Elsevier

Eating Behaviors

Volume 42, August 2021, 101527
Eating Behaviors

Predictors of eating-related psychopathology in transgender and gender nonbinary individuals

https://doi.org/10.1016/j.eatbeh.2021.101527Get rights and content

Highlights

  • Nearly one third of participants reported current eating-related psychopathology.

  • Greater transgender congruence was associated with lower odds of disordered eating behaviors and cognitions.

  • Increased internalized transphobia was associated with increased odds of eating-related symptoms.

Abstract

Objective

Research examining the prevalence and severity of eating-related psychopathology in transgender and gender nonbinary individuals is limited. This study examined how identity development and minority stress relate to the presence of disordered eating behaviors and cognitions in transgender and gender nonbinary individuals, and improvement at one-year follow-up.

Methods

Data come from a multi-site, longitudinal study of transgender and gender nonbinary individuals (n = 287) and includes assessment of transgender congruence, receipt of gender-affirming care, minority stress, and disordered eating symptoms. Hierarchical multivariable logistic regression was used to test for associations between identity development, minority stress, and eating-related psychopathology.

Results

Eighty-three participants (28.9%) met criteria for current eating-related psychopathology. Loss of control eating was the most commonly endorsed behavior, followed by laxative, diuretic, or other medication use, and compulsive exercise. Higher transgender congruence was associated with lower odds of disordered eating symptoms (OR = 0.72, 95% CI 0.55–0.94), whereas increased internalized transphobia was associated with greater odds of disordered eating symptoms (OR = 1.41, 95% CI = 1.04–1.91). Participants with eating-related psychopathology had greater odds of having received gender-affirming psychotherapy in the year prior to assessment (OR = 2.33, 95% CI = 1.32–4.14).

Conclusions

Results suggest that gender identity development and internalized transphobia are associated with eating-related psychopathology in transgender and gender nonbinary individuals. Mental health providers should consider assessing all transgender and gender nonbinary individuals for eating-related psychopathology and unique risk factors associated with disordered eating, including low transgender congruence and internalized transphobia.

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.

References (45)

  • T. Udo et al.

    Prevalence and correlates of DSM-5–defined eating disorders in a nationally representative sample of U.S. adults

    Biological Psychiatry

    (2018)
  • M. Ålgars et al.

    Disordered eating and gender identity disorder: A qualitative study

    Eating Disorders

    (2012)
  • K. Anderson et al.

    Residents’ and fellows’ knowledge and attitudes about eating disorders at an Academic Medical Center

    Academic Psychiatry

    (2017)
  • W. Bockting et al.

    The transgender identity survey: A measure of internalized Transphobia

    LGBT Heal.

    (2020)
  • W. Bockting et al.

    Stigma, mental health, and resilience in an online sample of the US transgender population

    American Journal of Public Health

    (2013)
  • W. Bockting et al.

    Stigma, mental health, and resilience in an online sample of the US transgender population

    American Journal of Public Health

    (2013)
  • M. Brewster et al.

    Unpacking body image concerns and disordered eating for transgender women: The roles of sexual objectification and minority stress

    Journal of Counseling Psychology

    (2019)
  • S. Budge et al.

    Coping and psychological distress among Genderqueer individuals: The moderating effect of social support

    Journal of LGBT Issues in Counseling

    (2014)
  • J. Calzo et al.

    Eating disorders and disordered weight and shape control behaviors in sexual minority populations

    Current Psychiatry Reports

    (2017)
  • A. De Vries et al.

    Young adult psychological outcome after puberty suppression and gender reassignment

    Pediatrics

    (2014)
  • L. Derogatis

    The brief symptom inventory: An introductory report

    Psychological Medicine

    (1983)
  • E. Diemer et al.

    Beyond the binary: Differences in eating disorder prevalence by gender identity in a transgender sample

    Transgender Heal.

    (2018)
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