Abstract
This study examined whether exposure to weight discrimination modified the association between sexual orientation, self-reported eating disorders, self-reported depression and academic impairment in a large sample of college students. Participants (n=13,782) were from the 2015–2018 College Student Health Survey. Logistic regressions tested whether weight discrimination magnified psychological health concerns and academic impairment in sexual minority students (ie, lesbian, gay) relative to their heterosexual peers and were stratified by gender (cisgender men and cisgender women). Sexual minority men and women reported more weight discrimination, eating disorders, depression, and academic impairment than their heterosexual peers, even after controlling for BMI and race. Among sexual minority men and women, weight discrimination was associated with increased eating disorders and academic impairment, but not depression. Weight discrimination increased the rate of eating disorders, depression, and academic impairment, however the rate was still higher among sexual minority students regardless of weight discrimination status or gender. College-based interventions should aim to reduce weight stigmatization and its associated influence on psychological health and academic functioning, and address the needs of sexual minority college students, as they may be at highest risk. Clinicians should work to reduce the harms of weight discrimination, particularly in sexual minority young adults.
Keywords: LGB+ health, weight discrimination, eating disorders, academic impairment, stress, sexual minority health
Sexual minority young adults, or young adults who identify as lesbian, gay, bisexual, or otherwise non-heterosexual are at increased risk for psychological health concerns, such as eating disorders and depression (Diemer et al., 2015; Russell & Fish, 2016). This brings significant cause for concern, as eating disorders have the highest mortality rate of all psychiatric illnesses (Smink, Hoeken, & Hoek, 2012) and have profound long-term health consequences for those affected (Arcelus, Mitchell, Wales, & Nielsen, 2011; Croll, Neumark-Sztainer, Story, & Ireland, 2002). Moreover, eating disorders and depression are associated with increased suicide risk (Pisetsky et al., 2013), which highlights the crucial need to reduce mental health disparities in these populations.
Mental health concerns among sexual minority college students may influence disparities in academic success. Indeed, past research suggests that sexual minority college students report more frequent mental health issues and a more frequent impact on academics because of these issues relative to their heterosexual peers (Oswalt & Wyatt, 2011). Academic impairment during college is likely to influence major career decisions and can have long-term impacts on financial well-being in sexual minority populations (Schneider & Dimito, 2010). It is critically important to address the needs of sexual minority young adults to improve both psychological health and academic success in these populations.
The minority stress theory suggests that health disparities are driven by exposure to discrimination related to a marginalized social identity (Meyer, 2003). Consistent with this theory, empirical evidence suggests sexual minority college students are exposed to discrimination related to their sexual orientation and are less likely to feel comfortable in their academic environment relative to heterosexual students (Oswalt & Wyatt, 2011). Sexual minority college students are exposed to more harassment, hostility, and violence than heterosexual college students (Oswalt & Wyatt, 2011). These experiences are known to increase stress and psychological health risk (Hatzenbuehler, 2009; Meyer, 2003), but may also have significant negative effects on academic success (Oswalt & Wyatt, 2011), and as a result, long-term career outcomes (Schneider & Dimito, 2010).
Given the known harms of sexual minority-based discrimination, exposure to additional forms of discrimination may compound minority stress and further increase health risk and academic impairment (Balsam, Molina, Beadnell, Simoni, & Walters, 2011). To this end, weight discrimination has been shown to increase risk of eating disorders, depression, and academic impairment (Braningan, 2017; Pearl, White, & Grilo, 2014), and thus may influence the relationship between sexual orientation and the outcomes of interest. Preliminary research suggests that sexual minority students may be at greater risk of exposure to weight discrimination relative to heterosexual students (Puhl, Himmelstein, & Watson, 2019). The purpose of the present study was to examine the role of weight discrimination in the relationship between sexual orientation with psychological health and academic impairment among sexual minority and heterosexual cisgender students. It was hypothesized that exposure to weight discrimination would more strongly influence psychological health and academic impairment among sexual minority college students relative to their heterosexual peers.
