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. Author manuscript; available in PMC: 2021 Aug 23.
Published in final edited form as: Eat Behav. 2021 May 15;42:101528. doi: 10.1016/j.eatbeh.2021.101528

Characterizing eating disorder diagnosis and related outcomes by sexual orientation and gender identity in a national sample of college students

Anne Claire Grammer a,*, Melissa M Vázquez a, Ellen E Fitzsimmons-Craft a, Lauren A Fowler a, Gavin N Rackoff b, Natasha A Schvey c, Sarah Ketchen Lipson d, Michelle G Newman b, Daniel Eisenberg e, C Barr Taylor f,g, Denise E Wilfley a
PMCID: PMC8380708  NIHMSID: NIHMS1718971  PMID: 34049053

Abstract

Objective:

In a national sample of college students, the current study aimed to: 1) examine differences in probable diagnoses of EDs (i.e., anorexia nervosa (AN), clinical/subthreshold bulimia nervosa (BN), or binge eating disorder (BED)) and weight and shape concerns by sexual orientation and gender identity, and 2) examine differences in ED chronicity and probable comorbid psychiatric diagnoses by sexual orientation and gender identity.

Method:

Students across nine U.S. universities completed an online screener for DSM-5 clinical or subthreshold ED diagnoses, comorbid depression and anxiety disorders, and self-reported ED chronicity. Self-reported sexual orientation and gender identity were also collected. Tukey-corrected logistic and linear regressions examined differences in outcomes separately by sexual orientation and gender identity, adjusting for age, race, and ethnicity.

Results:

A total of 8,531 students (24% sexually diverse (SD); 2.7% gender diverse (GD)) were studied. Students who identified as bisexual or other sexual orientation reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to heterosexual students. Cisgender female students and GD students reported significantly greater odds of a probable ED diagnosis and greater elevations in weight and shape concerns compared to cisgender male students. Some SD students and GD students who met criteria for probable EDs were also more likely to report chronic ED symptoms and probable comorbid psychiatric diagnoses compared to heterosexual students and cisgender males, respectively.

Discussion:

Some SGD students may be at heightened risk for EDs, highlighting the need to identify mechanisms that contribute to disparities.

Keywords: College students, Eating disorders, Sexual and gender diverse, Comorbidities

1. Introduction

Approximately 13.5% of females and 3.6% of males enrolled at U.S. universities screen positive for a clinical eating disorder (ED) (Eisenberg et al., 2011), and an additional 20–67% of college students report ED symptoms (Eisenberg et al., 2011; Hoerr et al., 2002; Lipson & Sonneville, 2017). EDs are highly comorbid with other psychiatric diagnoses (e.g., depression, anxiety; Eisenberg, Gollust, et al., 2007) and associated with severe medical complications (Mitchell, 2016; Mitchell & Crow, 2006) and academic impairment (Simone et al., 2020). However, only 20% of students with EDs report receiving treatment (Fitzsimmons-Craft, Karam, et al., 2019). Delayed detection and treatment of EDs may further disease progression (Ward et al., 2019), highlighting the need for early screening, particularly in at-risk subgroups of college students (Grammer et al., 2020).

Recent reviews (Calzo et al., 2017; Grammer et al., 2019; Miller & Luk, 2019) suggest that young adults who identify as sexually diverse (SD) (i.e., those who do not identify as heterosexual) and/or gender diverse (GD) (i.e., those whose sex assigned at birth is discordant with their gender identity or who have diverse gender identities/gender expressions) are at increased risk for EDs and ED symptoms. These disparities may be explained, in part, by minority stress and sociocultural mechanisms. Minority stress theory posits that poor health outcomes in sexual and gender diverse (SGD) populations result from the experience of discrimination, prejudice, and internalized stigma associated with one’s minority status (Meyer, 2003). Thus, disordered eating may develop as a maladaptive coping strategy for managing anxiety and depressive symptoms associated with minority stress (Katz-Wise et al., 2017a) and lack of social support from family and peers (Watson et al., 2017). Sociocultural theories posit that SGD persons are at heightened risk for EDs due to internalization of SGD-specific community appearance standards (Calzo et al., 2017). This may lead to disordered eating or appearance-altering behaviors to conform to these standards or to conceal natal sex characteristics inconsistent with their gender identity or expression (Coelho et al., 2019). In support of minority stress theory, SGD college students experience unique stressors such as higher rates of harassment, discrimination, and greater perceived barriers to accessing inclusive mental health care compared to cisgender, heterosexual students (Bouris & Hill, 2017; Dunbar et al., 2017). Further, in support of sociocultural theory, GD college students (Diemer et al., 2015) and SD male college students (Laska et al., 2015) report higher body dissatisfaction and more frequent use of unhealthy weight control behaviors, whereas findings among SD female students are less consistent (Laska et al., 2015; VanKim et al., 2015).

