Sexual orientation as a factor in risk for binge eating and bulimia nervosa: a review

Sexual orientation and disordered eating in women: a meta-analysis

PURPOSE

Homosexuality is a clear risk factor for disordered eating in men; however, for women, research has yielded contradictory results. We conducted a meta-analysis to examine the association between sexual orientation and disordered eating in women.

METHODS

PRISMA guidelines were used. Studies comparing disordered eating between lesbians and heterosexual women were identified using PsycNet database and Google Scholar. Twenty-one studies met inclusion criteria. Overall disordered eating, restricting, binging and purging were examined for heterosexual, lesbian, bisexual and 'mostly heterosexual' women.

RESULTS

Whereas there was no significant difference in overall disordered eating between lesbians and heterosexual women, lesbians reported restricting less and binging more than heterosexual women. Bisexual women were more likely than lesbian women to restrict food intake and purge, and more likely than heterosexual women to have overall disordered eating and restrict food intake. "Mostly heterosexual" women were more likely than heterosexual women to restrict food intake, binge and purge.

CONCLUSIONS

Women of different sexual orientations show distinct patterns of disordered eating. Bisexual and "mostly heterosexual" women appear to be particularly at risk. Stress resulting from binegativity and rigid views of sexuality in a dichotomous society, rather than sexual orientation itself, may be associated with disordered eating in women. Findings should be viewed with caution because there were few studies with bisexual and "mostly heterosexual" women. This study elucidates the nature of the association between disordered eating and sexual orientation. Findings provide a possible explanation for previous inconsistencies, since opposing trends for different behaviors cancel each other out.

LEVEL OF EVIDENCE

Level I, systematic review and meta-analysis.

Exploring the Roles of Race, Ethnicity, Nationality, and Skin Color in the Sexual Partner Choices of Bisexual Latino Men

Racial and ethnic differences are well-documented social factors shaping sexual interactions. However, these racial/ethnic dynamics have been mostly overlooked in the context of sexual fluidity, specifically for bisexual individuals. Furthermore, there is limited literature on how sexual objectification based on skin color and ethnicity, factors well documented to influence individual's sexual partnering decision, might be different for male, female, and/or transgender partners of bisexual individuals. From 2009 to 2014, we conducted a mixed methods study examining how bisexual Latino men construct and participate in their sex markets. In the qualitative component of the study, we asked behaviorally bisexual Latino men (n = 148) how race/ethnicity, prejudice, stereotyping, and objectification intersected with their sexuality, specifically perceptions of their sexual experiences, decision making regarding sexual partners, and their reflection of their own race/ethnicity in their sexuality. We conducted a content analysis and identified three recurrent themes that are fully described in this article: (1) Bisexual Latino men objectify other men based on skin color, ethnicity, and race; (2) the race and ethnicity of women and transgender partners were not a dominant factor in sexual partnering decision making; and (3) sexual objectification based on skin color and ethnicity was a frequent, dominant experience throughout the sexual histories of our study participants. In summary, our findings suggest that bisexual Latino men participate in sex markets where race, ethnic, and nationality differences play a role in shaping men's desires for other men as sexual partners and they themselves are objects of desire.

Body Image and Sociocultural Norms

Internalization of sociocultural norms about the body has been theorized to be an important factor in fostering body dissatisfaction in women. Some theorists have suggested that a lesbian identity may buffer or immunize lesbians from the damaging effects of society's pressure to be thin by reducing this internalization. This study was designed to test this claim empirically. Questionnaires were completed by 108 lesbians and 115 heterosexual women recruited through snowball sampling. Lesbians felt more fit, reported less negative attitudes toward their lower bodies, and internalized sociocultural norms less than heterosexual women. For all women, internalization of sociocultural norms significantly predicted body attitudes. Lesbians and heterosexual women appear to be similarly exposed to and aware of society's messages, and as such their body attitudes substantially overlap. However, lesbians are buffered from these views in some specific areas. These differences appear to be primarily the result of differential internalization of sociocultural norms.