Materials and Methods
Sample
Participants (n=13782) include students who participated in the College Student Health Survey (CSHS; Eisenberg, Lust, Mathiason, & Porta, 2017) during years 2015–2018. The CSHS is an annual survey collected from Minnesota colleges and universities (n=27). The most recent wave of data collection was used for schools that were sampled more than once. The University of Minnesota’s Institutional Review Board approved study procedures.
Measures
Sexual Orientation.
Sexual orientation was self-reported with one question: “Which of the following terms best describes your sexual identity?” Response options include: heterosexual or straight, gay or lesbian, bisexual, I am not sure, I am not sure what this question means, and I prefer an alternative identifier. Given the nature of the study, participants who endorsed “I am not sure what this question means” were removed from the analyses. Participants who identified as: gay, lesbian, bisexual, I am not sure, and I prefer an alternative identified were categorized as sexual minority students.
Weight Discrimination.
Weight discrimination was assessed with one item derived from the everyday discrimination scale (Williams, Yu, Jackson, & Anderson, 1997). Participants selected from a list of characteristics for which they experienced discrimination, including weight. Responses to the item labeled “your weight” (yes/no) were used to identify participants who were exposed to weight discrimination.
Psychological Health Outcomes.
Psychological health was assessed with a self-reported checklist of psychological health diagnoses. Participants who reported a diagnosis of “anorexia” or “bulimia” within the past 12 months or more than 12 months ago were categorized as having a lifetime eating disorder diagnosis. Participants who reported a diagnosis of “depression” within the past 12 months or more than 12 months ago were categorized as having a lifetime depression diagnosis.
Academic Impairment.
Self-reported academic impairment was assessed from a list of 20 potential problems (e.g., being homeless) influencing academic performance. Participants who endorsed “stress” or “mental health problems” and that their “academics have been affected” by it were categorized as reporting stress-specific or mental health-specific academic impairment.
Covariates.
Because individuals living in larger bodies are known to experience more frequent weight discrimination, self-reported Body Mass Index (BMI) was included as a covariate in the models (Puhl, Andreyeva, & Brownell, 2008). Self-reported BMI (kg/m2) was calculated with self-report height and weight. Racial identity was also included as a covariate in the model. Racial identity was assessed with the question: “What is your racial identity? (Check all that apply) with response options: American Indian or Alaska Native, Asian, Black or African American, White (includes Middle Eastern), or I prefer an alternative identifier. Due to sample size restrictions, the present study included a dichotomous measure (White/Person of Color) in the analyses.
Gender Identity.
Gender identity was assessed with question: “What is your sex or current gender? (Check all that apply).” Response options included: Male, Female, TransMale/Transman, TransFemale/Transwoman, Genderqueer, I prefer an alternative identifier. Due to sample size constraints and limited statistical power, stratified logistic regression analyses included only cisgender men and cisgender women.
Analytic Strategy
All analyses were computed with SPSS 25. Chi-square tests examined prevalence of weight discrimination by sexual orientation. The sample was split into four groups based on sexual orientation and weight discrimination: heterosexual without discrimination, heterosexual with discrimination, sexual minority without discrimination, and sexual minority with discrimination. Logistic regressions with planned contrasts examined whether sexual minority students with weight discrimination are at greater frequency of self-reported eating disorders, depression, and two types of academic impairment (stress-and mental health-specific) relative to students in all remaining groups, while controlling for BMI and race. Item-level missingness in the analytic sample was very low, ranging from 0.6–1.5%. Pairwise deletion was used (e.g., missing on the independent and dependent variables) to handle item-level missingness.
Results
All sample characteristics and chi-square comparisons between sexual minority and heterosexual college students are presented in Table 1. A majority of the sample identified as heterosexual (86.4%), White (81.6%), and cisgender women (63.9%). Chi square tests revealed that sexual minority students reported greater prevalence of weight discrimination, self-reported eating disorders and depression, and both forms of academic impairment relative to heterosexual students (ps < .001).