To date, there are a paucity of national data on probable ED diagnoses and ED-related symptoms by sexual orientation and gender identity in college students, and prior findings indicate that ED rates and ED symptoms vary substantially within SGD subgroups (Diemer et al., 2015; Hazzard et al., 2020; Laska et al., 2015; Lipson et al., 2019; Matthews-Ewald et al., 2014; Simone et al., 2020; Sonneville & Lipson, 2018). Previous research has shown elevations in probable ED diagnoses and ED symptoms among cisgender college students who identified as gay, bisexual, or unsure/questioning compared to cisgender, heterosexual students (Diemer et al., 2015; Hazzard et al., 2020; Matthews-Ewald et al., 2014; Simone et al., 2020). Preliminary findings in GD college students showed that students who identify as transgender or gender-queer/gender-nonconforming demonstrated elevations in ED diagnoses compared to cisgender males or females (Diemer et al., 2015; Lipson et al., 2019; Simone et al., 2020). Further examination of ED diagnoses and symptoms by SGD status in college students is crucial given that emerging adulthood is a critical period for the development and persistence of EDs (Goldschmidt et al., 2016; Nelson et al., 2008; Ward et al., 2019) as well as sexual orientation and gender identity developmental milestones (e.g., coming out, transitioning; Katz-Wise et al., 2017b). Additionally, the salience of ED risk factors (e.g., body dissatisfaction, unhealthy weight control behaviors) among SGD college students may contribute to a more severe clinical presentation compared to cisgender, heterosexual students; however, to date, no studies have examined whether ED chronicity and psychiatric comorbidities vary by SGD status in college students who screen positive for EDs.

The present study used a national sample of U.S. college students to examine differences in probable ED diagnoses and weight and shape concerns stratified by sexual orientation and gender identity separately. A secondary aim was to examine differences in ED chronicity and self-reported comorbid disorders (i.e., depression, anxiety) stratified by sexual orientation and gender identity separately among those with probable ED diagnoses. In line with recent findings, we hypothesized that students who identified as bisexual or GD would be more likely to screen positive for EDs and report greater weight and shape concerns compared to students who identify as heterosexual or cisgender male, respectively. Among students who screened positive for EDs, we hypothesized that students who identified as bisexual or GD would be more likely to report chronic ED symptoms and screen positive for comorbid disorders compared to students identifying as heterosexual or cisgender male, respectively.

2. Material and methods

2.1. Participants

Data were collected from 11,576 students across nine U.S. universities who completed online screening for an ongoing randomized control trial evaluating a mobile self-help program (Clinicaltrials.gov ID: NCT04162847). Participants were eligible for the screen if they were ≥18 years of age; enrolled at one of the nine participating universities; provided informed consent to participate in the screen; and passed a one-item attention check. Participants were excluded for failing to provide informed consent (n = 1,568), being under 18 years old (n = 25), or failing an attention check (n = 1,406). The final sample of eligible students were 8,577 students from public and private universities across the Northeast (n = 2,843), South (n = 2,969), Midwest (n = 1,103), and West (n = 1,662). Of the 8,577 students who were eligible for the study, 8,531 students (99.4%) reported their sexual orientation (s) and gender identity/identities and were included in the analyses.

