- LGBTQ youth experience eating disorders at higher rates than their peers.
- Over the past year, the risk of attempting suicide was four times greater among those who had an eating disorder diagnosis.
- Experts say eating disorders are underdiagnosed in LGBTQ youth because medical professionals fail to accurately assess and understand how they present among this group.
- Limited access to healthcare and fear of discrimination can also prevent LGBTQ youth from seeking help.
The Trevor Project released a new research brief that highlights how LGBTQ youth are at greater risk of developing eating disorders and how this can affect their mental health as well as risk of suicide.
Experts say this kind of research is necessary to raise awareness about ways to put better interventions in place to help LGBTQ youth not only manage and seek treatment for eating disorders, but also address other underlying mental health issues.
What the research shows
Amy Green, PhD, vice president of research at The Trevor Project, told Healthline that most research on eating disorders tends to center on white, cisgender young women. It doesn’t always capture the full scope of who is affected and what other underlying issues might be at play.
“With well-documented relationships between eating disorders and suicide, it is important to better understand eating disorders among a diverse sample of LGBTQ youth — who we know to be at a higher risk for suicide compared to their peers,” Green said.
“Our findings shed much-needed insight into the experiences of LGBTQ young people, while also examining the intersection of race and ethnicity. Especially at a time when our country is facing a crisis of youth mental health, it is crucial that we understand the mental health needs of LGBTQ youth so that we are better situated to address them through policy and practice,” she added.
The new research brief used data collected from an online survey conducted from October to December 2020 involving 34,759 LGBTQ youth. Participants were recruited by way of targeted social media ads.
In the survey, participants were asked, “Have you ever been diagnosed as having an eating disorder?” to determine self-reported eating disorders. They were given response options of “No,” “No, but I think I might have one,” and “Yes.”
Among the findings, 9 percent of surveyed LGBTQ youth ages 13 to 24 said they had been diagnosed with an eating disorder, while 29 percent said they haven’t received an official diagnosis but suspect they might have an eating disorder.
Among these numbers, cisgender LGBTQ males reported the lowest rates of both receiving an eating disorder diagnosis and suspecting they might have one.
Trans males and nonbinary youth who were assigned female at birth showed signs of the highest rates of receiving an eating disorder diagnosis and suspecting they might have an eating disorder.
Cisgender female respondents, transgender female respondents, and nonbinary youth who were assigned male at birth all had equivalent rates of either having an official diagnosis or suspicions of having an eating disorder.
Going a step further than similar surveys, The Trevor Project wanted to capture the full scope of the LGBTQ community by depicting a picture that wasn’t predominantly or solely white.
They found that 12 percent of Native American and 10 percent of Indigenous youth as well as multiracial young people reported having been officially diagnosed with an eating disorder — some of the highest rates among those surveyed.
Separately, 33 percent of both of these groups suspected they might have an eating disorder but did not receive an official diagnosis.
Five percent of Asian Pacific Islander LGBTQ youth reported having an eating disorder diagnosis, while 4 percent of Black youth did.
Black youth reported similar rates of suspecting they might have an eating disorder to white peers (28 percent compared with 27 percent).
This number stands out given white youth are diagnosed at “more than twice the rate of Black LGBTQ youth” at 9 percent to 4 percent, according to The Trevor Project’s brief.
The LGBTQ young people surveyed who had been diagnosed with an eating disorder showed nearly four times greater odds of attempting suicide in the past year compared with their peers who thought they might have an eating disorder but had not received an official diagnosis.
The Trevor Project also found that the risk of suicide is higher among those individuals who suspected they might have an eating disorder but did not receive a diagnosis. They had 2.38 times greater reported odds of a suicide attempt in the past year compared with those who never suspected they had an eating disorder.
Generally, the link between suicide attempts and eating disorder diagnoses was similar between cisgender LGBQ youth and their transgender and nonbinary peers.
What might account for these statistics?
When asked about the higher odds of suicide risk tied to diagnosis of eating disorders, Green said there is no sole explanation for why an LGBTQ young person could have a higher risk of developing an eating disorder or attempting suicide.
Everyone’s experience varies; there is no uniform set of experiences, especially among such a diverse population of people.