Table 1.
Sample Characteristics of 13501 Heterosexual and Sexual Minority College Students in Minnesota from the College Student Health Survey
| Characteristic | Heterosexual Students1 (n=11847, 86.4%) | Sexual Minority Students1 (n=1654, 12.1%) |
|---|---|---|
| Gender identity | ||
| Cisgender women | 7737 (65.3)a | 1192 (72.1)b |
| Cisgender men | 4110 (34.7)a | 462 (24.9)b |
| Race2 | ||
| American Indian or Alaskan Native | 285 (2.4)a | 78 (4.7)b |
| Asian | 1249 (10.5) | 168 (10.2) |
| Black or African American | 686 (5.8) | 99 (6.09) |
| Native Hawaiian or other Pacific Islander | 42 (0.4) | 10 (0.6) |
| White (includes Middle Eastern) | 9661 (81.5) | 1347 (81.4) |
| Prefer Alternative | 223 (5.1)a | 57 (11.9)b |
| Weight discrimination | ||
| Yes | 1755 (14.8)a | 350 (21.2)b |
| No | 10092 (85.2)a | 1304 (78.8)b |
| Analytic group3 | ||
| Heterosexual and no discrimination | 10092 (74.8) | |
| Heterosexual and discrimination | 1755 (13.0) | |
| Sexual minority and no discrimination | 1304 (9.7) | |
| Sexual minority and discrimination | 350 (2.6) | |
| Outcomes | ||
| Eating disorders | 398 (3.4)a | 143 (8.8)b |
| Depression | 2957 (25.2)a | 822 (50.2)b |
| Stress-specific academic impairment | 8459 (72.0)a | 1404 (85.6)b |
| Mental health-specific academic impairment | 4027 (34.2)a | 1073 (65.6)b |
Note. Superscript letters reflect group differences across columns based on the results of chi-square tests where p<.05;
Data represent the No. (%) within each group;
Participants were able to respond with more than one racial category, resulting in a total percentage greater than 100;
Data represent the No. (%) of the entire sample
Adjusted logistic regression results revealed significant differences in self-reported eating disorders and depression, and academic impairment for both cisgender men and women. Sexual minority cisgender men and women were more likely to endorse self-reported eating disorders and depression, as well as mental health-and stress-specific academic impairment relative to heterosexual cisgender men and women, regardless of weight discrimination exposure status.
The results also revealed minor gender differences in the role of weight discrimination in the association between sexual orientation, psychological health, and academic impairment particularly among sexual minority students. Adjusted logistic regression results and their associated pairwise comparisons for cisgender men are presented in Table 2. Relative to heterosexual cisgender men who did not experience weight discrimination, sexual minority cisgender men who experienced weight discrimination experienced 6.75 times greater risk of a self-reported eating disorder, 3.30 times greater risk of self-reported depression, 5.95 times greater risk of stress-specific academic impairment, and 5.09 times greater risk of mental health-specific academic impairment. Among sexual minority cisgender men, exposure to weight discrimination was associated with higher rates of self-reported eating disorders and stress-specific academic impairment, but not depression or mental health-specific academic impairment.
Table 2.