Physical Attractiveness, Body Image, and Women's Sexual Self-Schema

Recently, Andersen and Cyranowski (1994) presented a self-report measure of women's sexual self-schema, or cognitive view of the self regarding sexuality. In the current study, we investigated potential relationships between women's sexual self-schema and physical attractiveness, body size and shape, and body image. Young adult women ( N = 199) completed questionnaires and were weighed, measured, and rated for facial attractiveness. Results revealed that sexual self-schema was unrelated to body size or shape, general body dissatisfaction, history of teasing about weight, and degree of investment in personal appearance. Sexual self-schema scores significantly correlated with experimenter-rated facial attractiveness, self-rated facial and bodily attractiveness, and degree of social avoidance due to concerns over personal appearance, however. In a multiple regression analysis, only self-rated facial attractiveness and social avoidance were unique predictors. Results are discussed with regard to implications for the development of women's sexual self-schema and directions for future research.

Body Image, Weight, and Self-Concept in Men

In the traditional debate between biological and environmental determinants of body weight, the body has most often been explored in terms of its anatomical, genetic, or hormonal influences on personality, experience, and behavior. While obesity has been identified as a threat to our public health, correlating attitudes toward body image and self-concept have been explored within women to a limited extent, and even less so in relation to men. Consequently, men's body image will be discussed in light of current literature reveals for women. For men, as for women, as the social pressure to attain an "ideal" physique increases, the discrepancy between that ideal and one's body increases as well. This dynamic is more readily recognized for women than for men. As men are socialized not to discuss their body image concerns, negative self-concept and esteem may reinforce behaviors resulting in weight gain. In recent years, the proliferation of media has served to reinforce messaging related to one's body. This review of existing data and literature suggests that body image and self-concept are related to body weight in men (as with women) and need to be addressed as part of healthy weight management practices.

Minority stress and binge eating among lesbian and bisexual women

Previous research demonstrates that lesbian and bisexual (LB) women report more binge eating behaviors compared to heterosexual women although the explanations for this disparity are not well understood. LB women also experience distal (e.g., discrimination) and proximal (e.g., expectations of rejection) minority stressors that are related to negative mental and physical health outcomes. The present study investigated the association between minority stressors and binge eating behaviors in LB women. A sample of 164 LB women completed an online survey that included measures of distal and proximal sexual minority stressors, emotional-focused coping, social isolation, negative affect, and binge eating. The resultant model partially supported both the psychological mediation framework and the affect regulation model. The principal finding was that among LB women, proximal stressors were associated with social isolation and emotion-focused coping, which in turn were associated with negative affect and ultimately binge eating. Overall, the study provides evidence that minority stress is associated with binge eating and may partially explain the disparity in binge eating between LB and heterosexual women.

Sexual orientation and disordered eating behaviors among self-identified male and female college students

This study compared the risk of a) clinically diagnosed eating disorders, and b) disordered eating behaviors, separately among three groups of United States college students, controlling for known covariates. These groups included college students self-identifying as: 1) gay/lesbian; 2) bisexual; and, 3) unsure, with self-identified heterosexuals as the reference. Data from the American College Health Association's National College Health Assessment II (2008-2009) were utilized (N=110,412). Adjusted logistic regression analyses, stratified by self-reported gender, examined the effect of self-identified sexual identity on clinical eating disorder diagnosis and disordered eating behaviors. Covariates included self-reported binge drinking (past 2 weeks), stress (last 12 months), smoking (past 30 days), depression (past 12 months), fraternity/sorority membership, college athletics participations, and race. Additional logistic regression sub-analyses examined sexual minorities only, with gay/lesbian as the referent. Gay, unsure, or bisexual men were at significantly increased odds to report both clinical eating disorders and disordered eating behaviors when compared to heterosexual men in both the unadjusted and adjusted models (p<.002). All sexual minority men and women were significantly more likely to report dieting to lose weight compared to heterosexual men and women (p<.002). Targeted disordered eating and eating disorder prevention efforts are needed for those who are sexual minorities, particularly for sexual minority men.

Patterns of disordered eating behavior in women by sexual orientation: a review of the literature

Most disordered eating research has focused on White, heterosexual women. More empirical work is needed to better understand disordered eating among women of diverse backgrounds. Given evidence of disparities between heterosexual and sexual minority (i.e., non-heterosexual) women in other health behaviors (e.g., tobacco use) and outcomes (e.g., cardiovascular disease), it appears important to study disordered eating behaviors among sexual minority women. In this article, we review the extant literature on disordered eating behaviors in women across sexual orientations, with a focus on research examining potential mechanisms of disparities in disordered eating, including awareness and internalization of sociocultural norms.