That said, there are underlying social issues that can come into play.
“Minority stress has been shown to have a significant relationship with both [eating disorders and suicide]. The Minority Stress Model suggests that experiences of LGBTQ-based victimization — such as bullying, discrimination, and internalized stigma based on one’s LGBTQ identity — can compound and result in higher risk of multiple mental health challenges including depression, anxiety, and eating disorders, as well as suicide,” Green added.
She explained that eating disorders may be more likely among LGBTQ young people due to the same reasons that we see higher rates of other related negative mental health outcomes among this larger population of people.
The answer?
LGBTQ youth often find themselves “mistreated in society and the internalized stigma and shame that often result from such mistreatment,” Green said.
“For transgender and nonbinary youth in particular, distress over one’s body image and efforts to align their body with their authentic gender identity may result in disordered eating. Our findings show that a number of LGBTQ youth suspect they have an eating disorder but have never been diagnosed,” she added.
“From this, we can infer that a number of LGBTQ youth may avoid seeking care out of fear of being mistreated or stigmatized by healthcare providers,” Green said.
Additionally, she said that healthcare professionals might have major limitations. They might fail to assess accurately (and even understand) how eating disorders might present in LGBTQ young people and their underlying causes.
This is especially true if these individuals don’t “fit the traditional profile of a young cisgender woman,” Green stressed.
“Unfortunately, many doctors lack the cultural competencies needed to provide LGBTQ youth with the care they deserve,” she said.
Dr. Jason Nagata, assistant professor of pediatrics in the division of adolescent and young adult medicine at the University of California, San Francisco (UCSF), said that, as a doctor who specializes in the care of youth with eating disorders, he works with many LGBTQ young people experiencing various eating disorders.
He said more than one-fifth of youth who are hospitalized for an eating disorder at UCSF are LGBTQ+.
“Peers, family, and the media influence LGBTQ youth’s perception of the ideal body,” said Nagata, who was not affiliated with this research brief.
“Constant exposure to unattainable body ideals through social media may lead to body dissatisfaction and eating disorders,” he said. “In transgender youth, a perceived mismatch between one’s own body and gendered body ideals may lead to body dissatisfaction.”
Nagata told Healthline that factors such as social isolation, disruptions in regular routines, and heightened anxiety have resulted in a surge of both eating disorders and suicide attempts over the course of the COVID-19 pandemic.
“LGBTQ youth may be particularly vulnerable to loneliness during the pandemic,” Nagata added. “Keeping connected to support networks and communities can be an important way to mitigate disordered eating during the pandemic.”
Nagata echoed Green, saying that harsh, discriminatory realities of daily life for members of the greater LGBTQ community (both youth and adults) play a big role. Think things like “discrimination, prejudice, and stigma,” all of which can lead to depression, body dissatisfaction, and suicide risk, he added.
“Eating disorders have high mortality rates with life threatening physical and psychological consequences. If an LGBTQ young person with an eating disorder starves themselves, in a way they are attempting suicide,” Nagata said.
Providing better interventions
Green said one key thing to look at within this data is how many of these stressors particularly affect those who are most vulnerable in American society.
She cited previous research from The Trevor Project that shows LGBTQ Youth of Color who report “higher rates of not being able to access mental health care when they wanted it compared to their white peers.”
These young People of Color said it was a challenge just to find healthcare professionals who even “understood their identity and culture.”
“Historically, both eating disorders and suicide have been conceptualized as impacting white populations most. However, in recent years, Black youth have seen the greatest increase in suicide risk compared to their peers,” Green said.
“Similarly, we could see increases for related concerns such as eating disorders or depression. We hope this data will urge healthcare professionals to be cognizant of the ways in which eating disorders may impact youth with multiple marginalized identities.”
Nagata added that LGBTQ Youth of Color might experience significant levels of discrimination, prejudice, and stress tied to their sexual orientation, gender identity, and race and ethnicity all at once.
“These stressors can be additive,” he said.
When asked what resources are available for LGBTQ young people struggling with eating disorders and related mental health issues like suicidal ideation, Nagata said it’s important to look at and assess warning signs.