Adjusted logistic regression outcomes reflecting higher rates of eating disorders, depression, and two forms of academic impairment among sexual minority cisgender men relative to their heterosexual peers
| Variablesa | N | % | B | SE | OR | CI | Pairwise Group Comparisons |
|---|---|---|---|---|---|---|---|
| Eating Disorders (n=12694) | |||||||
| 1. Heterosexual no WD | 27 | 0.8 | -- | -- | -- | -- | 1 < 2 = 3 < 4 |
| 2. Heterosexual with WD | 7 | 1.3 | 0.72 | 0.47 | 2.06 | 0.82–5.17 | |
| 3. Sexual minority no WD | 10 | 2.7 | 1.28 | 0.40 | 3.60** | 1.65–7.82 | |
| 4. Sexual minority with WD | 4 | 5.1 | 1.91 | 0.63 | 6.75* | 1.96–23.23 | |
| Depression (n=12767) | |||||||
| 1. Heterosexual no WD | 605 | 17.1 | -- | -- | -- | -- | |
| 2. Heterosexual with WD | 132 | 24.7 | 0.28 | 0.12 | 1.32* | 1.04–1.68 | 1 < 2 < 3 = 4 |
| 3. Sexual minority no WD | 117 | 31.4 | 0.79 | 0.13 | 2.20** | 1.71–2.83 | |
| 4. Sexual minority with WD | 38 | 47.5 | 1.20 | 0.24 | 3.30** | 2.05–5.31 | |
| Stress AI (n=12778) | |||||||
| 1. Heterosexual no WD | 2038 | 57.6 | -- | -- | -- | -- | |
| 2. Heterosexual with WD | 371 | 69.3 | 0.45 | 0.11 | 1.56** | 1.26–1.93 | 1 < 2 = 3 < 4 |
| 3. Sexual minority no WD | 280 | 74.5 | 0.70 | 0.13 | 2.02** | 1.56–2.62 | |
| 4. Sexual minority with WD | 72 | 88.9 | 1.78 | 0.38 | 5.95** | 2.84–12.46 | |
| Mental health AI (n=12794) | |||||||
| 1. Heterosexual no WD | 743 | 21.0 | -- | -- | -- | -- | 1 < 2 < 3 = 4 |
| 2. Heterosexual with WD | 184 | 34.3 | 0.59 | 0.11 | 1.80** | 1.45–2.23 | |
| 3. Sexual minority no WD | 174 | 46.2 | 1.16 | 0.12 | 3.17** | 2.51–4.01 | |
| 4. Sexual minority with WD | 50 | 61.7 | 1.63 | 0.24 | 5.09** | 3.16–8.19 |
=all analyses controlled for BMI and Race; B=unstandardized beta; SE=standard error; OR=Odds Ratio; CIs=95% confidence intervals; WD=weight discrimination; AI=academic impairment;
= p<.001;
= p<.05
Logistic regression and pairwise comparison results for cisgender women are presented in Table 3. Relative to heterosexual women who did not experience weight discrimination sexual minority women who experienced weight discrimination were 4.69 times more likely to self-report an eating disorder, 4.27 more likely to self-report depression, 3.63 times more likely to endorse stress-specific academic impairment, and 6.21 times more likely to endorse mental health-specific academic impairment. Exposure to weight discrimination did not influence likelihood of self-reported depression diagnoses among sexual minority cisgender women.
Table 3.
