Show Summary Details
Page of

(p. 327) Eating Disorders and Disordered Eating in the LGBTQ Population 

(p. 327) Eating Disorders and Disordered Eating in the LGBTQ Population
Chapter:
(p. 327) Eating Disorders and Disordered Eating in the LGBTQ Population
Author(s):

Jon Arcelus

, Fernando Fernández-Aranda

, and Walter Pierre Bouman

DOI:
10.1093/med-psych/9780190630409.003.0019
Page of

date: 15 October 2018

Many epidemiological studies investigating prevalence rates of eating disorders and disordered eating psychopathology in sexual minorities have used the term LGBT to define the population studied. The term LGBT stands for lesbian, gay, bisexual, and transgender people (Canaday, 2014). This term, used since the 1990s, has been adopted by the majority of sexuality and gender identity-based communities and by the media of most English-speaking countries.

The terms lesbian, gay, and bisexual are used to refer to people (men and women) with a sexual attraction to members of their own sex (or to both, as is the case for people who identify as bisexual). The term transgender, or trans, is used to describe a diverse population of people who do not present and/or identify as the gender they were assigned at birth, either some or all of the time (Richards & Barker, 2013). Transgender identities include transgender women and men, respectively, who feminize or masculinize their bodies with cross-sex hormone treatment and/or gender-confirming surgery, and other gender-variant individuals, who may identify and/or present in a way that is outside the gender dichotomy of man/woman. This can include nonbinary people (not part of the binary gender), genderqueer (neither entirely male nor entirely female), bigender (encompasses both binary genders), pangender (infinite number of genders), genderfluid (gender identity varies over time), or agender (no gender), among others (Richards, Bouman, & Barker, 2017). Lately the letter “Q” has been added to the LGBT term in order to clarify that people who identify as queer (or nonbinary) or those questioning their gender identity are also included under this term. The term “cisgender” is used to describe people whose assigned gender at birth matches their gender identity (Richards et al., 2016). LGBTQ is therefore used to refer to anyone who identifies as nonheterosexual and/or non-cisgender.

(p. 328) Although the term LGBTQ is intended to emphasize a diversity of sexuality and gender identity-based culture, it remains unclear, and sometimes confusing, why people with a diverse sexual orientation are grouped together with people with a diverse gender identity. Although the fight for equal rights and civil liberties has brought sexual and gender identity minorities together as part of the same group (Knauer, 2009), scientifically it may not be as helpful because research findings from sexual minority studies are not necessarily generalizable to gender identity minorities.

The grouping of transgender people with gay, lesbian, and bisexual people in scientific literature is likely due to the low prevalence rates of transgender people in society. A recent study investigating meta-analytical prevalence rates of transgender people accessing transgender health services found 4.6 transgender people per every 100,000 individuals; it was 6.8 for transgender women and 2.6 for transgender men, with time analysis finding an increase in reported prevalence rates during the past 50 years (Arcelus et al., 2015). However, this study includes only a very specific population of transgender people, namely those fulfilling a rather narrow clinical diagnosis of being transgender as well as those accessing transgender health services. Because not every transgender person requires gender-confirming medical intervention (Beek, Kreukels, & Cohen-Kettenis, 2015; Bockting, Coleman, & De Cuypere, 2011), and therefore access to transgender services, the meta-analytical prevalence rates found in the study by Arcelus et al. likely underestimate the true prevalence of transgender people in the community (Makadon, 2011). Recent population surveys, with much wider inclusion criteria, have found prevalence rates of gender incongruity between 1.1% and 4.6% among people assigned male at birth and 0.8% and 3.2% among people assigned female at birth (Kuyper & Wijsen, 2014; Van Caenegem et al., 2015).

The high prevalence rates of people reporting gender incongruity in population studies may explain the significant increase in the number of people referred to transgender health services in Europe and North America (Aitken et al., 2015; de Vries, Kreukels, T’Sjoen, Ålgars, & Mattila, 2015). This increased prevalence is likely due to a number of interrelated factors, including an increase in the visibility of transgender people in the media, the wide availability of information on the Internet, and the increased availability of gender-confirming medical treatments and transgender health services in certain countries (Coleman et al., 2012; Wylie et al., 2014).

Gay, lesbian, and bisexual people, as well as transgender people, are a very diverse group. This is important to understand because generalizing findings from a group of people who identify as gay or lesbian to all people who identify as gay or lesbian is not always valid. The gay world is often represented as some sort of monolithic whole that shares the same culture. This is not true. For example, within the male gay culture, several groups have been socially constructed that are primarily based on femininity, masculinity, and body shape. Among these groups is the “bear” group, which is composed of usually large, hairy, and masculine-looking gay men (Gough & Flanders, 2009; Moskowitz, Turrubiates, Lozano, & Hajek, 2013). However, not every gay man belongs to a specific group, (p. 329) and a large number of gay men do not view themselves as belonging to any group. Studies that have investigated eating disorders among the gay population have frequently selected a subgroup of gay men who are single and young. For example, a study by Meyer, Blissett, and Oldfield (2001) showed that the relation between homosexuality in men and women and dieting behavior (or subclinical restrictive eating) is linked to levels of femininity and not to sexual orientation. Meyer et al. hypothesized that femininity might be viewed as a specific risk factor for the restrictive type of eating disorders, whereas masculinity is likely to be a protective factor. However, this study focuses on only restrictive eating and not on current diagnosis of eating disorder. When other potential confounding variables (namely self-esteem) were considered, both high femininity and high masculinity were found to be associated with eating problems (Heep, Spindler, & Milos, 2005). Accordingly, more recent studies (Griffiths, Murray & Touyz, 2015) have identified that masculinity can also be a risk factor for specific eating disorders, which are linked to muscularity (Murray, Rieger, Karlov, & Touyz, 2013).