“Warning signs include a preoccupation with appearance, body size, weight, food, or exercise in a way that worsens their quality of life. LGBTQ youth may be less likely to seek care for eating disorders due to barriers to accessing healthcare or experiences of discrimination at the clinic,” he said. “LGBTQ youth who have concerns about their appearance, size, weight, or eating in a way that worsens their quality of life should seek professional help.”
He stressed that it is up to doctors and mental health professionals to “foster a welcoming environment in their practices and have inclusive forms for sexual and gender minorities” to prevent these young people from feeling “discouraged from seeking care.”
“Young people with eating disorders should have an interdisciplinary care team including a physician, dietitian, and mental health professional. They can seek initial help from their primary care provider,” Nagata said.
He highlighted the National Eating Disorder Association’s (NEDA) helpline for people who need to seek out a resource or know of a young person who is looking for one today.
Similarly, The Trevor Project has 24/7 resources where people can get immediate support if they’re considering either harming themselves or need a resource to turn to in real time.
Nagata stressed that the experiences of LGBTQ youth can be very different based on the intersections of multiple identities.
“Eating disorders in LGBTQ youth may be under-recognized, especially in boys and Youth of Color,” he said. “Eating disorders can affect people of all genders, sexual orientations, races, ethnicities, and sizes. It is important to recognize that eating disorders can affect diverse populations. You cannot tell if someone has an eating disorder just based on their appearances.”
Adding to that, Green zeroed in on the relatively high numbers of LGBTQ youth who suspected they might have an eating disorder but did not receive an official diagnosis.
Even though they don’t have that diagnosis in hand, “these youth reported more than two times greater odds of a suicide attempt in the past year compared to those who never suspected they had an eating disorder,” she said.
What this research does is highlight the need to better understand why these young people have never been diagnosed officially.
“We can hypothesize that it may relate to challenges accessing medical and mental health care, negative experiences based on a lack of culturally competent healthcare providers, and a failure of current diagnostic practices to properly capture all youth struggling with disordered eating,” Green said.
Further data can help understand this and center a spotlight on ways to improve the diagnosis and treatment of eating disorders among the nation’s LGBTQ youth.
“If we are better prepared to help youth address underlying concerns related to their mental health and well-being, ultimately we will be better prepared to prevent suicide,” Green said.
Eating Disorder Treatment Often Excludes Transgender People
Trans people are much more likely to experience eating disorders, but current care systems overlook their unique needs and often do more harm. These advocates are working to change that.
Bee, a transgender, genderqueer person living in Portland, Oregon, once worked as a therapist serving trans, nonbinary, and intersex clients with eating disorders (EDs).
Now, they’re back in recovery from their own ED.
Bee, 36, was diagnosed with anorexia nervosa at 14 and entered recovery for the first time as a teen. They identified as recovered by their 20s, but during the COVID-19 pandemic, they said, they experienced “a full-blown relapse.”
Bee said their trans identity influences their ED, as it does for many people. Yet, they said that frontline ED treatment modalities often exclude, erase, or even harm trans folks in recovery.
Experts and advocates say that Bee is far from alone in feeling that way.
Trans people are more likely to experience eating disorders
Bee said their relationships with their body and food began to shift when puberty started.
“While I wasn’t necessarily cognizant of it at the time, looking back at it, there was definitely a lot of gender stuff at play,” they told Healthline. “I was just trying to take up as little space as possible.”
They said their gender dysphoria — extreme physical and emotional discomfort caused by perceiving your body as incongruent with your gender — continues to contribute to their ED.
Research suggests that trans people are much more likely to develop EDs and engage in disordered eating than cisgender people, and dysphoria likely plays a role.
A study including more than 289,000 college students, 479 of whom were transgender, found that rates of ED diagnoses and disordered eating behaviors were much higher among trans students.
More than 15% of the trans people surveyed reported ED diagnoses, compared with 0.55% of the cisgender, heterosexual men and 1.85% of the cisgender, heterosexual women.
Unpacking the disparity
While there are no clear causes of EDs in any population, several risk factors appear to contribute.
Trans people can contend with many of the same risk factors as cis people, such as trauma and food insecurity, but they may be more likely to experience them as a result of living in a transphobic society, according to Hannah Coakley, MS, RD.