2.2. Procedure

Students enrolled at participating universities received an email invitation to complete a brief survey on health and well-being. The survey was administered through Qualtrics. Participating students were entered in a raffle to win one of several $100 gift cards. In total, 83,512 recruitment emails were sent, with a response rate of 13.9%. The protocol was approved by the Institutional Review Boards at the coordinating universities.

2.3. Measures

2.3.1. Sexual orientation

Sexual orientation was assessed with the item: “How would you describe your sexual orientation? (select all that apply)”. Response options were heterosexual, lesbian, gay, bisexual, queer, questioning, or other orientation (self-identify).

2.3.2. Gender identity

Gender identity was assessed with the item: “What is your gender identity?” Response options were male, female, trans male/trans man, trans female/trans woman, genderqueer/gender non-conforming, or other gender identity (self-identify).

2.3.3. Probable ED diagnosis

A probable diagnosis of anorexia nervosa (AN) or clinical/subthreshold bulimia nervosa/binge eating disorder (BN/BED) was measured using the self-report Stanford-Washington University ED Screen (SWED) (Graham et al., 2019). The SWED includes 11 items adapted from psychometrically valid measures of ED behaviors and cognitions in addition to self-reported height and weight. The SWED has been validated in a sample of college females and demonstrates good sensitivity (0.80) and specificity (0.82) for detecting EDs compared to semi-structured diagnostic interviews (Graham et al., 2019). Given that students in the current sample did not exclusively identify as female, items on the SWED were modified to include gender-neutral language. Participants screened positive for a probable DSM-5 diagnosis of AN if they scored ≥59 on the Weight Concerns Scale and had a body mass index (BMI) ≤ 18.45 based on self-reported height and weight. Participants screened positive for probable DSM-5 diagnosis of clinical/subthreshold BN/BED if they endorsed six or more objective binge episodes, vomiting episodes, and/or diuretic/laxative episodes to control shape or weight in the past three months.

2.3.4. Weight and shape concerns

Weight and shape concerns were assessed using the Weight and Shape Concerns Scale (WCS), a 5-item self-report measure of ED attitudes (Killen et al., 1994; Killen et al., 1996). Total scores ranged from 0 to 100, with higher scores indicating greater weight/shape concerns. A score of 47 indicates elevated weight/shape concerns; this cut-off has fair sensitivity (0.79) and specificity (0.67) (Jacobi et al., 2004).

2.3.5. ED chronicity

Self-reported onset of ED symptoms was assessed with the item: You indicated that you have been experiencing some concerns related to your eating, shape, or weight. When did you first start experiencing these concerns? Responses were on a 7-point scale ranging from 1 (“Within the past month”) to 7 (“More than 5 years ago”), with higher numbers indicating greater chronicity. Responses to this continuous item were negatively skewed and unsuitable for linear regression; we therefore dichotomized responses using a theory-driven cutoff to be compatible with binary logistic regression (MacCallum et al., 2002). A cutoff of 6 was used, where “1” indicated >6 (i.e., ED symptoms started more than 5 years ago) and “0” indicated ≤6 (i.e., ED symptoms started less than 5 years ago). The cutoff of 5 years or more was chosen consistent with the severe and enduring ED literature, which defines chronic EDs as having persisted for a minimum 5-year duration (Wonderlich et al., 2012).

2.3.6. Comorbid psychiatric diagnoses

2.3.6.1. Probable major depressive disorder (MDD) diagnosis.

MDD symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) (Kroenke et al., 2001). Participants reported frequency of MDD symptoms over the past two weeks on a four-point scale ranging from 0 (“Not at all”) to 3 (“Nearly every day”). The PHQ-9 ranges from 0 to 27, and a clinical cut-off of 10 was used to dichotomize the presence or absence of a probable DSM-5 MDD diagnosis. This cut-off demonstrates good sensitivity (0.88) and specificity (0.85) compared to semi-structured diagnostic interviews (Levis et al., 2019).

