculine appearance may increase risk for muscle-building behaviors (Lavender, Brown, & Murray, 2017; Rodgers, Ganchou, Franko, & Chabrol, 2012). Prior research has identified muscularity-oriented body image concerns as a distinct eating disorder phenotype emerging in midadolescence when sociocultural pressures to appear masculine peak (Calzo et al., 2016). Muscle-building behaviors have also been linked to nonprescribed drug use, dietary restraint, and high eating disorder psychopathology (Calzo et al., 2016; Lavender et al., 2017). Thus, when evaluating the behaviors of adolescents who desire a masculine appearance, it may be important to assess for the use of unhealthy muscle-building practices.

An interesting pattern of results emerged regarding excessive exercise. Cisgender girls and boys both engaged in greater excessive exercise than transfeminine and transmasculine adolescents. Previous work has suggested that gender minority adolescents may use excessive exercise to relieve gender incongruence (Coelho et al., 2019), whereas presumed-cisgender adolescents may be more motivated by a desire to lose weight (White & Halliwell, 2010). Future work ought to compare whether excessive exercise serves a different function for gender minority and cisgender adolescents, and whether gender incongruence or weight dissatisfaction is more strongly associated with this behavior.

The current study is among the first to examine disordered eating among gender nonbinary adolescents, who do not identify with a singular, binary gender category (male or female), as well as questioning adolescents, who are unsure of their gender identity. In the current study, nonbinary/questioning adolescents engaged in less excessive exercise than cisgender adolescents with the same sex assigned at birth, indicating that a nonbinary or questioning gender identity may be associated with lower risk for excessive exercise. A growing number of adolescents are identifying as nonbinary or gender fluid, or are unsure of their gender identity (Diamond, 2020). In fact, this diverse category now makes up the majority of gender minority adolescents (Diamond, 2020). Because disordered eating has been thought to develop as a means to obtain masculine or feminine characteristics, nonbinary and questioning adolescents’ behaviors are especially important to examine. In the current study, nonbinary and questioning adolescents exhibited the highest rates of binge eating, a behavior known to be associated with the stigmatization and victimization gender minority adolescents experience (Watson et al., 2017). While there are femininity and masculinity hypotheses of eating disorders (Griffiths, Murray, & Touyz, 2015; Meyer, Blissett, & Oldfield, 2001; Murnen & Smolak, 1997), future research must examine the emergence of eating pathology in adolescents who identify along a gender continuum (Murray, 2017).

While some notable differences in symptom presentation emerged when examining the role of gender identity and sex assigned at birth, the similarities between gender minority and cisgender adolescents are also important to acknowledge. Further, where there were differences, effect sizes were small. For researchers and clinicians working with adolescents, the current findings suggest that all dimensions of disordered eating should be considered. In addition, these data on the prevalence of disordered eating by gender identity suggest that research designed to explore how adolescents’ motivations for engaging in unhealthy dietary behaviors differ between gender identity subgroups is warranted.

A final aim of the study was to examine the role of gender identity congruence in gender minority adolescents’ disordered eating. Results suggest that when adolescents feel greater alignment with their gender identity, they are less likely to engage in disordered eating behaviors. High gender identity congruence was associated with lower levels of binge eating, cognitive restraint, purging, caloric restriction, and muscle building. Adolescence is an important period for the consideration of techniques for increasing gender identity congruence, as more types of gender-affirming care become available at the onset of puberty (e.g., hormone therapy or pubertal suppression) (Bonifacio, Maser, Stadelman, & Palmert, 2019). Gender-affirming care has been shown to alleviate body dissatisfaction associated with specific body parts (van de Grift et al., 2016) in addition to improving body image (Becker et al., 2018) and mental health (Fontanari et al., 2020). To most effectively increase gender identity congruence among these youth, gender-affirming care ought to take the mental and physical developmental features of adolescence into account (Bonifacio et al., 2019; Romito et al., 2021).