Coakley is a nonbinary, queer dietitian who works with clients in ED recovery through their private practice, Pando Wellness, in New York. Nearly half their clients identify across the transgender spectrum.
Coakley said trans folks face additional social, environmental, and physical experiences that influence the rates of EDs. For example, while not all trans people experience gender dysphoria, many do — and they’re subjected to increased scrutiny of their bodies.
“There’s the felt sense of dysphoria, which makes being in your body very challenging, and I find a lot of eating disorders come from how the body is trying to adapt to overwhelming states of being,” Coakley told Healthline.
“You develop other methods of not being in the body, or blunting some sensations in the body, or blunting even physical development.”
— Hannah Coakley, MS, RD (they/them)
While cis people can experience body dissatisfaction, gender dysphoria is different. It’s often an “intolerable physical experience,” Coakley said — one that can make your body feel foreign, detached, or terrifying because it doesn’t align with your gender.
Gender dysphoria and body dissatisfaction can co-occur. The dysphoria element, though, is a trauma specific to trans and nonbinary people.
Many trans people lack social support to transition or access to the gender-affirming medical care — including puberty blockers, hormone replacement therapy (HRT), and surgery — that can help ease dysphoria.
As a result, disordered eating may emerge as an attempt to control a body’s gendered characteristics, according to Coakley.
For example, trans men and transmasculine people sometimes report restricting food intake in order to shrink body parts that induce dysphoria, such as hips or chests, or to stop menstruation
It’s not just gender dysphoria itself: Transphobic discrimination and bullying may also affect EDs, especially among youth.
Where current eating disorder treatment may miss the mark
Although trans folks are disproportionately likely to experience EDs and disordered eating, they face prohibitive barriers to accessing treatment, ranging from financial obstacles to transphobia in care settings.
High costs and lack of insurance coverage
On average, the cost of inpatient ED treatment can range from $500–2,000 per day, and patients may need 3–6 months or more of care at that level. The cost of outpatient care may total more than $100,000 over time
Bee is on Oregon’s state insurance, and they said there’s only one inpatient treatment facility in the state. However, Bee said the facility didn’t accept them as a patient.
When that treatment center didn’t pan out, Bee felt like they were out of options because their insurance wouldn’t cover alternatives.
“My parents actually ended up paying for my first month of residential treatment out of pocket, which is [ridiculous], and I was able to get private pay insurance that was helping me pay for it after that,” they said.
But Bee acknowledges that they come from an affluent family and have financial privilege that many people — especially many other trans folks — don’t.
Trans people are much more likely to live in poverty and much less likely to have adequate health insurance than cis people.
To help close these gaps, some advocates and organizations are working to provide free and reduced-cost options for LGBTQIA+ people seeking ED treatment.
Transphobia in treatment facilities
When trans people are able to access formal ED treatment, many report further issues that can impede healing.
It’s difficult to find trans-informed clinicians offering ED treatment. When clinicians don’t understand how gender dysphoria interacts with EDs, it can lead to a disconnect.
Bee, as a former clinician and current patient, said that clinicians in ED treatment facilities engage in both direct and indirect transphobia.
For example, they said that many facilities require trans patients to have had expensive, physically demanding surgeries before allowing them to use the appropriate single-gender spaces. Plus, not all treatment centers offer gender-neutral spaces or allow access to HRT.
Bee said clinicians at one residential treatment facility regularly misgendered them and other trans people, including trans staff members.
They had to ask staff repeatedly for access to the all-gender restroom, and they said they were often ignored or even punished for their self-advocacy. At the same time, a trans woman Bee met during treatment was denied access to the women’s restroom.
“My safety was not taken into consideration as a trans person.”
— Bee (they/them)
When treatment centers meant to help people heal replicate the oppressive systems that contribute to EDs in the first place, the effects can be serious.
In one study, many trans people said they wished they’d never gone to ED treatment — even though they acknowledged that it had been lifesaving — because of the transphobia they experienced
Where body acceptance falls short
ED treatment often relies upon body acceptance or body positivity frameworks: helping patients learn to be OK with their bodies.