2.3.6.2. Probable anxiety disorder diagnosis.

Participants screened positive for a probable anxiety disorder if they met criteria for either social anxiety disorder (SAD), generalized anxiety disorder (GAD), or panic disorder (PD) according to self-report questionnaires. Probable SAD was assessed using the Social Phobia Diagnostic Questionnaire (SDPQ) (Newman et al., 2003). Probable GAD was assessed using the Generalized Anxiety Disorder Questionnaire-IV (GADQ-IV) (Newman et al., 2002). Probable PD was assessed using the Panic Disorder Self-Report (PDSR) (Newman et al., 2006). The SPDQ, GAD-IV, and PDSR assess the primary DSM-5 diagnostic criteria for SAD, GAD, and PD, respectively. Accordingly, each scale demonstrates good sensitivity and specificity, as well as excellent kappa agreement compared to semi-structured interviews (Newman et al., 2002; Newman et al., 2003; Newman et al., 2006).

2.4. Statistical analyses

Analyses were performed in R version 4.0.2. Binary logistic regressions (for categorical outcomes) and linear regressions (for continuous outcomes) were conducted to examine differences in probable DSM-5 diagnosis of any ED (i.e., AN or clinical/subthreshold BED/BN) and weight and shape concerns by sexual orientation collapsed across gender identity and gender identity collapsed across sexual orientation in the entire sample.1 Binary logistic regressions were conducted to examine ED chronicity and comorbid diagnoses (i.e., depression and anxiety) by sexual orientation collapsed across gender identity and by gender identity collapsed across sexual orientation only among students who screened positive for probable ED diagnoses. Significant results were followed with Tukey post-hoc tests to control for multiple comparisons. All logistic and linear regressions controlled for age, race (White vs. Non-White), and ethnicity (Hispanic vs. Non-Hispanic) given the associations among these variables and probable ED diagnosis in college students (Sonneville & Lipson, 2018). Prevalence estimates and means also adjusted for age, race, and ethnicity. Missing dependent variable data were handled using pairwise deletion. As such, the sample sizes for each analysis varied and are noted in the tables. Significance was defined at p ≤ .05.

3. Results

3.1. Sample characteristics

Students (M age = 19.20, SD age = 2.94) were predominately White (69.3%), Non-Hispanic (87.8%), and undergraduates (99.6%). 2,048 students (24%) identified as SD, and 234 students (2.7%) identified as GD. Sample characteristics of the entire sample stratified by gender identity are included in Table 1. Students who selected more than one sexual orientation, identified as queer, questioning, or other sexual orientation were combined into other sexual orientation to increase power. Due to the small number of individuals who identified as transgender and/or as other gender identities, a GD variable was created to categorize those who identified as trans male/trans man, trans female/trans woman, genderqueer/gender non-conforming, or other gender identity.

Table 1.

Participant demographics by gender identity.

Cisgender female (N = 5844) Cisgender male (N = 2453) Gender diverse (N = 234)
Sexual orientation
 Heterosexual 4365 (74.7%) 2113 (86.1%) 5 (2.1%)
 Gay or lesbian 144 (2.5%) 118 (4.8%) 38 (16.2%)
 Bisexual 742 (12.7%) 114 (4.6%) 59 (25.2%)
 Other sexual orientation 593 (10.1%) 108 (4.4%) 132 (56.5%)
Race
 White 4056 (69.4%) 1702 (69.4%) 158 (67.5%)
 Non-White 1486 (25.4%) 626 (25.5%) 61 (26.1%)
Ethnicity
 Hispanic 728 (12.5%) 261 (10.6%) 23 (9.8%)
 Non-Hispanic 5097 (87.2%) 2181 (88.9%) 211 (90.2%)
Age M (SD) (range = 18–66) 19.20 (2.92) 19.40 (3.05) 19.30 (2.30)
School level
 Graduate school 23 (0.4%) 3 (0.1%) 3 (1.3%)
 Other 3 (0.1%) 2 (0.1%) 1 (0.4%)
 Undergraduate 5817 (99.5%) 2447 (99.8%) 230 (98.3%)
Probable AN diagnosis 145 (2.5%) 13 (0.5%) 4 (1.7%)
Probable clinical/subthreshold BN/BED diagnosis 767 (13.1%) 227 (9.3%) 31 (13.2%)
Weight and shape concerns M (SD) (range = 0–100) 46.50 (25.4) 28.80 (22.3) 42.70 (26.3)
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Note. Values are n (%) unless otherwise noted as M (SD). Percentages were computed based on the total number of participants with complete data on a given variable.

