Predictors of eating-related psychopathology in transgender and gender nonbinary individuals
Introduction
Research examining eating-related psychopathology among transgender people is limited; studies to date suggest that transgender and gender nonbinary individuals experience lower body satisfaction (Bandini et al., 2013; Diemer et al., 2015; Witcomb et al., 2015) and higher rates of disordered eating behaviors and cognitions (Calzo et al., 2017; Guss et al., 2017; Nagata et al., 2020; Vocks et al., 2009; Watson et al., 2017) relative to cisgender individuals. Existing data come largely from studies focused on transgender youth (Diemer et al., 2015; Guss et al., 2017; Watson et al., 2017) or do not include individuals who have received gender-affirming medical interventions (Witcomb et al., 2015). The prevalence and severity of eating-related psychopathology in transgender and gender nonbinary adults, and across stages of gender identity development, remains poorly characterized.
There are several potentially important factors emerging from the literature on eating-related psychopathology and transgender individuals. First is whether an individual has undergone gender-affirming interventions, such as hormone therapy and/or surgery. Those who receive such interventions tend to report fewer eating disorder symptoms and less body dissatisfaction than those who have not (Jones et al., 2018, Jones et al., 2016). Second, minority stress, defined as the additional stress experienced by marginalized groups due to stigma and discrimination, is associated with increased body image concerns and disordered eating behaviors in transgender youth (Watson et al., 2017) and adults (Brewster et al., 2019; Velez et al., 2016), and disproportionately high rates of mental health issues overall (Bockting, Miner, Swinburne Romine, et al., 2013; Chodzen et al., 2019; Kuper et al., 2018; Lefevor et al., 2019; Valente et al., 2020). Together, these findings suggest that transgender congruence (i.e., congruence between gender identity and expression) and minority stress may relate to the presence and severity of eating-related psychopathology. Notably, the majority of studies examining eating-related psychopathology in the transgender population focus on binary transgender individuals (i.e., individuals who identify as women who were assigned male at birth, and vice versa). However, gender nonbinary individuals (i.e., individuals who identify as neither discretely woman or man) have been found to report higher levels of minority stress and increased psychological distress, including disordered eating, relative to binary transgender individuals (Diemer et al., 2018; Lefevor et al., 2019).
The aim of this study was to examine risk factors for eating-related psychopathology among transgender and gender nonbinary individuals. We first describe the prevalence of eating disorder-related symptoms in the sample, including how identification as transgender (i.e., transgender man or woman) or gender nonbinary impacts the presence or absence of symptoms. Building from existing research, we hypothesized that, (1) transgender congruence would be inversely related to eating-related psychopathology, (2) history of gender-affirming medical interventions would be associated with less disordered eating symptoms, and (3) minority stress would be predictive of eating-related psychopathology. Using longitudinal data, we explored how identity development and minority stress factors relate to changes in eating-related psychopathology over time.
Section snippets
Participants
This study is a secondary analysis of data from two consecutive years of Project AFFIRM, a multi-site, longitudinal cohort study of a community sample of transgender and gender nonbinary individuals ages 16 and older (R01-HD079603). Eating-related data was not collected during the first year of the parent study, thus we consider Year 2 as “baseline” and Year 3 as “one-year follow-up.” Study participants were fluent in English or Spanish and recruited in New York, San Francisco, and Atlanta
Baseline demographics
See Table 1 for demographics and non-eating related clinical characteristics. One participant was excluded from baseline assessments due to incomplete data, resulting in a sample of 287. 40.4% (n = 116) identified as TGF, 32.4% (n = 93) as TGM, and 27.3% (n = 78) as gender nonbinary. Among nonbinary participants, 69.2% (n = 54) were NB-AFAB and 30.8% (n = 24) were NB-AMAB.
Relative to TGF and TGM participants, gender nonbinary individuals reported greater anxiety (F(2,286) = 7.2, p = 0.001) and
Discussion
A lifetime history of disordered eating symptoms was endorsed by over half of our sample, confirming the importance of continued study of eating-related psychopathology in this population. Consistent with our hypotheses, identity development and minority stress were associated with eating-related psychopathology. Individuals with lower transgender congruence and greater internalized transphobia were more likely to report eating disorder symptoms. We did not find an association between prior
Conclusions
This longitudinal study of transgender and gender nonbinary adults investigated how identity development and minority stress relate to the presence of eating-related psychopathology. LOC eating was the most commonly endorsed disordered eating behavior, followed by laxative, diuretic, or other medication use, and compulsive exercise. Results indicate that transgender congruence and internalized transphobia were predictive of disordered eating symptoms. Individuals with eating-related
Role of funding sources
This work was supported by the National Institutes of Health [R01-HD079603 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Walter Bockting, PI) and T32 MH096679]. The NIH had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Contributors
Blair Uniacke conducted data analyses and manuscript preparation; Deborah Glasofer, Michael Devlin, Walter Bockting, and Evelyn Attia contributed to study design and manuscript preparation. All authors have approved this manuscript.
Declaration of competing interest
Dr. Glasofer has received honoraria from Oxford University Press. Dr. Attia serves as a Clinical Advisor to Equip Health, Inc., and receives royalties from UpToDate. Drs. Uniacke, Devlin, and Bockting report no conflicts of interest.
Acknowledgements
The authors would like to thank Project AFFIRM's transgender community advisory board for their contribution to this study.
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