Prevalence of Eating Disorders and Disordered Eating in the LGBTQ Population

Prevalence Rates in Transgender People

Epidemiological studies in the field of eating disorders have identified different prevalence rates in females compared to males. Although it has been traditionally assumed that 1 in 10 eating disorder cases are men (Fernández-Aranda & Jiménez-Murcia, 2014; Hoek & Van Hoeken, 2003), recent community samples report a ratio of 4:1 (Hudson, Hiripi, Pope, & Kessler, 2007; Mitchison, Hay, Slewa-Younan, & Mond, 2014). These results are based on the binary assumption of gender (male and female) as per assigned gender at birth.

If gender is not considered binary but, rather, is regarded as part of a spectrum (as sexuality is), providing prevalence rates of eating disorders according to gender becomes more complicated. The very few studies describing eating disorders among transgender people are case reports (Fernández-Aranda et al., 2000; Hepp & Milos, 2002; Hepp, Milos, & Braun-Scharm, 2004; Winston, Acharya, Chaudhuri, & Fellowes, 2004); therefore, conclusions about prevalence rates of eating disorders among this population are not possible.

The studies that have aimed to investigate prevalence rates of eating disorders in transgender people have focused on eating disorder psychopathology rather than clinically diagnosed eating disorders. In addition, these studies rarely include a control group. They also exclusively involve transgender people who are in contact with transgender health services, which limits the generalizability to the larger transgender population. Three studies have explored the relationship between eating disorder psychopathology and transgender people. More than 25 years ago, Silverstein, Carpman, Perlick, and Perdue (1990) distributed questionnaires to 188 women at a US university with the aim to explore the presence of (p. 330) a conflict in their gender identity. The study found that women who reported gender identity conflict were more likely to also report purging or frequent binging in comparison to women not reporting a conflicted gender identity. It is important to note that this study did not describe people who identified as transgender, so it is difficult to generalize the results to the overall transgender population. Despite this, the results are of interest because they suggest a relationship between unhappiness with one’s gender identity and binging/purging.

A relatively recent UK study further investigated degrees of eating disorder psychopathology in transgender people (Khoosal, Langham, Palmer, Terry, & Minajagi, 2009). The authors explored how eating disorder psychopathology changed during the course of gender-confirming medical treatment in a sample of 112 transgender women accessing a transgender health service. The study found that transgender women on cross-sex hormone treatment reported lower levels of eating disorder psychopathology and body image dissatisfaction in comparison to transgender people not on treatment. The study was limited by the lack of control for known risk factors for eating disorder psychopathology, such as age or personality factors. In an attempt to address some of the limitations of the aforementioned study, Witcomb et al. (2015) compared a large group of transgender people (n = 200) to a large group of people with a diagnosis of eating disorders (n = 200) and cisgender people (n = 200). The three groups were all matched by age and gender. The authors found that both transgender males and transgender females showed similar scores for drive for thinness, which were comparable to those of cisgender females and higher than those of cisgender males. The authors suggested that a female identity, by birth or by experienced gender, may be a risk factor for the development of eating disorders. The authors hypothesized that transgender females and males may internalize the same ideals that natal females do with regard to the ideal female body (Witcomb, Arcelus, & Chen, 2013). The strength of this study was that it included a large group of transgender people and compared this transgender sample with a matched control group. However, a limitation of the study is that the sample consists of only treatment-seeking transgender individuals, and the results do not necessarily translate to all transgender people.

The lack of studies focusing on an adequate number of transgender people makes it difficult to reach firm conclusions as to whether or not being transgender increases the risk of developing an eating disorder. Hence, clinical experience may also be taken into account. Two authors of this chapter (JA and WPB) work at a national service for transgender health care in the United Kingdom. This is one of the larger centers of its kind in Europe, with more than 1,000 new referrals per year. The clinical experience of the authors is that very few people who, at the time of assessment, present with a clinically diagnosable eating disorder. However, eating problems and eating disorder psychopathology may be underreported to clinical professionals by the transgender community. Some transgender people waiting to be assessed at a transgender health service may worry about reporting their eating disorder symptoms out of fear of not being accepted (p. 331) for gender-confirming medical treatment (Bouman & Arcelus, 2016). The term transnorexia has been adopted by certain transgender women (at least in the UK) to describe episodes of food restriction (Bouman & Arcelus, 2016). This is an underresearched area, and it appears to describe subthreshold levels of eating disorders. This particular group may be most at risk for developing severe psychopathology and, potentially, clinically significant eating disorders, suggesting the need for future studies targeting this group (Jones, Haycraft, Murjan, & Arcelus, 2016). As the number of transgender people in society increases, the number of people with a transgender identity who may present with an eating disorder may also increase.

Prevalence Rates in LGB People

Epidemiological studies have shown that there is a disproportionate number of gay men among the group of men with eating disorders. For example, Strong, Williamson, Netemeyer, and Geer (2000) found that eating disorder symptoms were 10 times more frequent among gay and bisexual men than among heterosexual men (10% and 1%, respectively). Among lesbian women, the data are less unequivocal. Whereas some studies found that lesbian and bisexual women had fewer symptoms of eating disorders compared to heterosexual women (Lakkis, Ricciardelli, & Williams, 1999; Strong et al., 2000), others found no differences (Feldman & Meyer, 2007). Some studies have reported female homosexuality to be a protective factor (Schneider, O’Leary, & Jenkins, 1995), whereas others have reported sexual orientation to be a risk factor (Heffernan, 1996). One explanation for these conflicting findings is the lack of any attempt to distinguish between the different groups of homosexual women, thus grouping them all into one category.