Abbreviations: AN, anorexia nervosa; BN; bulimia nervosa; BED, binge eating disorder.

3.2. Comparisons by sexual orientation

3.2.1. Probable ED diagnoses and weight and shape concerns

Probable DSM-5 diagnoses varied by sexual orientation (Table 2). Compared to heterosexual students, students who identified as bisexual (OR = 1.54; 95% CI: 1.27–1.86) or other sexual orientation (OR = 1.48; 95% CI: 1.21–1.81) had greater odds of a probable ED diagnosis. Weight and shape concerns varied by sexual orientation (Table 3). Bisexual students (M = 50.0, SE = 0.98) demonstrated significantly higher and clinically elevated weight and shape concerns compared to heterosexual students (M = 40.10, SE = 0.57) and students who identified as other sexual orientation (M = 44.30, SE = 1.02), or gay/lesbian (M = 42.10, SE = 1.62). Students who identified as other sexual orientation also reported higher weight and shape concerns compared to heterosexual students.

Table 2.

Summary of adjusted logistic regressions examining probable ED diagnoses by sexual orientation and gender identity in the entire sample.

n (%) B SE OR 95% CI
Probable ED diagnosis of AN or BN/BED (N = 1171)
Sexual orientation (Wald χ2 (3) = 30.17, p < .001)
 Heterosexual (ref) (N = 5978) 821 (13.7%) – – – –
 Gay or lesbian (N = 277) 38 (13.7%) 0.01 0.18 1.01 0.69–1.43
 Bisexual (N = 838) 167 (24.9%) 0.43 0.10 1.54*** 1.27–1.86
 Other sexual orientation (N = 752) 145 (19.3%) 0.39 0.10 1.48*** 1.21–1.81
Gender identity (Wald χ2 (2) = 45.11, p < .001)
 Cisgender male (ref) (N = 2264) 240 (10.6%) – – – –
 Cisgender female (N = 5368) 897 (16.7%) 0.53 0.08 1.71*** 1.46–2.00**
 Gender diverse (N = 213) 34 (16.0%) 0.52 0.20 1.68* 1.11–2.47
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Note. Tukey-corrected models and prevalence estimates adjusted for age, race, and ethnicity.

Abbreviations: ED, eating disorder; AN, anorexia nervosa; BN, bulimia nervosa; BED, binge eating disorder; OR, odds ratio; SE, standard error; CI, confidence interval.

***

p < .001.

**

p < .01.

*

p ≤ .05.

Table 3.

Summary of adjusted linear regressions examining weight and shape concerns by sexual orientation and gender identity in the entire sample.

B SE M 95% CI Significant contrasts
Shape and weight concerns
Sexual orientation (F(6,8013) = 25.19, p < .001)
 Heterosexual (ref) – – – –
 Gay or lesbian 1.99 1.58 42.10 − 1.11–5.09
 Bisexual 9.89 0.93 50.0*** 8.05–11.72 B > H, O, G/L
 Other sexual orientation 4.22 0.98 44.30*** 2.30–6.14 O > H
Gender identity (F (5,8014) = 176.8, p < .001)
 Cisgender male (ref) – – – –
 Cisgender female 17.81 0.61 46.80*** 16.61–19.01 F > M
 Gender diverse 14.41 1.74 43.40*** 11.00–17.82 GD > M
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Note. Tukey-corrected models and means adjusted for age, race, and ethnicity. All contrasts were significant at p < .001. Standard errors are of the adjusted regression coefficients not adjusted means.

Abbreviations: H, heterosexual; G/L, gay/lesbian; B, bisexual; O, other sexual orientation; SE, standard error; CI, confidence interval.