Adjusted logistic regression outcomes reflecting increased prevalence of self-reported eating disorders and two forms of academic impairment among sexual minority cisgender women who experience weight discrimination relative to their peers
| Variablesa | N | % | B | SE | OR | CI | Pairwise Group Comparisons |
|---|---|---|---|---|---|---|---|
| Eating Disorders (n=12694) | |||||||
| 1. Heterosexual no WD | 297 | 4.6 | -- | -- | -- | -- | 1 < 2 < 3 < 4 |
| 2. Heterosexual with WD | 67 | 5.6 | 0.43 | 0.15 | 1.53* | 1.15–2.05 | |
| 3. Sexual minority no WD | 90 | 9.9 | 0.86 | 0.13 | 2.35** | 1.83–3.02 | |
| 4. Sexual minority with WD | 39 | 14.8 | 1.55 | 0.20 | 4.69** | 3.18–6.93 | |
| Depression (n=12767) | |||||||
| 1. Heterosexual no WD | 1710 | 26.4 | -- | -- | -- | -- | 1 < 2 < 3 = 4 |
| 2. Heterosexual with WD | 510 | 42.1 | 0.47 | 0.07 | 1.61** | 1.40–1.84 | |
| 3. Sexual minority no WD | 492 | 53.6 | 1.19 | 0.07 | 3.30** | 2.85–3.82 | |
| 4. Sexual minority with WD | 175 | 65.8 | 1.45 | 0.14 | 4.27** | 3.25–5.60 | |
| Stress AI (n=12778) | |||||||
| 1. Heterosexual no WD | 4983 | 77.0 | -- | -- | -- | -- | 1 < 2 = 3 < 4 |
| 2. Heterosexual with WD | 1067 | 88.3 | 0.82 | 0.10 | 2.26** | 1.85–2.76 | |
| 3. Sexual minority no WD | 804 | 87.8 | 0.77 | 0.11 | 2.17** | 1.75–2.68 | |
| 4. Sexual minority with WD | 248 | 92.5 | 1.29 | 0.24 | 3.63** | 2.26–5.84 | |
| Mental health AI (n=12794) | |||||||
| 1. Heterosexual no WD | 2426 | 37.4 | -- | -- | -- | -- | 1 < 2 < 3 < 4 |
| 2. Heterosexual with WD | 674 | 55.6 | 0.67 | 0.07 | 1.95** | 1.70–2.23 | |
| 3. Sexual minority no WD | 638 | 69.9 | 1.37 | 0.08 | 3.93** | 3.37–4.58 | |
| 4. Sexual minority with WD | 221 | 79.6 | 1.83 | 0.16 | 6.21** | 4.53–8.52 |
=all analyses controlled for BMI and Race; B=unstandardized beta; SE=standard error; OR=Odds Ratio; CIs=95% confidence intervals; WD=weight discrimination; AI=academic impairment;
= p<.001;
= p<.01
Exposure to weight discrimination among heterosexual cisgender men and heterosexual cisgender women was associated with a greater likelihood of self-reported eating disorders, self-reported depression, stress-specific academic impairment, and mental health-specific academic impairment. In general, heterosexual men and heterosexual women who did not experience weight discrimination were least likely to endorse a lifetime eating disorder or depression diagnosis, or stress-specific and mental health-specific academic impairment.
Discussion
The present study examined the role of weight discrimination on rates of self-reported eating disorders and depression, as well as two measures of academic impairment among heterosexual and sexual minority college students. The results of the present study indicated that sexual minority college students experience more weight discrimination than their heterosexual peers and that exposure to weight discrimination was associated with higher rates eating disorder and depression diagnoses, as well as two forms of academic impairment.
The results from the current study partially supported the hypothesis that exposure to weight discrimination more strongly influences psychological health and academic impairment among sexual minority college students relative to their heterosexual peers. Specifically, the present findings provided significant evidence that exposure to weight discrimination is associated with an increased likelihood of self-reported eating disorders among sexual minority cisgender men and women. Exposure to weight discrimination among sexual minority cisgender men and women was associated with a greater likelihood of a self-reported eating disorder. Indeed, sexual minority cisgender men and women reported the highest rate of self-reported eating disorders, (5.1% and 14.5%, respectively) across all groups. In contrast, while sexual minority cisgender men and women who experienced weight discrimination reported the highest rates of self-reported depression (47.5% and 65.8%, respectively), the differences between sexual minority cisgender men and women who were or were not exposed to weight discrimination were insignificant. This finding suggests that exposure to weight discrimination among sexual minority college students may only inflate risk of outcomes directly associated with weight and eating concerns, such as self-reported eating disorders. However, the present results still provide support for the minority stress framework (Meyer, 2003) as likelihood of self-reported eating disorders, self-reported depression, and academic impairment were higher among sexual minority cisgender men and women regardless of weight discrimination exposure.
