Eating Disorders: Not Just for Cisgender, Heterosexual Women

By Kait Scalisi, MPH

Most conversations about eating disorders focus on women, specifically those who are cisgender and heterosexual. This group, however, may not be at the highest risk. New data from the most recent American College Health Association’s National College Health Assessment (ACHA-NCHA) highlight the intersections of sexuality, gender identity, and eating disorders.

The most recent iteration of the ACHA-NCHA surveyed over almost 300,000 students at 233 US colleges and universities. Data collection took place between Fall 2008 and Fall 2011. All data was collected anonymously. For this analysis/study, only data from the first semester that each institution participated in ACHA_NCHA. This ensured all responses were unique.

To study connections among gender identity, sexuality, and eating disorders, the researches classified individuals into the following seven categories.

transgender
cisgender sexual minority (SM) men
cisgender unsure men
cisgender heterosexual men
cisgender SM women
cisgender unsure women
cisgender heterosexual women (reference)

Individuals in the last category were used as the reference group since most eating disorder research has been conducted on them, providing a rich data set to make comparisons to. “Sexual minority” included individuals identified as gay or bisexual.

Eating disorder status was assessed by asking individuals if they had been diagnosed or treated for an ED in the last 12 months and whether they had vomited, taken laxatives, or taken diet pills in the last 30 days. Covariates assessed included race/ethnicity, smoking frequency, binge drinking frequency, stress level and participation in athletics.

Rates of ED diagnosis or behaviors were highest among transgender individuals and lowest among cis, hetero males. Of the transgender students, those who were unsure of their sexual orientation had the highest rates of eating disorder diagnosis and use of laxatives, diet pills, and vomiting. That being said, rates of these outcomes for all subgroups of transgender folks were higher than any other group. Cisgender SM males also had elevated rates of eating disorder diagnosis.

The authors list several possible reasons for these heightened rates. These include:

Using eating disorder behaviors to suppress or accentuate particular gendered feature.
Experiencing minority stress.
Having a greater likelihood of contact with mental health professionals due to both the heightened rates of mental health issues among SM and the fact that most transgender individuals must receive therapy in order to have gender-affirming surgery.

Most likely, the truth is some combination of the above along with genetic risk factors highlighted in previous research.

One major critique of the study is that it excluded questions about binge eating disorder, a diagnosis only recently added to the DSM but which is thought to affect as many if nor more individuals that anorexia and bulimia. Another limitation is the inability of the researchers to distinguish among the different groups of transgender individuals (e.g. male-to-female, female-to-male, and gender-queer). Like any group, transgender people are not a monolith. They are all individuals with different risk factors and lived experiences, some of which may vary depending on which subgroup of transgender they fall into.

Despite these limitations, this was the first ACHA-NCHA with enough transgender individuals to make statistically significant comparisons to other gender identities. This is hugely important as much research excludes this population due to either low response rates or oversight on the researcher’s behalf. Such lack of representation in the literature means that we cannot create quality health education programs or policy to meet transgender individuals’ unique needs.

Overall this study is groundbreaking in what it adds to our understanding about the intersections of gender identity, sexual orientation, and eating disorders. It provides health educators with new learning objectives for their programs and researchers, a jumping off to point to study additional underlying factors, risk facts, and outcomes for anyone dealing with an eating disorder.