3.2.2. ED chronicity and psychiatric comorbidity among students with probable ED diagnoses

There were sexual orientation differences in the probability of ED chronicity and psychiatric comorbidities among students with probable ED diagnoses (Table 4). Students who identified as bisexual (OR = 1.74; 95% CI: 1.19–2.54) or other sexual orientation (OR = 1.78; 95% CI: 1.22–2.62) were more likely to have reported chronic ED symptoms for more than five years compared to heterosexual students. Compared to heterosexual students, students who identified as bisexual (ORs = 2.60, 2.69; 95% CIs: 1.70–4.09, 1.82–4.06) or other sexual orientation (ORs = 3.01, 2.43; 95% CIs: 1.88–5.04, 1.61–3.74) were also more likely to have screened positive for probable MDD or any anxiety disorder, respectively.

Table 4.

Summary of Adjusted Logistic Regressions Examining ED Chronicity and Probable Psychiatric Diagnoses by Sexual Orientation and Gender Identity among Students Who Screened Positive for Probable ED Diagnoses.

n (%) B SE OR 95% CI
ED chronicity > 5 years (N = 443)
Sexual orientation (Wald χ2 (3) = 14.84, p = .002)
 Heterosexual (ref) (N = 738) 283 (38.3%) – – – –
 Gay or lesbian (N = 34) 17 (50.0%) 0.36 0.36 1.44 0.70–2.93
 Bisexual (N = 140) 72 (51.4%) 0.55 0.19 1.74* 1.19–2.54
 Other sexual orientation (N = 137) 71 (51.8%) 0.58 0.19 1.78* 1.22–2.62
Gender identity (Wald χ2 (2) = 15.83, p < .001)
 Cisgender male (ref) (N = 223) 68 (30.5%) – – – –
 Cisgender female (N = 794) 358 (45.1%) 0.63 0.17 1.88*** 1.36–2.63
 Gender diverse (N = 32) 17 (53.1%) 0.98 0.39 2.67* 1.24–5.86
Probable MDD diagnosis (N = 802)
Sexual orientation (Wald χ2 (3) = 34.45, p < .001)
 Heterosexual (ref) (N = 819) 519 (63.4%) – – – –
 Gay or lesbian (N = 38) 26 (68.4%) 0.29 0.37 1.33 0.66–2.88
 Bisexual (N = 167) 137 (82.0%) 0.95 0.22 2.60*** 1.70–4.09
 Other sexual orientation (N = 144) 120 (83.3%) 1.10 0.25 3.01*** 1.88–5.04
Gender identity (Wald χ2 (2) = 11.56, p = .003)
 Cisgender male (ref) (N = 239) 142 (59.4%) – – – –
 Cisgender female (N = 895) 632 (70.6%) 0.46 0.16 1.59** 1.17–2.15
 Gender diverse (N = 34) 28 (82.4%) 1.12 0.47 3.07* 1.29–8.54
Probable anxiety disorder diagnosis (N = 709)
Sexual orientation (Wald χ2 (3) = 37.67, p < .001
 Heterosexual (ref) (N = 817) 450 (55.1%) – – – –
 Gay or lesbian (N = 38) 26 (68.4%) 0.62 0.37 1.86 0.92–4.00
 Bisexual (N = 166) 127 (76.5%) 0.99 0.20 2.69*** 1.82–4.06
 Other sexual orientation (N = 143) 106 (74.1%) 0.89 0.21 2.43*** 1.61–3.74
Gender identity (Wald χ2 (2) = 26.90, p < .001)
 Cisgender male (ref) (N = 237) 110 (46.4%) – – – –
 Cisgender female (N = 893) 572 (64.1%) 0.70 0.15 2.02*** 1.50–2.72
 Gender diverse (N = 34) 27 (79.4%) 1.64 0.47 5.16*** 2.18–14.29
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Note. Tukey-corrected models and prevalence estimates adjusted for age, race, and ethnicity.

Abbreviations: ED, eating disorder; MDD, major depressive disorder; OR, odds ratio; SE, standard error; CI, confidence interval.

***

p < .001.

**

p < .01.

*

p ≤ .05.