Sexual minority cisgender men who were exposed to weight discrimination were more likely to report stress-specific academic impairment relative to sexual minority men who did not experience weight discrimination and heterosexual men who did and did not experience weight discrimination. In contrast, exposure to weight discrimination among sexual minority cisgender women was associated with higher rates of self-reported eating disorder diagnoses and both mental health-and stress-specific academic impairment relative to sexual minority cisgender women who did not experience weight discrimination and heterosexual cisgender women who did and did not experience weight discrimination. This finding suggests that the influence of weight discrimination on academic impairment may be particularly strong for sexual minority cisgender women. In sum, sexual minority college students reported a higher frequency of self-reported eating disorders, self-reported depression, academic impairment, and exposure to weight discrimination relative to their heterosexual peers, regardless of their BMI or racial identity, highlighting a critical need for preventive interventions among these communities.
The results from the present study revealed increased psychological health risk and academic impairment following exposure to weight discrimination among heterosexual students. Specifically, among heterosexual cisgender men and women, exposure to weight discrimination was associated with increased rates of self-reported eating disorders, self-reported depression, as well as both mental health-and stress-specific academic impairment. Colleges should seek to reduce prevalence of weight discrimination on college campuses, among students, staff, and faculty, to reduce its relative influence on academic functioning among students. Such efforts should consider the unique needs of sexual minority college students to ensure that all students experience the benefits of such efforts.
Limitations of the study include that it was a brief, self-report assessment of psychological health variables. Future research should aim to examine disparities in the harms of weight discrimination among sexual minority college students using well-validated clinical assessments. Additionally, the present study included one question about gender identity that included terminology associated with sex assigned at birth rather than two separate questions; one assessing sex assigned at birth and one measuring gender identity. The current study only included cisgender identified men and women due to small sample sizes among transgender and genderqueer college students. Due to small sample sizes, the present study examined sexual minority college students as a single group, rather than several distinct and unique subgroups of individuals (ie, gay, lesbian, queer). Future studies should seek to examine differences in the consequences of weight discrimination exposure across subgroups of sexual minority young adults. Similarly, due to a lack of statistical power, the present study included race as a dichotomous variable rather than a categorical variable representing the several potential racial identities. It is possible that the intersection sexual orientation and weight discrimination differentially relate to race in a more nuanced way that cannot be accounted for with a dichotomous measure of race. As such, future studies should seek to examine the intersection of sexual orientation, weight, and a full spectrum of racial identities. The study included a small number of sexual minority men who were exposed to weight discrimination and experienced a self-reported eating disorder (n=4). While the logistic regression had enough power to test the desired effects, the 95% confidence intervals were quite wide, suggesting that future research should seek to replicate the present findings. The sample was limited to college students in Minnesota and thus the generalizability may be limited. The cross-sectional nature of the study also restricts the ability to examine the temporality of the associations included the study. Future studies including a national-level sample with multiple measurement occasions are needed.
In sum, the present study sheds light on the burden of weight discrimination among sexual minority students. The results from the present study suggest that interventions should target the unique concerns of sexual minority students (ie, sexual minority stigma). The identified disparities in psychological health and academic impairment in response to weight discrimination among heterosexual and sexual minority students suggest that colleges should aim to improve campus climate, and more specifically, the high rates of discrimination and victimization on college campuses. The minimal gender differences revealed in the present study indicate that prevention efforts may target sexual minority men and women in the same programs. Interventions tailored for sexual minority college students should target internalized weight discrimination and body image, as well sexual minority stress processes, such as internalized homophobia, concealment of sexual orientation, and coping strategies (Meyer, 2003) to reduce the psychological and academic burden of multiple forms of minority stress.
Clinical Implications.
Sexual minority college students are at increased mental health risk
Mental health risk is influenced by multiple forms of discrimination
Academic impairment is influenced by exposure to discrimination
Sexual minority college students may be more vulnerable to weight discrimination
Acknowledgements
This work was supported by the National Institute of Mental Health under Award Number T32MH082761 (PI: Scott Crow). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.
Footnotes
Declaration of Interest Statement
No competing financial interests exist.
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