Disordered Eating in Transgender and Gender Nonbinary Individuals

Written by Blair Uniacke MD and Kayla Nitahara.

The data are pretty clear – eating disorders do not discriminate by age, race, ethnicity, gender, or sexuality. In fact, some research suggests that individuals who are members of marginalized groups may face higher rates of eating disorders, including people who are transgender (i.e., identify as a different gender than the one assigned to them at birth) or gender nonbinary (i.e., do not identify as either discretely male or female).

Here is what we know so far:

1. Transgender and gender nonbinary individuals appear to experience lower body satisfaction than people who identify as the gender they were assigned as birth (or, cisgender individuals for short).
2. Transgender and nonbinary people also report higher rates of disordered eating behaviors and more difficulty with eating disordered beliefs than their cisgender counterparts.

To get a better sense of the scope of eating disorder-related symptoms in transgender and gender nonbinary people across the lifespan, we teamed up with Walter Bockting, PhD, Director of the Program for the Study for LGBT Health at Columbia University/New York State Psychiatric Institute, on Project AFFIRM, a multi-site, longitudinal study examining factors related to identity development and the health of transgender and gender nonbinary individuals ages 16 and up.

Study Specifics

Project AFFIRM participants complete an interview every year for three years. They are asked about a wide range of topics, including gender identity, personal relationships, and general health and well-being. In the second year of the project, our group started collecting additional information about past and present disordered eating behaviors – such as restrictive eating, binge-eating, and various methods of purging – and thoughts – such as fear of gaining weight.

Beyond our desire to understand if and to what degree transgender and nonbinary people experience eating disorder symptoms, we also sought to explore how these symptoms might relate to minority stress. Minority stress refers to the added stress experienced by marginalized groups due to stigma and discrimination. Minority stress is known to be correlated with mental health issues, but less is known about its connection to eating disorder symptoms specifically. Lastly, we hoped that through our involvement with Project AFFIRM, we could begin to disentangle if and how factors related to gender identity development – such as receiving gender-affirming treatment – were related to the presence of eating disorder symptoms.  

Study Results

Over half of the study participants reported a lifetime history of disordered eating symptoms, with loss of control eating being the most common disordered behavior, followed by compulsive exercise. We found that people who experienced more similarity between their external appearance and current gender identity were less likely to report disordered eating symptoms. Those people who reported less internalized transphobia were also less likely to endorse disordered eating behaviors and beliefs (Internalized transphobia refers to discomfort with one’s own transgender identity as a result of internalizing society’s expectations about gender.). We were surprised that we did not find an association between having had gender-affirming medical care (e.g., surgical or hormonal interventions) and the presence of eating disorder-related symptoms. Unexpectedly, we also learned that in our sample, receiving gender-affirming psychotherapy during the prior year was associated with increased disordered eating symptoms.

What does it all mean?

In this study, the prevalence of disordered eating symptoms in transgender and nonbinary individuals alone underscores the importance of our field’s need to better understand the unique risk factors for these populations. Because our sample included many people who had already received gender-affirming medical care, more research is needed to explore the connection between type and extent of care received and disordered eating symptoms.

We hope that the association between disordered eating symptoms and gender-affirming psychotherapy reflects that people with these symptoms are seeking out care. Now, it is imperative to ensure that clinicians providing care for sexual and gender minority individuals are regularly screening patients for eating disorders, and have some comfort in how to treat these symptoms and when and where to refer individuals for specialized care.

For a closer look at our recent publication, read here:

Uniacke B, Glasofer DR, Devlin MJ, Bockting W, & Attia E. (2021). Predictors of eating-related psychopathology in transgender and gender nonbinary individuals. Eating Behaviors, https://doi.org/10.1016/j.eatbeh.2021.101527

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