Treatment of Eating Disorders in the LGBTQ Population

In view of the higher prevalence of eating disorders among the LGBTQ population, particularly gay men, attempts have been made to develop preventative interventions. One study showed positive results when using a dissonance-based eating disorders program to prevent eating disorder psychopathology among the gay population (Brown & Keel, 2015). After randomizing 87 gay males to either a cognitive dissonance-based intervention (two sessions) or wait-list control condition, the authors found improvement in body dissatisfaction after 4 weeks of follow-up. Regarding treatment for eating disorders in the LGBTQ population, no studies have been published. Although there have been modifications of treatments for eating disorders, such as cognitive–behavioral therapy (CBT) and interpersonal psychotherapy (IPT), for males, they have not been specifically adapted for the LGBTQ people (Greenberg & Schoen, 2008). In addition, although some (p. 332) of the characteristics and themes inherent to being grouped as an LGBTQ population may be specific and particular to this group only, there is no clinical indication that the development of different types of treatment for the LGBTQ population with eating disorders is required. Treatments such as CBT and IPT have been found to be as useful, or not, for an LGBTQ person with an eating disorder as for anyone else (Fernández-Aranda et al., 2009). Based on our clinical experience, some of the issues that need to be considered when working with the LGBTQ population are described next.

Establishing Rapport

Before addressing the eating disorder, it is important to establish a positive rapport with the patient. This may be even more important with LGBTQ people due to possible experiences of discrimination and abuse. Establishing trust toward the professional may take longer than with other patients, but it is vital for a positive outcome.

It is important to ask how the person wants to be addressed; including the name and the pronoun the person prefers (and do not assume anything). For example, many people who identify as nonbinary prefer the pronoun “they” to be used (Richards et al., 2016). The professional may also want to ask how the person identifies (as male, female, transgender, nonbinary, etc.). Unfortunately, many LGBTQ people have encountered and continue to encounter abuse and discrimination (Clements-Nolle, Marx, & Katz, 2006; Yang, Manning, Van den Berg, & Operario, 2015). This occurs not only in their social and family life and at work but also within the health service (McNeil, Bailey, Ellis, Morton, & Regan, 2012; Whittle, Turner, & Al-Alami, 2007). Consequently, the person may feel anxious and cautious when talking to others, and the person may appear defensive in the first instance. The professional may want to spend some time putting the patient at ease and establishing a rapport.

Legally, it is important to understand that transgender people are protected by law in many countries. Information regarding previous names and identity may be accessible only with the permission of the patient or, in some cases, not at all. Such information may not be necessary or relevant, but some professionals may require access to previous treatment and historical information from the medical history. It is vital to remember that the transgender person needs to give consent. If inpatient treatment is offered, professionals also need to be aware of the law regarding the use of certain facilities, such as toilets (Eliason, Dibble, & Robertson, 2011). Transgender people must be able to use the toilet and changing room and, in case of single sex wards, be placed according to their expressed gender identity.

Once rapport has been established, a treatment plan can be developed. Some of the aims of treatment, particularly when targeting maintaining factors of the eating disorder, are described next and summarized in Table 19.1. (p. 333)

Table 19.1 Summary of the Aims of Therapy When Working with the LGBTQ Population with Eating Disorders

Aim

Treatment

Understanding the role of the eating disorder

  • If stopping the development of their adult body is the goal, consider a referral to transgender health services.

  • Addressing self-acceptance, fears of coming out, fears of non-acceptance by others, or having to be part of the LGBTQ community

Addressing body dissatisfaction

  • Adapting body image treatments for this specific population aiming at challenging ideal bodies

  • Working with expectations regarding gender-confirming medical treatment

  • Challenging thoughts regarding ideal male and female bodies

Targeting concurrent mental health problems and low self-esteem

  • Assessing the need for concurrent treatment for mental health problems, such as antidepressants

  • Using interventions to address self-esteem and its roots, keeping the minority stress theory in mind

Increasing support

  • Working with families or the couple

  • Providing space for psychoeducation and negotiation

  • Discussing grief, guilt, or fears about the future

Reducing interpersonal problems and increasing interpersonal skills

Use of interpersonal psychotherapy (IPT) to address eating disorders and concurrent mental health problems by targeting interpersonal skills and relationships. IPT will examine the gains and losses of the new role using “role transition” as the main focus of treatment.

Understanding the Role of the Eating Disorder

Understanding the role of the eating disorder in the life of the LGBTQ person may be the first aim of the assessment, in preparation for treatment. Ålgars, Alanko, Santtila, and Sandnabba (2012) found that the majority of transgender individuals reported current or past disordered eating in an attempt to suppress features of their biological gender or to accentuate features of their gender identity. This makes sense theoretically; however, only the small qualitative study by Ålgars et al. has reported these findings.

For many LGBTQ people, the eating disorder may function to block painful and distressing feelings about their gender or their sexuality, including the “coming out” process (Bekker & Boselie, 2002; Lampard, Byrne, McLean, & Fursland, (p. 334) 2011). In these cases, therapy may allow LGBTQ people to disentangle their feelings from their eating. This may take a significant amount of time. Self-acceptance and addressing internalized trans- and/or homophobia will be required first, and therapy could offer a space for this (Bockting & Coleman, 2016). The LGBTQ person may also discuss fears of not being accepted by others, worries about establishing relationships in the future, and the pressures of having to fit into specific communities, among other themes. For example, previous qualitative studies have described the worries that some gay men have about peer group influences and how these can affect their body image (Fernández-Aranda & Jiménez-Murcia, 2014; Morgan & Arcelus, 2009). They express concerns that gay bars and clubs are unhealthy environments due to the huge level of competition between men. Morgan and Arcelus discuss how young gay men may be extremely susceptible when coming out, due to media and peer group influences, as they seek to identify with role models and a new range of social norms.

