Plus, what needs to be done to change the health disparity.

By Maggie O'Neill
June 29, 2020
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At least 30 million Americans live with an eating disorder, according to the National Association of Anorexia Nervosa and Associated Disorders (ANAD)—and even that number may not be completely accurate. "We don't know the specific numbers because of underreporting," Claire Mysko, the CEO of the National Eating Disorders Association (NEDA) tells Health. But what we do know is this: Eating disorders kill more people than any other mental illness, with one death every 62 minutes directly resulting from an eating disorder, reports the ANAD. Disordered eating also affects all races and ethnic groups, and it's highly influenced by a combination of genetics, environmental factors, and personality traits.

What's often not talked about, however, is how much eating disorders disproportionately affect certain communities—specifically the lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) community. "What we know is that this population is at high risk for the development of an eating disorder,” Sydney Brodeur McDonald, senior director of clinical services at Veritas Collaborative, an eating disorder treatment healthcare system, tells Health. And the statistics don't lie: The ANAD reports that 16% of college-aged students have reported having an eating disorder; and in the same national study of college students, 3.5% sexual minority women and 2.1% of sexual minority men reported having an eating disorder.

The NEDA has stats, as well: According to existing research cited by the organization, gay males are believed to account for just 5% of the total male population, but they make up 42% of men who have eating disorders; and compared to heterosexual men, gay men were seven times more likely to report binging and 12 times more likely to report purging. Females, too, who identified lesbian, bisexual, or "mostly heterosexual" were also twice as likely to report binge-eating at least once per month in the last year, compared to heterosexual women.

Still, the NEDA says that more in-depth research as to why LGBTQ individuals are at a higher risk of developing disordered eating is lacking, Mysko says, adding that eating disorders, in general, receive lower amounts of funding than other mental health diagnoses. "We don't have a solid base of research," she explains, adding that NEDA is advocating for more studies on how the LGBTQ community is affected by eating disorders. But despite scant research, experts have some insight as to why members of this community are more likely to suffer from disordered eating—and what needs to be done to bring more attention to eating disorders among LGBTQ individuals to help remedy the disparity.

Bullying

Eating disorders most often develop between the ages of 12 and 24, McDonald says—that's also the age when many adolescents and teenagers begin to experience bullying. And LGBTQ youth are among the most likely to experience this bullying, along with harassment and violence. "We know there's a strong connection between bullying and disordered eating," Mysko says. The NEDA reports that as many as 65% of people with eating disorders say bullying contributed to their condition.

In a Mortality and Morbidity Weekly Report, published by the Centers for Disease Control and Prevention in June 2018, the health agency looked at six different categories of priority health-related behaviors among youth and young adults: behaviors that contribute to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors related to unintended pregnancy and sexually transmitted infections, unhealthy dietary behaviors, and physical inactivity. The report found that high school students who identified as lesbian, gay, or bisexual (LGB), experienced both cyberbullying (27.1%) and bullying on school property (33%) far more often than their heterosexual peers (13.3% and 17.1%, respectively). The problem is so severe that, per the CDC report, a tenth of LGB individuals claimed they had avoided attending school due to concerns for their safety.

There are multiple reasons that bullying can cause the development of an eating disorder, Chelsea Woodard, LPC-MHSP, site director at the The Renfrew Center of Nashville, a national network of eating disorder treatment facilities, tells Health. "So with bullying, particularly for younger folks, it leads to a feeling of disconnection and lower self-esteem," Woodward explains. "So, oftentimes, to try to feel more connected, what we see is that our clients will develop [an eating disorder] to change the way they look to fit in more." Woodward adds that, additionally, some people turn to disordered eating after being bullied to try to numb out the affects that bullying has had on them.

Trauma

Trauma, which is defined as a deeply disturbing experience, is known to play a role in the development of eating disorders. Research from 2018 published in the journal Appetite showed that among 182 individuals at an outpatient eating disorder treatment facility, 35% had experienced at least one traumatic event, examples of which included sexual abuse, domestic violence, and the death of a loved one. “Providers working with adolescents diagnosed with eating disorders of all weight statuses should consider assessing for past and current trauma,” the paper says.

LGBTQ individuals are also more likely to have experienced traumatic events than their heterosexual peers, according to the National Child Traumatic Stress Network (NCTSN). Common traumatic events experienced by LGBTQ youth, specifically, include intimate partner violence, sexual and physical abuse, traumatic loss, and harassment, among others, per the NCTSN.

Mysko emphasizes how big of a role trauma can play in the development of eating disorders among LGBTQ individuals. "Eating disorders don't exist in a vacuum," she says, adding that many in the LGBTQ community "have past histories of trauma." For this reason, experts have called for the availability of trauma-informed treatment for individuals struggling with an eating disorder. “Trauma-informed approaches to eating disorder treatment are needed to avoid potentially activating or exacerbating trauma related distress for adolescents in eating disorder treatment,” the authors of the Appetite paper wrote.