3.3. Comparisons by gender identity

3.3.1. Probable ED diagnoses and weight and shape concerns

Probable DSM-5 ED diagnoses varied by gender identity (Table 2). Compared to cisgender males, cisgender females (OR = 1.71; 95% CIs: 1.46–2.00) and GD students (OR = 1.68; 95% CIs: 1.11–2.47) had greater odds of a probable ED diagnosis. Weight and shape concerns varied by gender identity (Table 3). Cisgender females (M = 46.80, SE = 0.55) and GD students (M = 43.40, SE = 1.72) demonstrated significantly higher weight and shape concerns compared to cisgender males (M = 29.00, SE = 0.68). Notably, weight and shape concerns among cisgender females were clinically elevated.

3.3.2. ED chronicity and psychiatric comorbidity among students with probable ED diagnoses

There were gender identity differences in the likelihood of ED chronicity and psychiatric comorbidities among students with probable ED diagnoses (Table 4). Compared to cisgender male students, cisgender female students (OR = 1.88; 95% CI: 1.36–2.63) and GD students (OR = 2.67; 95% CI: 1.24–5.86) were more likely to report chronic ED symptoms lasting more than five years. Cisgender females were also more likely to screen positive for probable MDD (OR = 1.59; 95% CI: 1.17–2.15) and any anxiety disorder (OR = 2.02; 95% CI: 1.50–2.72) compared to cisgender males. GD students were more likely than cisgender males to screen positive for probable MDD (OR = 3.07; 95% CI: 1.29–8.54) and any anxiety disorder (OR = 5.16; 95% CI: 2.18–14.29).

4. Discussion

In a large, national sample of college students across nine U.S. universities, significant differences in probable EDs and weight and shape concerns were observed by SGD status, controlling for relevant covariates. Across gender identity, students who identified as bisexual or other sexual orientation (i.e., queer, questioning, or other sexual orientation) reported significantly greater odds of probable ED diagnoses and significantly greater elevations in weight and shape concerns. Across sexual orientation, cisgender female students and GD students reported significantly greater odds of probable ED diagnoses and significantly greater elevations in weight and shape concerns compared to cisgender male students.

These findings are consistent with prior evidence that has shown greater odds of EDs among students who identify as bisexual (Hazzard et al., 2020; Matthews-Ewald et al., 2014; Simone et al., 2020) and transgender or gender-queer/gender non-conforming (Diemer et al., 2015; Lipson et al., 2019; Simone et al., 2020). We also found that students who identified as other sexual orientation were more likely to report probable ED diagnoses and endorse greater elevations in weight and shape concerns compared to heterosexual students. Sexual identity descriptions are increasingly fluid among contemporary young adults (e. g., pansexual, queer) (Katz-Wise, 2015; Russell et al., 2009), which is consistent with the substantial number of students in the current sample (9.8%) who endorsed a sexual orientation other than heterosexual, lesbian/gay, or bisexual. Thus, students who identify with a sexual orientation other than heterosexual, lesbian/gay, or bisexual may represent an important subgroup of SD young adults at risk for EDs. ED screens should include in-depth assessments of sexual orientation and gender identity in order to disentangle whether young adults with fluid sexual and/or gender identities are at increased ED risk. In line with our findings by gender identity, prior research has shown that cisgender female students (Eisenberg et al., 2011; Simone et al., 2020) and GD students (Simone et al., 2020) are at higher risk for probable EDs and endorse greater ED symptoms compared to cisgender male students, with no differences in ED prevalence among cisgender female students and GD students (Simone et al., 2020). More data are needed to examine whether cisgender female students and GD students are at equal risk for probable EDs and identify risk and maintenance factors.

Differences in ED chronicity and probable psychiatric comorbidities by SGD status were also observed among those with probable EDs. The odds of chronic ED symptoms and psychiatric comorbidities were significantly greater among students with probable EDs who identified as bisexual or other sexual orientation compared to heterosexual students. The proportions of psychiatric comorbidities were generally higher than estimates in community samples of SD college students not at risk for EDs (Liu et al., 2019; Przedworski et al., 2015). GD students and cisgender females with probable EDs were also significantly more likely to endorse chronic ED symptoms and screen positive for probable psychiatric comorbidities compared to cisgender males. Specifically, compared to cisgender males, cisgender females and GD students were more likely to screen positive for MDD and any anxiety disorder. Taken together, these findings suggest that some subgroups of SGD students with probable ED diagnoses may have more severe clinical presentations compared to heterosexual students and cisgender male students with probable ED diagnoses.