Addressing Body Dissatisfaction

A commonly cited explanation for the increase in eating disorder psychopathology, such as a drive for thinness, among the LGBTQ population (male and female) may be linked to their body dissatisfaction, which has been widely reported (Cash, Winstead, & Janda, 1986). This is particularly important because the literature suggests that body dissatisfaction plays a key role in the development of eating disorders and disordered eating in the general population (Ålgars et al., 2012; Jones et al., 2016; Silverstein et al., 1990).

Studies investigating body image in transgender people have found higher levels of body dissatisfaction among this population compared to cisgender people (Ålgars, Santtila, & Sandnabba, 2010; Vocks, Stahn, Loenser, & Legenbauer, 2009). However, many of these studies have measured levels of body dissatisfaction using tools not specifically designed for the transgender population, which may limit their results. It is not surprising that people who believe that their body does not match their gender identity will be dissatisfied with any part of their body that reminds them of the gender assigned at birth. This will include not only their primary and secondary sexual characteristics but also their height, legs, hands, neck, hips, or shoulders, among other parts (Becker et al., 2016; Fernández-Aranda et al., 2000). Several studies have investigated body image in the transgender population. For example, Fisher et al. (2013) found that transgender females dislike more body parts than do transgender males. These findings are consistent with clinical findings suggesting that a past history of disordered eating is more common among transgender females than males.

The stage of transition of a transgender person, which may include being on cross-sex hormones and having undergone gender-confirming surgery, may also affect the level of body dissatisfaction among this population. Two studies found that body dysphoria and dissatisfaction decrease only after cross-hormone treatment has been commenced (de Vries, Steensma, Doreleijers, & (p. 335) Cohen-Kettenis, 2011). This was also confirmed in a study by Bandini and colleagues (2013), which found that transgender individuals without gender-confirming surgery had levels of body dissatisfaction (measured as body uneasiness) higher than those of controls and comparable to those of individuals with eating disorders. However, after gender-confirming surgery, transgender people reported lower levels of body dissatisfaction compared to those without surgery, but not as low as those of cisgender controls (Bandini et al., 2013). This study supports the view that body dissatisfaction in transgender people, although it can be reduced via gender-confirming medical interventions, is still higher than in cisgender people. Exploring the roots of this body dissatisfaction in more depth, Witcomb et al. (2015) found that although the body parts that caused the most dissatisfaction were those associated with gender assigned at birth, they also included those related to body shape, such as stomach, waist, hips, and bottom. Because these aspects of the body can be changed by dietary restriction, the authors suggest that this may put this population at higher risk of developing disordered eating.

Studies of eating disorders/body image and sexual orientation are complicated by rapidly changing cultural pressures on men and women and also the fluidity of definitions of sexual orientation and gender diversity. Male body image objectification seems to be increasing among men in general, and younger straight men are increasingly confronted with the same impossible body image ideals that have challenged women and gay men throughout the years (Cash et al., 1986; Morgan & Arcelus, 2009; Núñez-Navarro et al., 2012). This may also explain the increased rate of body dissatisfaction and eating disorders symptomatology among straight men (Allen, Byrne, Oddy, & Crosby, 2013; Raevuori, Keski-Rahkonen, & Hoek, 2014; Striegel-Moore et al., 2009). Although body dissatisfaction appears to be high among gay men (Cash et al., 1986; Greenberg & Schoen, 2008), research has shown that lesbian and bisexual women have lower levels of body dissatisfaction compared to heterosexual women (Herzog, Newman, Yeh, & Warshaw, 1992).

Addressing body dissatisfaction as a preventative measurement or as part of the eating disorders treatment for the LGBTQ population may require adapting some of the body image treatments currently available (Morgan, Lazarova, Schelhase, & Saeidi, 2014).

Targeting Concurrent Mental Health Problems and Low Self-Esteem

The prevalence of Axis I mental health problems, such as depression and anxiety, among LGBTQ people has been found to be higher than in the general heterosexual, cisgender population, even when risk factors such as age and gender are taken into account (Dhejne, Van Vlerken, Heylens, & Arcelus, 2016). This is not surprising because non-acceptance and stigmatization by others can force people into isolation, affecting their self-esteem and confidence (Núñez-Navarro et al., 2012). As a consequence, depressive and anxiety symptoms may develop. Depression (p. 336) has also been found to be comorbid with and predicts the development of certain eating disorders, such as bulimia nervosa (Fernández-Aranda et al., 2007). In addition, depression may act as a maintaining factor for an eating disorder. If that is the case, the treatment of the eating disorder may also require the management of concurrent mental health disorders. The minority stress model described by Meyer (1995) explains that the stress which particular minority groups can experience is due to the relationship between minority and dominant values that results in conflicts with their social environment. This model suggests that stress in specific minority groups, which include LGBTQ people, can be explained predominantly by stressors induced by a hostile, trans- or homophobic culture, which often results in a lifetime of harassment, abuse, victimization, and discrimination. Although difficult, addressing and increasing self-esteem should be part of any intervention aimed at reducing eating disorder symptoms.