4.1 |. Limitations and future directions

There are important limitations to consider in this study. First, assessment was limited to disordered eating symptomatology; we did not formally assess for DSM eating disorders. Second, we did not assess the underlying motivations for engaging in disordered eating. For example, it remains unknown whether gender minority and cisgender adolescents engage in caloric restriction for the same reasons, or whether this behavior is motivated by unique gender-related stressors, although recent qualitative work suggests a complex set of transgender-related and broader factors in gender minority adolescents’ disordered eating (Romito et al., 2021). Similar to cisgender adolescents, gender minority adolescents may engage in caloric restriction due to weight dissatisfaction. Further, transmasculine adolescents may use caloric restriction to reduce the appearance of breasts and hips, as well as to prevent or delay menstruation (Ålgars et al., 2012; Avila et al., 2019). Transfeminine adolescents may restrict their intake to appear thin, a trait associated with femininity (Couturier et al., 2015; Strandjord, Ng, & Rome, 2015). Importantly, behaviors typically deemed “disordered” or “pathological” may need to be reconceptualized when working with gender minority populations, as they could be motivated by non-pathological reasons, such as affirming or expressing one’s gender identity. Third, because the current study is crosssectional, we were unable to examine the temporal relationship between these phenomena. Especially in the case of adolescents, who must navigate increased sociocultural appearance pressures at a time of rapid physical change, longitudinal studies are needed to increase our understanding of the development of disordered eating, taking gender identity congruence into account. It is also important to address the current study’s data and statistical approach. While our data represented adolescents from all 50 U.S. states (plus D.C. and Puerto Rico), it was not a nationally representative dataset. The majority of cisgender adolescents in the current study reported a sexual minority identity, which is not representative of the U.S. population. Multiple multivariate regression analyses controlled for sexual orientation, though the prevalence of disordered eating reported in this sample might reflect disordered eating among sexual minorities, who have been shown to engage in disordered eating behaviors at higher rates than cisgender, heterosexual populations (Calzo, Blashill, Brown, & Argenal, 2017; Diemer et al., 2015; Simone et al., 2020). Further, effect sizes in the current study were small, indicating that observed differences and associations between constructs were modest.

In addition to the intersection of gender identity and sexual orientation, differences based on racial and ethnic identity should also be explored in future work. Adolescents with different racial and ethnic identities may have different experiences that influence their disordered eating behaviors (Austin, 2015; Beccia et al., 2019), and the compounding effect of intersectional identities on disordered eating risk is supported by emerging research (Burke, Schaefer, Hazzard, & Rodgers, 2020). Future research informed by an intersectional perspective is imperative to fully understand how multiple layers of minority identities may combine to uniquely impact disordered eating behaviors (Burke et al., 2020).

5 |. CONCLUSIONS

The current study is among the first to compare disordered eating between specific subgroups of gender minority adolescents by examining the role of gender identity in predicting these behaviors and cognitions. Our findings suggest that as researchers and clinicians, we ought to consider the unique stressors faced by gender minority youth that contribute to elevated rates of certain disordered eating behaviors, such as caloric restriction. Disordered eating has long been thought of as sexually dimorphic, primarily affecting cisgender girls and women. However, the field has begun to acknowledge that cisgender men and boys also experience disordered eating, though the clinical presentation may differ depending on whether the individual desires a masculine or feminine appearance (Murray, Rieger, Karlov, & Touyz, 2013). Research must move beyond biological sex, instead considering how gender identity, and whether it is congruent with one’s biological sex, may result in a range of clinical presentations of disordered eating (Murray, 2017). Furthermore, gender minority youth should not be considered a homogenous group, as feminine-identifying, masculine-identifying, gender nonbinary, and questioning adolescents may internalize disparate appearance ideals. Conflating these identities could disguise the presentation of disordered eating in this population. It is imperative that we consider novel mechanisms for the emergence of eating disorder symptomatology among gender minority adolescents in order to better serve this understudied population.