However, these frameworks may not be helpful for many trans people — and can even harm them, as these approaches can lead to trans patients being asked to accept characteristics of their bodies that induce dysphoria.
That’s why research suggests that ED treatment professionals consider gender-affirming medical care part of recovery for trans people who want or need it. Access to HRT seems to lower the risk of EDs for youth and adults (5, 8, 12Trusted Source).
How eating disorder treatment can become more trans-inclusive
Understanding trans patients’ unique needs should be a top priority in ED treatment, according to Coakley.
They emphasize gender affirmation in their practice, recognizing that trans clients’ discomfort with their bodies may require a different approach.
For example, when working with a transmasculine client whose ED stemmed in part from a desire to reduce the appearance of their chest, Coakley led conversations about top surgery as a potential element of their recovery.
When periods have caused dysphoria, Coakley has discussed HRT and healthcare options known to help slow menstruation, such as intrauterine devices.
“The question always being, ‘How can we affirm, validate, and address it without being in an eating disorder?’” Coakley said. “What are some other ways to achieve congruence?”
They work with most of their clients on sliding-scale or pro-bono bases, since costs often make treatment inaccessible.
“It’s just affirming the experiences and trying to create a space where someone feels like they can show themselves love.”
— Hannah Coakley, MS, RD (they/them)
Additionally, Bee said that clinicians should challenge the transphobia, fatphobia, ableism, racism, classism, and other systemic forms of oppression within healthcare systems to create more inclusive care settings.
How to find resources and get involved
Bee is a member of Fighting Eating Disorders in Underrepresented Populations (FEDUP), a trans and intersex collective supporting marginalized folks with EDs.
FEDUP facilitates trainings for clinicians, connects trans folks with treatment through a dietitian match program, leads virtual support groups, supplies grocery funds to trans and intersex Black, Indigenous, and People of Color, and more.
The group also maintains a scorecard rating residential treatment centers for accessibility and keeps a list of trans-identified and trans-allied ED treatment professionals.
Other resources include:
- Project HEAL: a nonprofit offering financial assistance for ED treatment, including direct funding and help with navigating insurance, especially for marginalized people
- Trans Lifeline: the only trans-led helpline for trans and nonbinary people — Trans Lifeline is divested from police (meaning nobody you talk to will contact law enforcement on your behalf) and also offers microgrants for HRT and name change costs
- National Eating Disorders Association: a large national organization that manages a helpline and has compiled a list of free and low cost support resources here
- National Center for Transgender Equality: a large nonprofit connecting trans people to resources, including a list of sources offering financial aid
- Resilient Fat Goddex: a blog by SJ, a “super fat, trans, non-binary, poor, neurodivergent, and queer” coach, consultant, and writer who also offers peer support groups and trainings for care professionals
- Let’s Queer Things Up: a blog by Sam Dylan Finch, a trans person writing about ED recovery, mental health, and other topics
- ThirdwheelED: a blog by OJ and CJ, two people writing about ED recovery “through a queer lens and (documenting) the dual perspectives of patient and nontraditional caregiver”
If you need HRT, this map compiled by Erin Reed, a trans activist, may help you find local informed consent clinics (meaning they won’t require therapists’ letters or other gatekeeping measures).
There are also remote care organizations operating across the United States, such as Folx Health and Plume.
One last thing
Trying to “do it right” when it comes to nutrition may feel tempting, but it can backfire. If you are preoccupied with food or your weight, feeling guilt surrounding your food choices, or otherwise struggling with nourishing yourself, consider reaching out for support. These behaviors may indicate a disordered relationship with food or an eating disorder.
FEDUP maintains a list of trans-identified and trans-allied clinicians who may be able to help. Other organizations listed above may be able to connect you with affirming care as well.
You can also check out Healthline’s guide to finding a healthcare professional who is an LGBTQIA+ ally and explore other trans health resources here.
Remember that disordered eating and eating disorders can affect anyone, regardless of gender identity, race, age, socioeconomic status, or other identities.
And you — no matter who or where you are — deserve support and the opportunity to heal.
Sources:
https://laportelibrary.org/trans-healthcare-resources/
https://www.sciencedirect.com/science/article/abs/pii/S1471015321000441
https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-020-00327-y