Woodard explains that experiencing trauma can lead to an eating disorder for multiple reasons. Among them is the motivation to numb out feelings that arose because of the traumatic incident. "We also know that LGBTQ+ people are more prone to sexual violence," Woodard points out. She adds that, sometimes, LGBTQ+ people who have experienced trauma try to change their body in order to feel less targeted. "They're using those [disordered eating] behaviors [to] manipulate their body in a way that feels safer," Woodard explains. "I've had a number of transgender clients, in particular, make themselves smaller, which helps them to feel they're less of a target, less seen."

Additionally, people who have experienced trauma might develop an eating disorder because it gives them a sense of control, Kasey Goodpaster, PhD, a psychologist and director of behavioral sciences at the Bariatric & Metabolism Institute at Cleveland Clinic, tells Health. "If they've experienced violence or trauma, they're likely to develop PTSD," Dr. Goodpaster explains. The false sense of control that an eating disorder can give someone "might sort of soothe some of the symptoms related to PTSD," Dr. Goodpaster says, explaining that it could be because whatever trauma the individual experienced made them feel out of control.

Cultural pressure

Another reason that eating disorders affect the LGBTQ community more so than other communities boils down to pressures put on people who identify with certain genders (a problem which, of course, affects people of all sexual orientations, but can be especially burdensome for gay men). Additionally, people who identify as LGBTQ might partake in certain disordered eating behaviors (such as restricting food intake or purging) in an attempt to chase after secondary sex characteristics, McDonald explains. “Eating disorders serve as a function: They might stop getting their period. Their hips will be smaller,” she says.

The cultural pressure to look a certain way is especially problematic within the gay community, where men are often pressured to aspire to dangerously small sizes, Ryan Sheldon, an ambassador for NEDA, tells Health. As a member of the LGBTQ community who has also been diagnosed with binge eating disorder, Sheldon knows all too well what this outside pressure can do to a gay man's mental health. "It is such a fair statement to say the second I came out is the second my eating disorder amplified," says Sheldon. The pressure put on Sheldon to be a smaller size has been so great that it's caused him to ask tough questions about what his identity means to him. At times, it can feel like losing weight comes with the territory of being a gay man. "Either I date women or lose weight," Sheldon says.

A statement from American Addiction Centers, a health care company that specializes in behavioral addictions and substance abuse, summarizes part of this complex problem this way: “Research suggests that eating disorders are more common among men who identify as gay…That high prevalence could be due, in part, to cultural pressures within this community of men.” Mysko adds that this “pressure from the outside culture around body image” does have an impact on LGBTQ individuals. “These are all pieces that do impact the disordered eating mindset. That is a complex piece of it,” Mysko says. Sheldon adds that the problem is exacerbated by the media, which rarely show images of larger-bodied gay men. "You have shows like Queer Eye. Every guy that's on there—they fit that cultural ideal mold. Where are all the larger-size-bodied gay men?"

Loneliness

Feeling isolated—no matter what your sexual orientation or gender identity—can contribute to the development of an eating disorder. A 2011 paper in the Journal of Psychology explains: “Eating disorders—including anorexia nervosa, bulimia nervosa, and eating disorders that are not otherwise specified, which include binge eating disorder—are challenging health issues. Each of these diagnoses specifically relates to loneliness.” This specific emotion can exacerbate symptoms caused by eating disorders, the paper goes on to say.

It’s no secret that identifying as a member of the LGBTQ community can feel especially isolating. “Certainly, there’s a fear of coming out and if they will be accepted, [which leads to] feeling very alone, isolated,” explains McDonald. She adds that when LGBTQ individuals internalize society’s rejection, this too can fuel eating disorder symptoms. McDonald says that the loneliness felt by LGBTQ individuals can also be caused by both internalized homophobia and fear of rejection, leading to a sense of isolation.

Loneliness can trigger an eating disorder when the affected individual believes that changing their body can lead to firmer connections than the ones they have in their lives. "We see people develop eating disorders as a method of trying to connect with other people," Woodard says, adding that low self esteem plays a role in this process. Unfortunately, she adds, eating disorders can actually leave people feeling less connected to the people around them, since eating disorders can rob people of meaningful social experiences.

For all the reasons listed above—bullying, trauma, cultural pressure, and loneliness; all of which can lead to eating disorders—it’s crucial to actively support LGBTQ individuals you know at work, school, within your family, or anywhere else, McDonald adds. “What we know about the LGBTQ folks who do best—they are connected to a strong, affirming community. What parents and loved ones can do is provide affirmative support,” she explains, adding that it’s imperative to use your voice to show those individuals that you are with them and for them. “There’s ways to get involved with ally-ship,” McDonald says. “Saying things like, ‘I understand you identify as gay. I will walk beside you.’ That’s different than being passively accepting.”

If you or someone you know is struggling with an eating disorder, you can call the National Eating Disorders Association Helpline at 1-800-931-2237, text "NEDA" to 741-741 or click to chat.

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