Our findings are consistent with minority stress and sociocultural explanations of ED disparities in SGD young adults. The increased odds of chronic ED symptoms and psychiatric comorbidities among students with probable EDs who identified as bisexual, other sexual orientation, or GD may suggest the role of proximal social stressors as risk factors for EDs in these subgroups. Indeed, one longitudinal study found that internalizing symptoms partially mediated the positive association between SD-specific stressors (e.g., bullying victimization) and coping-motivated eating among young adults (Katz-Wise et al., 2017a). Consistent with sociocultural theory, social stressors may be especially prevalent among certain subgroups of SGD students, such as those who identify as bisexual or other sexual orientation, due to difficulties navigating ones identity according to both in-group (i.e., SGD community) and out-group appearance standards (Oswalt & Wyatt, 2011). In support of minority stress theory, distal stressors, such as lack of access to affirming mental health providers on college campuses, may deter some SGD students from seeking ED treatment (Bouris & Hill, 2017; Dunbar et al., 2017), which could exacerbate symptoms and lead to chronic disease progression. Longitudinal data are needed to examine the developmental trajectories of EDs and comorbid psychiatric disorders overtime in SGD populations to identify precise moments for intervention.

Study strengths include a large, geographically diverse sample of college students with a robust representation of SGD persons and the use of validated screens to diagnose probable DSM-5 EDs, depression, and anxiety disorders. Further, to our knowledge, this study is the first to examine ED chronicity and comorbid psychiatric diagnoses by SGD status in students who screened positive for probable EDs. Study limitations include the inability to examine the interaction between sexual orientation and gender identity on ED diagnoses, due to a limited sample of students simultaneously belonging to SD and GD groups. Similarly, we were unable to independently examine several SGD subgroups, including students who identified as queer, endorsed two or more sexual orientations, questioning, or gender-queer/gender non-conforming. Future research should prioritize rigorous data collection in these subgroups to evaluate ED risk and symptomology among understudied SGD populations. Additionally, the language of the SWED was modified for the current study to be inclusive of other gender identities. Although the SWED has not been validated among college students with diverse gender identities, it has been used to examine ED pathology in non-exclusively cisgender female college students (Fitzsimmons-Craft, Balantekin, et al., 2019). Future studies should validate this modified version in SGD college students. Findings on ED chronicity should also be carefully interpreted given the use of a single-item measure that was dichotomized due to skewness of responses. Finally, although consistent with response rates from other mental health online surveys (Eisenberg, Golberstein, & Gollust, 2007; Lipson et al., 2019), only 13.9% of students responded to the screen, which may have biased study findings. Given the impairment of mental health disorders on academic functioning in college students (Eisenberg et al., 2009), particularly SGD students (Dunbar et al., 2017), efforts to bolster student responsiveness to mental health surveys are urgently needed.

5. Conclusions

Overall, SGD college students were more likely to screen positive for probable EDs and report elevated weight and shape concerns, with pronounced disparities among students who identified as bisexual, other sexual orientation, or GD. SD students and GD and cisgender female students who screened positive for EDs were also more likely to report chronic ED symptoms and screen positive for probable comorbid psychiatric diagnoses compared to heterosexual students and cisgender males, respectively. Future examination of mechanisms contributing to ED disparities in SGD young adults is needed to inform tailored screening and intervention efforts.

Acknowledgments

Role of funding sources

This work was supported by NIMH Grant R01MH115128 (PI: Denise E. Wilfley). The funding sources had no involvement in study design, in the collection, analysis and interpretation of data, in the writing of the report, or in the decision to submit the article for publication.

Footnotes

Declaration of competing interest

All authors declare no potential conflicts of interest. The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense.

1

Examination of the interaction between sexual orientation and gender identity was considered but ultimately not pursued due to extreme parameter estimates that resulted from small cell sizes.

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