Increasing Support and Understanding

Studies examining levels of social support among the LGBTQ population have found lower levels of reported social support among this group, particularly among transgender women, compared to controls (Davey, Bouman, Arcelus, & Meyer, 2014). Lack of social support has also been found to predict mental health problems among this population (Brown & Keel, 2013). Within gay culture, studies investigating eating disorders in this group found that being married or in a relationship protects the person from developing an eating disorder (Brown & Keel, 2013), as is the case in the straight population. Social support, particularly among gay men, can be a double-edged sword. On the one hand, having a close and supportive group of gay friends will increase support and self-esteem; on the other hand, social life may be limited mainly to gay bars and clubs, which may portray an unhealthy image of what it is like to be gay (Morgan & Arcelus, 2009).

Because lack of social support may be a risk factor for the development of eating disorders (Sharpe, Schober, Treasure, & Schmidt, 2014), it can be an important focus for treatment. Family and/or couples therapy can be useful interventions to increase social support for the LGBTQ person with eating disorders. Themes that may need to be addressed when working with this population and their families include feelings of grief (e.g., the loss of the son or daughter who is transitioning to a different gender), fears about the future (e.g., about abuse and discrimination), worries about making a mistake (e.g., “What if this is only a phase?”), guilt (e.g., false beliefs about the etiology of LGBTQ and different modes of parenting), and how to disclose to the rest of the family (including children). Therapy sessions can be a useful source for psychoeducation and negotiations about the future. Improving social and family support may provide a sense of acceptance and improve the person’s mental health, including the person’s eating disorder. As suggested in previous studies, CBT group therapy (in small groups) might offer an effective therapy option for addressing some of these topics (Fernández-Aranda & Jiménez-Murcia, 2014).

(p. 337) Reducing Interpersonal Problems

The term interpersonal relates not only to the interaction between the individual and significant others but also to the process by which these interactions are internalized and form part of the self-image (Sullivan, 1968). Good interpersonal skills are considered crucial to good mental health and aid the development of meaningful relationships (Klinger, 1977). Being involved in secure and fulfilling relationships is perceived by most individuals as critical to well-being and happiness (Berscheid & Peplau, 1983). It is therefore not surprising that interpersonal difficulties are strongly associated with many mental health problems, including eating disorders (Arcelus, Haslam, Farrow, & Meyer, 2013).

Regarding transgender people, a recent study found more interpersonal problems in this population than in a matched cisgender control group (Davey, Bouman, Meyer, & Arcelus, 2015). The authors found that among the transgender group studies, there were greater difficulties with being sociable and assertive. These findings suggest that trusting people may be more difficult for some transgender people, which may be a reflection of years of victimization and non-acceptance by society (Clements-Nolle et al., 2006; Yang et al., 2015). The role of interpersonal difficulties and their association with mental health problems in young transgender people has also been highlighted in a recent study (Arcelus, Claes, Witcomb, Marshall, & Bouman, 2016). This study identified interpersonal problems as the main predictors of mental health problems among the population studied. Lack of interpersonal skills throughout the transitional process may make the individual more vulnerable to the development of mental health problems, such as depression and eating disorders (Arcelus et al., 2013).

Interpersonal psychotherapy is regarded as a useful treatment for eating disorders (Arcelus, Whight, & Haslam, 2011; Klerman, Weissman, Rounsaville, & Chevron, 1984), and it may be an appropriate treatment to consider when working with a member of the LGBTQ population with an eating disorder. This is not only due to the interpersonal problems found in the transgender population (Davey et al., 2015) but also because IPT has been found to reduce eating disorder symptoms and depression while at the same time focusing on the transitioning process. One of the problem areas that can be addressed in IPT is “transitional role” (transitioning from one gender to another or from a straight life to a gay one). Therapists can help patients assess their life before and after transitioning and how their interpersonal life has change for good or bad (Whight et al., 2011). The focus of IPT could be to explore transition and acknowledge the losses and gains from the transitional process.

Conclusion

Studies have demonstrated an overall increase in eating disorder psychopathology among the LGBTQ population. Regarding transgender people, possibly due to the low reported prevalence rate of transgender people in society, very few studies (p. 338) have reached a clear conclusion as to whether being transgender increases the risk of developing an eating disorder. Studies investigating eating disorders among the LGB population have reached more firm conclusions, with more eating disorders among gay men compared to straight men but not compared to lesbian women. Femininity has been hypothesized as a possible risk factor for the development of eating disorders, more so than sexual orientation, with masculinity as a protective factor; however, this requires further study. The rapid increase in the number of transgender people attending transgender health services may affect the number of these people who develop an eating disorder and attend eating disorder services for treatment. For transgender people, pressure to conform to a gender, which is incongruous with their body, could precipitate body dissatisfaction for both genders and an eating disorder as a consequence. For gay men, trying to conform to specific roles, and the effect of the media, may also affect body dissatisfaction. In addition, concurrent mental health problems, such as depression, low self-esteem, and interpersonal difficulties, in the LGBTQ population may make these individuals more vulnerable to developing eating disorders. As part of an evidence-based treatment for their eating disorders, the following could be helpful: addressing the maintaining factors of the eating disorder through therapy; considering specific themes for this population, such as coming out, fears of rejection, and personal and society acceptance; and improving interpersonal skills.