Do lesbian women have a better body image? Comparisons with heterosexual women and model of lesbian-specific factors

Body dissatisfaction is prevalent among women but may be less common among lesbian women. Although research trends toward this conclusion when samples are well-matched and body mass index (BMI) is controlled for, many studies do not exhibit these characteristics. Furthermore, few studies have examined sociocultural contributors to group differences. I addressed limitations of past research with a large community sample of lesbian (n=479) and heterosexual (n=400) women. I contrasted the two sexual identity groups on several body dissatisfaction measures, and tested theoretically derived relationships between lesbian-specific cultural factors and body dissatisfaction. As predicted, lesbian women reported lower body dissatisfaction than did heterosexual women on three of four measures, and expressed a larger ideal body size. A structural equation model of lesbian-specific risk and protective factors for body dissatisfaction did not reveal significant relationships. This study represents a first attempt to model culturally specific influences on lesbian body image.

Exploring gender differences in body image, eating pathology, and sexual harassment

This study examines the relationship between body image (weight/shape concerns), eating pathology, and sexual harassment among men and women (N=2446). Hierarchical regressions controlling for depression revealed main effects of gender such that women reported greater weight/shape concerns, eating pathology, dietary restraint, eating concerns, and binge eating compared to men. Main effects for sexual harassment indicated that as harassment increased, participants reported increased weight/shape concerns, eating pathology, dietary restraint, eating concerns, binge eating, and compensatory behaviors. There were small but significant interactions between gender and harassment for eating pathology total score (which included each of the domains listed above), weight/shape concerns, dietary restraint, and eating concerns such that the relationship between increased harassment and increased pathology was stronger for women compared to men. The largest interaction was found for compensatory behaviors, such that while women and men's scores both increased as harassment increased, the relationship was stronger for men.

Sexual orientation disparities in weight status in adolescence: findings from a prospective study

A growing number of studies among adult women have documented disparities in overweight adversely affecting lesbian and bisexual women, but few studies have examined sexual orientation-related patterns in weight status among men or adolescents. We examined sexual orientation group trends in BMI (kg/m(2)), BMI Z-scores, and overweight using 56,990 observations from 13,785 adolescent females and males in the Growing Up Today Study (GUTS), a large prospective cohort of US youth. Participants provided self-reported information from six waves of questionnaire data collection from 1998 to 2005. Gender-stratified linear regression models were used to estimate BMI and BMI Z-scores and modified Poisson regression models to estimate risk ratios for overweight, controlling for age and race/ethnicity, with heterosexuals as the referent group. Among females, we observed fairly consistently elevated BMI in all sexual orientation minority groups relative to heterosexual peers. In contrast, among males we documented a sexual-orientation-by-age interaction indicating steeper increases in BMI with age from early-to-late adolescence in heterosexuals relative to sexual orientation minorities. Additional prospective research is needed to understand the determinants of observed sexual orientation disparities and to inform appropriate preventive and treatment interventions. The long-term health consequences of overweight are well-documented and over time are likely to exact a high toll on populations with elevated rates.

Objectification Theory and Psychology of Women: A Decade of Advances and Future Directions

Fredrickson and Roberts (1997) proposed objectification theory as an integrative framework for understanding how women's socialization and experiences of sexual objectification are translated into mental health problems. This article reviews the past decade of research grounded in objectification theory and highlights needed directions for future scholarship in this area. Specifically, this article reviews research organized according to the following themes: (a) self-objectification and its proposed consequences, (b) sexual objectification experiences as a proposed precursor, and (c) disconnections from bodily functions. An overview of emerging objectification theory research with men is also provided. The review concludes with needed directions for future theoretical and research efforts aimed to advance the psychology of women.

Sexual orientation, weight concerns, and eating-disordered behaviors in adolescent girls and boys

OBJECTIVE

To examine sexual orientation group differences in eating disorder symptoms in adolescent girls and boys.

METHOD

Cross-sectional associations were examined using multivariate regression techniques using data gathered in 1999 from 10,583 adolescents in the Growing Up Today Study, a cohort of children of women participating in the Nurses' Health Study II.

RESULTS

Ninety-two percent of the cohort described themselves as heterosexual, 5% as mostly heterosexual, 1% as lesbian/gay/bisexual, and 2% as unsure. Both mostly heterosexual girls and boys had greater concerns with weight and appearance and were less happy with their bodies compared with same-gender heterosexuals (all p < .05). Compared with heterosexual girls, the mostly heterosexual girls were more likely to vomit/use laxatives to control weight (odds ratio 1.7; 95% confidence interval = 1.2-2.6) and to binge eat (odds ratio 2.3; 95% confidence interval = 1.4-3.8) in the past year. Compared with heterosexual boys, gay/bisexual boys were more concerned with trying to look like men in the media (p < .05) and more likely to binge (odds ratio 15.2; 95% confidence interval = 3.3-69). Compared with heterosexual girls, lesbian/bisexual girls were happier with their bodies (p < .05) and less concerned with trying to look like women in the media (p < .05).

CONCLUSIONS

Mostly heterosexual girls and boys are a newly identified group at increased risk of eating disorder symptoms. Gay/bisexual boys were also at increased risk.

A Biopsychosocial Model of Disordered Eating and the Pursuit of Muscularity in Adolescent Boys

This review provides an evaluation of the correlates and/or risk factors associated with disordered eating and the pursuit of muscularity among adolescent boys. One of the main conclusions is that similar factors and processes are associated with both behavioral problems. Several factors found to be consistently associated with disordered eating among boys are also similar to those found with girls. These include body mass index, negative affect, self-esteem, perfectionism, drug use, perceived pressure to lose weight from parents and peers, and participation in sports that focus on leanness. However, as many of the findings have only been verified using cross-sectional designs, prospective studies are now needed.

Transtornos alimentares em homens: um desafio diagnóstico

Poucos transtornos na medicina em geral e na psiquiatria em particular têm uma distribuição por gênero tão assimétrica quanto os transtornos alimentares (TA), com apenas 10% dos casos ocorrendo no sexo masculino. Esta disparidade pode ser atribuída a fatores biológicos e culturais, mas também indica a existência de dificuldades no diagnóstico dos TA em homens. Embora tenha crescido o interesse pelos TA nas últimas décadas, seu reconhecimento no sexo masculino ainda é pobre e limitado por estereótipos. O presente estudo tem como objetivo discutir as semelhanças e diferenças dos TA em homens e mulheres, enfatizando os tópicos que têm implicações práticas para os profissionais de saúde mental.

Gender identity disorder and eating disorders

We report three cases of transsexual patients who are suffering from an eating disorder: a biological male patient diagnosed with anorexia nervosa (AN), a biological male patient with bulimia nervosa (BN), and a biological female patient with AN as well as a severe alcohol dependence. The relationship between eating behavior, gender identity, sexual orientation, and body dissatisfaction is discussed.

Homosexuality as a specific risk factor for eating disorders in men

OBJECTIVE

The current study examined whether homosexuality is a specific risk factor for disordered eating in men.

METHOD

Men (64 heterosexual and 58 homosexual) completed the Beck Depression Inventory (BDI), the Rosenberg Self-Esteem Scale (RSE), the Masculinity and Femininity scales of the Bem Sex-Role Inventory (BSRI), the Bulimia Test-Revised (BULIT-R), the Eating Attitudes Test (EAT-26), and the Body Shape Questionnaire (BSQ).

RESULTS

Homosexual men had more pathological scores on the BDI, RSE, BULIT-R, EAT-26, and BSQ. Additionally, homosexual men reported greater discomfort with sexual orientation. After controlling for differences in depression, self-esteem, and comfort with sexual orientation, sexual orientation continued to account for significant variance in BULIT-R, EAT-26, and BSQ scores.

DISCUSSION

Future research may benefit from exploring aspects of homosexuality that may contribute specifically to risk for disordered eating in men.

Binge eating disorder: a review of the literature after publication of DSM-IV

Binge eating disorder (BED) is a syndrome marked by recurrent episodes of binge eating, in the absence of the regular use of inappropriate compensatory behaviors. Since the inclusion of BED in DSM-IV as a Diagnostic Category in Need of Further Research, a great deal of research has been conducted. This paper reviews research on BED since publication of DSM-IV in 1994. We conclude that questions about the definition of BED persist. Furthermore, recent studies which have strictly used the DSM-IV definition of BED have found that the full syndrome is found in less than 3% of obese adults seeking weight loss treatment and occurs in less than 1% of the general adult population. Binge eating is a common symptom associated with obesity, however. BED may be conceptualized as a psychiatric syndrome or it may be viewed as a behavioral symptom associated with obesity. We conclude that clarification of this conceptual issue is needed if research on BED is to progress.