ACKNOWLEDGMENTS

We thank Michael Marshal for his assistance with the study design and measures. This study was funded in part by the University of Pittsburgh Central Research Development Fund through an award to Drs. Salk, Thoma, and Choukas-Bradley. Dr. Thoma was supported by NIMH grants K01 MH117142 and T32 MH018951, and Dr. Salk was supported by NIMH grant T32 MH018269.

Funding information

National Institute of Mental Health, Grant/ Award Numbers: K01 MH117142, T32 MH018269, T32 MH018951; University of Pittsburgh Central Research Development Fund

Footnotes

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request, following completion of a data sharing agreement.

REFERENCES

  1. Ålgars M, Alanko K, Santtila P, & Sandnabba NK (2012). Disordered eating and gender identity disorder: A qualitative study. Eating Disorders, 20(4), 300–311. 10.1080/10640266.2012.668482 [DOI] [PubMed] [Google Scholar]
  2. Austin SB (2015). With transgender health inequities so large and the need so great, the burden is on all of us to find solutions. Journal of Adolescent Health, 57(2), 133–134. 10.1016/j.jadohealth.2015.05.009 [DOI] [PubMed] [Google Scholar]
  3. Avila JT, Golden NH, & Aye T (2019). Eating disorder screening in transgender youth. Journal of Adolescent Health, 65(6), 815–817. 10.1016/j.jadohealth.2019.06.011 [DOI] [PubMed] [Google Scholar]
  4. 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 US high school students. Eating Behaviors, 34, 101299. 10.1016/j.eatbeh.2019.05.002 [DOI] [PubMed] [Google Scholar]
  5. Becker I, Auer M, Barkmann C, Fuss J, Möller B, Nieder TO, … Richter-Appelt H (2018). A cross-sectional multicenter study of multi-dimensional body image in adolescents and adults with gender dysphoria before and after transition-related medical interventions. Archives of Sexual Behavior, 47(8), 2335–2347. 10.1007/s10508-018-1278-4 [DOI] [PubMed] [Google Scholar]
  6. Bockting WO, & Allen MP (2012). Gender disorder, transgenderism and transsexuality. In Cash TF (Ed.), Encyclopedia of body image and human appearance (Vol. 2, pp. 445–452). San Diego, CA: Elsevier Academic Press. 10.1016/B978-0-12-384925-0.00071-7 [DOI] [Google Scholar]
  7. Bonifacio JH, Maser C, Stadelman K, & Palmert M (2019). Manage-ment of gender dysphoria in adolescents in primary care. Canadian Medical Association Journal, 191(3), E69–E75. 10.1503/cmaj.180672 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Brewster ME, Velez BL, Breslow AS, & Geiger EF (2019). Unpacking body image concerns and disordered eating for transgender women: The roles of sexual objectification and minority stress. Journal of Counseling Psychology, 66(2), 131–142. 10.1037/cou0000333 [DOI] [PubMed] [Google Scholar]
  9. 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, 1605–1609. 10.1002/eat.23371 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Calzo JP, Blashill AJ, Brown TA, & Argenal RL (2017). Eating disorders and disordered weight and shape control behaviors in sexual minority populations. Current Psychiatry Reports, 19(8), 49. 10.1007/s11920-017-0801-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Calzo JP, Horton NJ, Sonneville KR, Swanson SA, Crosby RD, Micali N, … Field AE (2016). Male eating disorder symptom pat-terns and health correlates from 13 to 26 years of age. Journal of the American Academy of Child & Adolescent Psychiatry, 55(8), 693–700.e2. 10.1016/j.jaac.2016.05.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Christian C, Perko VL, Vanzhula IA, Tregarthen JP, Forbush KT, & Levinson CA (2020). Eating disorder core symptoms and symptom pathways across developmental stages: A network analysis. Journal of Abnormal Psychology, 129(2), 177–190. 10.1037/abn0000477 [DOI] [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. Connolly MD, Zervos MJ, Barone CJ, Johnson CC, & Joseph CLM (2016). The mental health of transgender youth: Advances in understanding. Journal of Adolescent Health, 59(5), 489–495. 10.1016/j.jadohealth.2016.06.012 [DOI] [PubMed] [Google Scholar]
  15. Couturier J, Pindiprolu B, Findlay S, & Johnson N (2015). Anorexia nervosa and gender dysphoria in two adolescents. International Journal of Eating Disorders, 48(1), 151–155. [DOI] [PubMed] [Google Scholar]
  16. Diamond LM (2020). Gender fluidity and nonbinary gender identities among children and adolescents. Child Development Perspectives, 14(2), 110–115. 10.1111/cdep.12366 [DOI] [Google Scholar]
  17. Diemer EW, Grant JD, Munn-Chernoff MA, Patterson DA, & Duncan AE (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57(2), 144–149. 10.1016/j.jadohealth.2015.03.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Donaldson AA, Hall A, Neukirch J, Kasper V, Simones S, Gagnon S,… Forcier M (2018). Multidisciplinary care considerations for gender nonconforming adolescents with eating disorders: A case series. International Journal of Eating Disorders, 51(5), 475–479. 10.1002/eat.22868 [DOI] [PubMed] [Google Scholar]
  19. Fontanari AMV, Vilanova F, Schneider MA, Chinazzo I, Soll BM, Schwarz K, … Brandelli Costa A (2020). Gender affirmation is associated with transgender and gender nonbinary youth mental health improvement. LGBT Health, 7(5), 237–247. 10.1089/lgbt.2019.0046 [DOI] [PubMed] [Google Scholar]
  20. Forbush KT, Wildes JE, & Hunt TK (2014). Gender norms, psychometric properties, and validity for the eating pathology symptoms inventory: Norms, psychometric data, and validity for the EPSI. International Journal of Eating Disorders, 47(1), 85–91. 10.1002/eat.22180 [DOI] [PubMed] [Google Scholar]
  21. Forbush KT, Wildes JE, Pollack LO, Dunbar D, Luo J, Patterson K, … Watson D (2013). Development and validation of the eating pathology symptoms inventory (EPSI). Psychological Assessment, 25(3), 859–878. 10.1037/a0032639 [DOI] [PubMed] [Google Scholar]
  22. Gordon AR, Austin SB, Krieger N, White Hughto JM, & Reisner SL (2016). “I have to constantly prove to myself, to people, that I fit the bill”: Perspectives on weight and shape control behaviors among low-income, ethnically diverse young transgender women. Social Science and Medicine, 165, 141–149. 10.1016/j.socscimed.2016.07.038 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Greytak EA, Kosciw JG, & Diaz EM (2009). Harsh realities: The experiences of transgender youth in our nation’s schools. In Gay, les-bian and straight education network (GLSEN). New York, NY: Gay, Les-bian and Straight Education Network (GLSEN). https://eric.ed.gov/? id=ED505687 [Google Scholar]
  24. Griffiths S, Murray SB, & Touyz S (2015). Extending the masculinity hypothesis: An investigation of gender role conformity, body dissatisfaction, and disordered eating in young heterosexual men. Psychology of Men & Masculinity, 16(1), 108–114. [Google Scholar]
  25. 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]
  26. Hepp U, & Milos G (2002). Gender identity disorder and eating disorders. International Journal of Eating Disorders, 32(4), 473–478. 10.1002/eat.10090 [DOI] [PubMed] [Google Scholar]
  27. Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a Foundation for Better Understanding. Washing-ton, DC: The National Academies Press. 10.17226/13128 [DOI] [PubMed] [Google Scholar]
  28. Jones BA, Haycraft E, Murjan S, & Arcelus J (2016). Body dissatisfaction and disordered eating in trans people: A systematic review of the literature. International Review of Psychiatry, 28(1), 81–94. 10.3109/09540261.2015.1089217 [DOI] [PubMed] [Google Scholar]
  29. Kozee HB, Tylka TL, & Bauerband LA (2012). Measuring transgender individuals’ comfort with gender identity and appearance: Development and validation of the Transgender Congruence Scale. Psychology of Women Quarterly, 36(2), 179–196. 10.1177/0361684312442161 [DOI] [Google Scholar]
  30. Lavender JM, Brown TA, & Murray SB (2017). Men, muscles, and eating disorders: An overview of traditional and muscularity-oriented disordered eating. Current Psychiatry Reports, 19(6), 32. 10.1007/s11920-017-0787-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Meyer C, Blissett J, & Oldfield C (2001). Sexual orientation and eating psychopathology: The role of masculinity and femininity. International Journal of Eating Disorders, 29(3), 314–318. 10.1002/eat.1024 [DOI] [PubMed] [Google Scholar]
  32. Murnen SK, & Smolak L (1997). Femininity, masculinity, and disordered eating: A meta-analytic review. International Journal of Eating Disorders, 22(3), 231–242. 10.1002/(SICI)1098-108X(199711)22:3&lt;231::AID-EAT2&gt;3.0.CO;2-O [DOI] [PubMed] [Google Scholar]
  33. Murray SB (2017). Gender identity and eating disorders: The need to delineate novel pathways for eating disorder symptomatology. Journal of Adolescent Health, 60(1), 1–2. 10.1016/j.jadohealth.2016.10.004 [DOI] [PubMed] [Google Scholar]
  34. Murray SB, Rieger E, Karlov L, & Touyz SW (2013). Masculinity and femininity in the divergence of male body image concerns. Journal of Eating Disorders, 1(1), 11. 10.1186/2050-2974-1-11 [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Rodgers RF, Ganchou C, Franko DL, & Chabrol H (2012). Drive for muscularity and disordered eating among French adolescent boys: A sociocultural model. Body Image, 9(3), 318–323. 10.1016/j.bodyim.2012.03.002 [DOI] [PubMed] [Google Scholar]
  36. 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]
  37. Salk RH, Thoma BC, & Choukas-Bradley S (2020). The Gender Minor-ity Youth Study: Overview of methods and social media recruitment of a nationwide sample of U.S. cisgender and transgender adolescents. Archives of Sexual Behavior, 49(7), 2601–2610. 10.1007/s10508-020-01695-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Simone M, Askew A, Lust K, Eisenberg ME, & Pisetsky EM (2020). Disparities in self-reported eating disorders and academic impairment in sexual and gender minority college students relative to their heterosexual and cisgender peers. International Journal of Eating Disorders, 53 (4), 513–524. 10.1002/eat.23226 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Strandjord SE, Ng H, & Rome ES (2015). Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned. International Journal of Eating Disorders, 48(7), 942–945. 10.1002/eat.22438 [DOI] [PubMed] [Google Scholar]
  40. van de Grift TC, Kreukels BPC, Elfering L, Özer M, Bouman M-B, Buncamper ME, … Mullender MG (2016). Body image in transmen: Multidimensional measurement and the effects of mastectomy. The Journal of Sexual Medicine, 13(11), 1778–1786. 10.1016/j.jsxm.2016.09.003 [DOI] [PubMed] [Google Scholar]
  41. van den Brink F, Vollmann M, & van Weelie S (2020). Relationships between transgender congruence, gender identity rumination, and self-esteem in transgender and gender-nonconforming individuals. Psychology of Sexual Orientation and Gender Diversity, 7(2), 230–235. 10.1037/sgd0000357 [DOI] [Google Scholar]
  42. Watson RJ., Veal JF., & Saewyc EM. (2017). Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors. International Journal of Eating Disorders, 50(5), 515––522.. 10.1002/eat.22627 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. White J, & Halliwell E (2010). Examination of a sociocultural model of excessive exercise among male and female adolescents. Body Image, 7 (3), 227–233. 10.1016/j.bodyim.2010.02.002 [DOI] [PubMed] [Google Scholar]

Associated Data

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

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request, following completion of a data sharing agreement.

RESOURCES