References

Aitken, M., Steensma, T. D., Blanchard, R., VanderLaan, D. P., Wood, H., Fuentes, A., … Zucker, K. J. (2015). Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. Journal of Sexual Medicine, 12, 756–763.Find this resource:

Ålgars, M., Alanko, K., Santtila, P., & Sandnabba, N. K. (2012). Disordered eating and gender identity disorder: A qualitative study. Eating Disorders, 20(4), 300–311.Find this resource:

Ålgars, M., Santtila, P., & Sandnabba, N. K. (2010). Conflicted gender identity, body dissatisfaction, and disordered eating in adult men and women. Sex Roles, 63, 118–125.Find this resource:

Allen, K. L., Byrne, S. M., Oddy, W. H., & Crosby, R. D. (2013). DSM-IV-TR and DSM-5 eating disorders in adolescents: Prevalence, stability, and psychosocial correlates in a population-based sample of male and female adolescents. Journal of Abnormal Psychology, 122, 720–732.Find this resource:

Arcelus, J., Bouman, W. P., Van De Noortgate, W., Claes, L., Witcomb, G. L., & Fernández-Aranda, F. (2015). Systematic review and meta-analysis of prevalence studies in transsexualism. European Psychiatry, 30(6), 807–815.Find this resource:

Arcelus, J., Claes, L., Witcomb, G. L., Marshall, E., & Bouman, W. P. (2016). Risk factors for nonsuicidal self injury among trans youth. Journal of Sexual Medicine, 13(3), 402–412.Find this resource:

Arcelus, J., Haslam, M., Farrow, C., & Meyer, C. (2013). The role of interpersonal functioning in the maintenance of eating psychopathology: A systematic review and testable model. Clinical Psychology Review, 33, 156–167.Find this resource:

Arcelus, J., Whight, D., & Haslam, M. (2011). Interpersonal problems in people with bulimia nervosa and the role of interpersonal psychotherapy. In P. Hay (Ed.), New (p. 339) insights into the prevention and treatment of bulimia nervosa (pp. 3–12). Rijeka, Croatia: InTech.Find this resource:

Bandini, E., Fisher, A. D., Castellini, G., Lo Sauro, C., Lelli, L., Meriggiola, M. C., … Ricca, V. (2013). Gender identity disorder and eating disorders: Similarities and differences in terms of body uneasiness. Journal of Sexual Medicine, 10, 1012–1023.Find this resource:

Becker, I., Nieder, T. O., Cerwenka, S., Briken, P., Kreukels, B. P. C., Cohen-Kettenis, P. T., … Richter-Appelt, H. (2016). Body image in young gender dysphoric adults: A European multi-center study. Archives of Sexual Behavior, 45(3), 559–574.Find this resource:

Beek, T., Kreukels, B. P. C., & Cohen-Kettenis, P. T. (2015). Partial gender request and underlying motives of applicants for gender affirming interventions. Journal of Sexual Medicine, 12, 2201–2205.Find this resource:

Bekker, M. H. J., & Boselie, K. A. H. M. (2002). Gender and stress: Is gender role stress? A re-examination of the relationship between feminine gender role stress and eating disorders. Stress and Health, 18(3), 141–149.Find this resource:

Berscheid, E., & Peplau, L. A. (1983). The emerging science of relationships. In H. H. Kelley, E. Berscheid, A. Christensen, J. H. Harvey, T. L. Huston, G. Levinger, … D. R. Peterson (Eds.), Close relationships (pp. 1–19). New York, NY: Freeman.Find this resource:

Bockting, W., & Coleman, E. (2016). Developmental stages of the transgender coming out process: Toward an integrated identity. In R. Ettner, S, Monstrey, & E. Coleman (Eds.), Principles of transgender medicine and surgery (pp. 185–209). New York, NY: Routledge.Find this resource:

Bockting, W., Coleman, E., & De Cuypere, G. (2011). Care of transsexual persons. New England Journal of Medicine, 364, 2259–2560.Find this resource:

Bouman, W. P., & Arcelus, J. (2016). Body dissatisfaction and maladaptive eating behaviors among people with gender dysphoria. National Eating Disorder Information Centre Bulletin, 31, 1–4.Find this resource:

Brown, T. A., & Keel, P. A. (2013). The impact of relationships, friendships, and work on the association between sexual orientation and disordered eating in men. Eating Disorders, 21(4), 342–359.Find this resource:

Brown, T. A., & Keel, P. A. (2015). A randomised controlled trial of a peer co-led dissonance-based eating disorders prevention program for gay men. Behavioural Research Therapy, 74, 1–10.Find this resource:

Canaday, M. (2014). LGBT history. Frontiers, 35(1), 11–19.Find this resource:

Cash, T. F., Winstead, B. W., & Janda, L. H. (1986). The great American shape-up: Body image survey report. Psychology Today, 20(4), 30–37.Find this resource:

Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51(3), 53–69.Find this resource:

Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., … Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13, 165–232.Find this resource:

Davey, A., Bouman, W. P., Arcelus, J., & Meyer, C. (2014). Social support and psychological well-being in gender dysphoria: A comparison of patients with gender dysphoria and matched controls. Journal of Sexual Medicine, 11(12), 2976–2985.Find this resource:

Davey, A., Bouman. W. P., Meyer, C., & Arcelus, J. (2015). Interpersonal functioning among individuals with gender dysphoria. Journal of Clinical Psychology, 71(12), 1173–1185Find this resource:

(p. 340) de Vries, A. L. C., Kreukels, B. P. C., T’Sjoen, G., Ålgars, M., & Mattila, A. (2015). Increase of referrals to gender identity clinics: A European trend? In Transgender healthcare in Europe. Ghent, Belgium: European Professional Association of Transgender Health.Find this resource:

de Vries, A. L. C., Steensma, T. D., Doreleijers, T. H., & Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study. Journal of Sexual Medicine, 8, 2276–2283.Find this resource:

Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender dysphoria: A review of the literature. International Review of Psychiatry, 28(1), 44–57.Find this resource:

Eliason, M. J., Dibble, S. L., & Robertson, P. A. (2011). Lesbian, gay, bisexual, and transgender (LGBT) physicians’ experiences in the workplace. Journal of Homosexuality, 58(10), 1355–1371.Find this resource:

Feldman, M. B., & Meyer, I. H. (2007). Eating disorders in diverse lesbian, gay and bisexual populations. International Journal of Eating Disorders, 40(3), 218–226.Find this resource:

Fernández-Aranda, F., & Jiménez-Murcia, S. (2014). Evidence-guided treatment for males with eating disorders. In I. Dancyger & V. Fornari (Eds.), Evidence based treatments for eating disorders: Children, adolescents and adults (2nd ed., pp. 203–218). New York, NY: Nova.Find this resource:

Fernández-Aranda, F., Krug, I., Solano, R., Núñez, A., Jiménez-Murcia, S., … Treasure, J. (2009). Male eating disorders and therapy: A pilot study. Behaviour Therapy and Experimental Psychiatry, 40, 479–486.Find this resource:

Fernández-Aranda, F., Peri, J. M., Badía-Casanovas, A., Navarro, V., Turón-Gil, V., & Vallejo- Ruiloba, J. (2000). Transsexualism in anorexia nervosa: A case report. Eating Disorders: Treatment and Prevention, 8, 63–66.Find this resource:

Fernández-Aranda, F., Poyastro Pinheiro, A., Tozzi, F., Thornton, L. M., Fichter, M. M., … Bulik, C. M. (2007). Symptom profile of major depressive disorder in females with eating disorders. Australian and New Zealand Journal of Psychiatry, 41, 24–31.Find this resource:

Fisher, A. D., Castellini, G., Bandini, E., Casale, H., Fanni, E., Ferruccio, N., … Rellini, A. H. (2013). Cross-sex hormonal treatment and body uneasiness in individuals with gender dysphoria. Journal of Sexual Medicine, 11(3), 709–719.Find this resource:

Gough, B., & Flanders, G. (2009). Celebrating “obese” bodies: Gay “bears” talk about weight, body image and health. International Journal of Men’s Health, 8(3), 235–253.Find this resource:

Greenberg, S. T., & Schoen, E. G. (2008). Males and eating disorders: Gender-based therapy for eating disorder recovery. Professional Psychology: Research and Practice, 39(4), 464–471.Find this resource:

Griffiths, S., Murray, S. B., & Touyz, S. (2015). Extending the masculinity hypothesis: An investigation of gender role conformity, body dissatisfaction, and disordered eating in young heterosexual men. Psychology of Men & Masculinity, 16(1), 108–114.Find this resource:

Heffernan, K. (1996). Eating disorders and weight concern among lesbians. International Journal of Eating Disorders, 19, 127–138.Find this resource:

Hepp, U., & Milos, G. (2002). Gender identity disorder and eating disorders. International Journal of Eating Disorders, 32(4), 473–478.Find this resource:

Hepp, U., Milos, G., & Braun-Scharm, H. (2004). Gender identity disorder and anorexia nervosa in male monozygotic twins. International Journal of Eating Disorders Review, 35(2), 239–243.Find this resource:

Hepp, U., Spindler, A., & Milos, G. (2005). Eating Disorder Symptomatology and Gender Role Orientation. International Journal of Eating Disorders, 37(3), 227–233.Find this resource:

(p. 341) Herzog, D. B., Newman, K. L., Yeh, C. J., & Warshaw, M. (1992). Body image satisfaction in homosexual and heterosexual women. International Journal of Eating Disorders, 11, 391–396.Find this resource:

Hoek, H. W., & Van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34(4), 383–396.Find this resource:

Hudson, J. I., Hiripi, E., Pope, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348–358.Find this resource:

Jones, B., Haycraft, E., Murjan, S., & Arcelus, J. (2016). Body image and disordered eating in the trans population: A systematic review of the literature. International Review of Psychiatry, 28(1), 81–94.Find this resource:

Khoosal, D., Langham, C., Palmer, B., Terry, T., & Minajagi, M. (2009). Features of eating disorder among male-to-female transsexuals. Sexual and Relationship Therapy, 24, 217–229.Find this resource:

Klerman, G. L., Weissman, M. M., Rounsaville, B., & Chevron, E. (1984). Interpersonal psychotherapy for depression. New York, NY: Basic Books.Find this resource:

Klinger, E. (1977). Meaning and void: Inner experience and the incentives in people’s lives. Minneapolis, MN: University of Minnesota Press.Find this resource:

Knauer, N. J. (2009). LGBT elder law: Toward equity in aging. Harvard Journal of Law & Gender, 32(1), 1–73.Find this resource:

Kuyper, L., & Wijsen, C. (2014). Gender identities and gender dysphoria in the Netherlands. Archives of Sexual Behavior, 43, 377–385.Find this resource:

Lakkis, J., Ricciardelli, L. A., & Williams, R. J. (1999). Role of sexual orientation and gender-related traits in disordered eating. Sex Roles, 41, 1–16.Find this resource:

Lampard, A. M., Byrne, S. M., McLean, N., & Fursland, A. (2011). Avoidance of affect in the eating disorders. Eating Behaviors, 12(1), 90–93.Find this resource:

Makadon, H. J. (2011). Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleveland Clinic Journal of Medicine, 78(4), 220–224.Find this resource:

McNeil, J., Bailey, L., Ellis, S., Morton, J., & Regan, M. (2012). Trans mental health and emotional well-being study. Edinburgh, Scotland: Scottish Transgender Alliance.Find this resource:

Meyer, C., Blissett, J., & Oldfield, C. (2001). Sexual orientation and eating psychopathology: The role of masculinity and femininity. International Journal of Eating Disorders, 29(3), 314–318.Find this resource:

Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56.Find this resource:

Mitchison, D., Hay, P., Slewa-Younan, S., & Mond, J. (2014). The changing demographic profile of eating disorder behaviors in the community. BMC Public Health, 14(1), 943.Find this resource:

Morgan, J. F., & Arcelus, J. (2009). Body image in gay and straight men: A qualitative study. European Eating Disorders Review, 17, 435–444.Find this resource:

Morgan, J. F., Lazarova, S., Schelhase, M., & Saeidi, S. (2014). Ten sessions body image therapy: Efficacy of a manualised body image therapy. European Eating Disorders Review, 22(1), 66–71.Find this resource:

Moskowitz, D. A., Turrubiates, J., Lozano, H., & Hajek, C. (2013). Physical, behavioral, and psychological traits of gay men identifying as bears. Archives of Sexual Behavior, 42, 775–784.Find this resource:

Murray, S. B., Rieger, E., Karlov, L., & Touyz, S. W. (2013). An investigation of the transdiagnostic model of eating disorders in the context of muscle dysmorphia. European Eating Disorders Review, 21(2), 160–164.Find this resource:

(p. 342) Núñez-Navarro, A., Agüera-Imbernón, Z. P., Krug, I., Araguz, N., Saldaña, S., Gorwood, P., … Fernández-Aranda, F. (2012). Do men with eating disorders differ from women in clinics, psychopathology and personality? European Eating Disorders Review, 20(1), 23–31.Find this resource:

Raevuori, A., Keski-Rahkonen, A., & Hoek, H. W. (2014). A review of eating disorders in males. Current Opinion in Psychiatry, 27, 426–430.Find this resource:

Richards, C., & Barker, M. (2013). Sexuality and gender for mental health professionals: A practical guide. London, England: Sage.Find this resource:

Richards, C., Bouman, W. P., & Barker, M. (Eds.). (2017). Genderqueer and non-binary gender. London, England: Palgrave Macmillan.Find this resource:

Richards, C., Bouman, W. P., Seal, L., Barker, M. J., Nieder, T. O., & T’Sjoen, G. (2016). Non-binary or genderqueer genders. International Review of Psychiatry, 28, 95–102.Find this resource:

Schneider, J. A., O’Leary, A., & Jenkins, S. R. (1995). Gender, sexual orientation, and disordered eating. Psychological Health, 10, 113–128.Find this resource:

Sharpe, H., Schober, I., Treasure, J., & Schmidt, U. (2014). The role of high-quality friendships in female adolescents’ eating pathology and body dissatisfaction. Eating and Weight Disorders, 19(2), 159–168.Find this resource:

Silverstein, B., Carpman, S., Perlick, D., & Perdue, L. (1990). Nontraditional sex role aspirations, gender identity conflict, and disordered eating among college women. Sex Roles, 23(11-12), 687–695.Find this resource:

Striegel-Moore, R. H., Rosselli, F., Perrin, N., DeBar, L., Wilson, G. T., May, A., & Kraemer, H. C. (2009). Gender difference in the prevalence of eating disorder symptoms. International Journal of Eating Disorders, 42, 471–474.Find this resource:

Strong, S. M., Williamson, D. A., Netemeyer, R. G., & Geer, J. H. (2000). Eating disorder symptoms and concerns about body differ as a function of gender and sexual orientation. Journal of Social & Clinical Psychology, 19, 240–255.Find this resource:

Sullivan, H. (1968). The interpersonal theory of psychiatry. New York, NY: Norton.Find this resource:

Van Caenegem, E., Wierckx, K., Elaut, E., Buysse, A., Dewaele, A., Van Nieuwerburgh, F., … T’Soe, G. (2015). Prevalence of gender nonconformity in Flanders, Belgium. Archives of Sexual Behavior, 15, 1281–1287.Find this resource:

Vocks, S., Stahn, C., Loenser, K., & Legenbauer, T. (2009). Eating and body image disturbances in male-to-female and female-to-male transsexuals. Archives of Sexual Behavior, 38, 364–377.Find this resource:

Whight, D., McGrain, L., Baggott, J., Meadows, L., Langham, C., & Arcelus, J. (2011). Interpersonal psychotherapy for bulimia nervosa (IPT BNm). London, England: Troubador.Find this resource:

Whittle, S., Turner, L., & Al-Alami, M. (2007). Engendered penalties: Transgender and transsexual people’s experiences of inequality and discrimination. Wetherby, England: Communities and Local Government Publications.Find this resource:

Winston, A. P., Acharya, S., Chaudhuri, S., & Fellowes, L. (2004). Anorexia nervosa and gender identity disorder in biologic males: A report of two cases. International Journal of Eating Disorders, 36(1), 109–113.Find this resource:

Witcomb, G., Arcelus, J., & Chen, J. (2013). Can cognitive dissonance methods developed in the West for combatting the “thin ideal” help slow the rapidly increasing prevalence of eating disorders in non-Western cultures? Shanghai Archives of Psychiatry, 25(6), 332–341.Find this resource:

Witcomb, G. L., Bouman, W. P., Brewin, N., Richards, C., Fernández-Aranda, F., & Arcelus, J. (2015). Body image dissatisfaction and eating-related psychopathology in (p. 343) trans individuals: A matched control study. European Eating Disorders Review, 23(4), 287–293.Find this resource:

Wylie, K. R., Barrett, J., Besser, M., Bouman, W. P., Bridgeman, M., Clayton, A., … Ward, D. (2014). Good practice guidelines for the assessment and treatment of adults with gender dysphoria. Sexual and Relationship Therapy, 29, 154–214.Find this resource:

Yang, M.-F., Manning, D., Van den Berg, J. J., & Operario, D. (2015). Stigmatization and mental health in a diverse sample of transgender women. LGBT Health, 2(4), 26–29.Find this resource: