Eating Disorder Screening in Transgender Youth

The Sick, Control, One Stone, Fat, Food (SCOFF) is a Valid Eating Disorder Questionnaire to Use With Transgender Youth

Transgender youth experience elevated rates of eating disorders, yet few screening measures have been validated with transgender patients. The purpose of this study was to provide initial evidence for the internal consistency and convergent validity of the Sick, Control, One Stone, Fat, Food (SCOFF) in a sample of transgender youth. Two hundred eight participants completed the SCOFF as part of a routine screening protocol. Exploratory factor analysis and confirmatory factor analysis were used to establish the factor structure of the SCOFF in this sample. Relationships between the SCOFF, Adolescent Binge Eating Disorder (ADO-BED), Nine-Item Avoidant/Restrictive Intake Disorder (NIAS), Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and demographic characteristics were explored. The SCOFF was significantly related to all convergent validity variables, with moderate correlations with other eating disorder scales (ADO-BED and NIAS). The SCOFF is a valid measure to screen for eating disorders among transgender youth and young adults.

Eating Disorders in Sexual and Gender Minority Adolescents

PURPOSE OF REVIEW

To consolidate recent literature addressing eating disorders and disordered eating behaviors among sexual and gender minority (SGM) adolescents, including but not limited to lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents.

RECENT FINDINGS

Sexual and gender minority adolescents are at heightened vulnerability to eating disorders and disordered eating behaviors compared to their cisgender and heterosexual peers, potentially due to minority stress, gender norms, objectification, and the influence of the media, peers, and parents. We report findings from recent literature on the epidemiology and prevalence, assessment, mental health comorbidity, quality of life and psychosocial functioning, risk and protective factors, and treatment and interventions for eating disorders in sexual and gender minority adolescents. Addressing eating disorders in sexual and gender minority adolescents requires an integrated approach consisting of screening, tailored treatment, and comprehensive support to address intersectional challenges. Gender-affirming and trauma-informed care approaches may be considered.

Body Mass Index Categories of Transgender and Gender Diverse Youth: Clinical Associations and Predictors

Background: Transgender/gender diverse (TGD) youth are at risk for weight-related problems. We describe factors associated with their body mass index (BMI) category. Methods: Chart review of 228 TGD patients, 12-20 years (u = 15.7, standard deviation 1.3), 72% female assigned at birth. BMI percentile was calculated using CDC growth charts. We examined bivariate relationships of 18 clinically derived factors, utilizing analysis of variance (ANOVA) for continuous variables and chi-squared/Fisher's exact test for categorical variables. Nonparametric Classification and Regression Tree (CART) analyses were used to predict BMI category. Results: Almost half (49.6%) of TGD youth presenting for their initial visit for pediatric gender-affirming care fell in the healthy weight range, 4.4% in the underweight range, 16.7% in the overweight range, and 29.4% in the obese range. Self-described weight, weight management intentions, unhealthy weight management, prescription of psychiatric medications, and medications associated with weight gain were associated with BMI category. Use of psychiatric medications (54.8%) and medications associated with weight gain (39.5%) was associated with BMI in the overweight/obese categories. Youth with obesity most often reported unhealthy weight management. In CART models, self-described weight was the strongest predictor of BMI category. Conclusion: TGD youth have high rates of underweight and overweight/obesity. Unhealthy BMI should be treated as part of gender-affirming care. Self-described body weight is associated with weight category. More than half of TGD youth were prescribed psychiatric medications; those with overweight and obesity were more likely prescribed psychiatric and medications with associated weight gain. Youth with obesity were most likely to use unhealthy weight management.

Prevalence of Eating Disorder Symptoms in Transgender and Gender Diverse Adolescents Presenting for Gender-Affirming Care

PURPOSE

To describe the prevalence of eating disorder symptoms among adolescents seeking gender-affirming care.

METHODS

Cross-sectional study of 660 gender-diverse adolescents who completed the Branched Eating Disorder Test to measure anorexia and bulimia symptoms.

RESULTS

23.9% (95% CI 20.7-27.4) reported both anorexia symptoms, namely overvaluation of weight and fear of (or recurrent interference with) weight gain. 0.9% (95% CI 0.3-2.0) reported all bulimia symptoms, namely overvaluation of weight, recurrent binge eating, and recurrent compensatory behaviors (e.g., weekly purging). For all symptoms, prevalence was higher among i) adolescents assigned female at birth compared to those assigned male at birth, and ii) adolescents who felt unsure about their gender identity compared to those who identified as trans or nonbinary.

DISCUSSION

Clinicians should monitor eating disorder symptoms among adolescents presenting for gender-affirming care, especially among those assigned female at birth or who are unsure about their gender identity.

Body Composition and Metabolic Syndrome Components in Transgender/Gender Diverse Adolescents and Young Adults

Purpose: The objective of this study was to examine the association of designated sex at birth, body composition, and gender-affirming hormone treatment (GAHT) with the components of metabolic syndrome (MetS) (overweight/obesity, elevated blood pressure [BP], altered glucose metabolism, and dyslipidemia) in transgender/gender diverse (TGD) adolescents and young adults. Methods: TGD individuals underwent body composition studies by bioelectrical impedance analysis according to designated sex at birth, and their muscle-to-fat ratio (MFR) z-scores were calculated. Generalized estimating equations with binary logistic models (n = 326) were used to explore associations while adjusting for potential confounders. Results: A total of 55 TGD females and 111 TGD males, with mean age of 18 ± 1.9 years and median duration of GAHT of 1.4 years (interquartile range = 0.6-2.5), were enrolled. Overall, 118/166 (71%) of the TGD cohort showed evidence of at least one MetS component, with a significantly higher rate among TGD males compared with TGD females (91.1% vs. 50.9%, p < 0.001). TGD males were at increased odds for overweight/obesity, elevated/hypertensive BP, elevated triglycerides (TGs), and an atherogenic dyslipidemia index (TG/high-density lipoprotein cholesterol [HDL-c], TG:HDL-c). The odds of overweight/obesity increased by 44.9 for each standard deviation decrease in the MFR z-score, while the odds for an elevated TG:HDL-c index increased by 3.7. Psychiatric morbidity increased the odds for overweight/obesity by 2.89. Conclusions: After considering confounding variables, the TGD males on GAHT were found to be at an increased risk for cardiometabolic disease. Our observations support the importance of targeted medical nutrition intervention in this group of individuals.

Disordered eating behaviors in gender-affirmative treatment seeking transgender people

This study aimed to explore disordered eating behaviors in gender-affirming treatment (GAT)-seeking transgender (TG) adults and cisgender people, in addition to analyzing the association between gender dysphoria intensity, body mass index, and disordered eating behaviors. Data were collected from 132 GAT-seeking TG people with gender dysphoria who had never received GAT (91 TG men, 41 TG women), and 153 cisgender (99 cisgender men, 54 cisgender women) participants from Turkey. The Utrecht Gender Dysphoria Scale was used to evaluate the intensity of gender dysphoria. Eating Disorder Examination Questionnaire and Questionnaire on Eating and Weight Patterns-5 were utilized to assess disordered eating. There was no difference between TG women and TG men in terms of ED psychopathology. The most prominent characteristic in all four groups was shape concern, which was significantly higher in TG men and TG women when compared to cisgender men and cisgender women. Binge eating was notably more frequent in TG men and TG women compared to cisgender men, with 11% of the TG men and 7.3% of the TG women meeting the criteria for possible binge eating disorder. Screening for disordered eating behaviors, particularly binge eating, may be recommended in routine care for TG people.

The association between gender-affirming care and disordered eating in transgender and gender diverse individuals: Exploring appearance congruence and gender-related motivating factors for weight loss

OBJECTIVE

The objective of this study is to explore between-group differences across different stages of gender-affirming care, and associations between appearance congruence, gender-related motivations for weight loss, and disordered eating in transgender and gender expansive (TGE) individuals.

METHOD

A total of 160 TGE adults (aged 18-30) were recruited across the United States. Participants completed a comprehensive online survey. Data were analyzed using generalized linear models and bivariate correlations.

RESULTS

Significant differences in appearance congruence among participants at different transition stages were revealed, with the group that achieved their desired transition reporting the highest appearance congruence compared to all other groups. Furthermore, gender-related motivations for weight loss were significantly lower in individuals who achieved their desired transition compared to those with no plans to transition.

DISCUSSION

Findings suggest significantly higher appearance congruence in those who achieved their desired transition compared to other groups, and individuals who attained their desired transition exhibited significantly reduced gender-related motivations for weight loss compared to those with no plans to transition. These findings underscore the potential psychological benefits associated with successful gender-affirming care, highlighting its role not only in fostering appearance congruence but also in mitigating gender-related motivations for weight loss among TGE individuals. Future research should include larger and more diverse samples, longitudinal designs, and considerations of other factors influencing body image outcomes in this population.

PUBLIC SIGNIFICANCE

This study sheds light on the crucial relationship between gender-affirming care and body image outcomes in TGE individuals. Understanding how appearance congruence and gender-related motivations for weight loss are associated with disordered eating can inform tailored support and interventions. By recognizing the association of gender affirming care and well-being, healthcare providers can enhance care for TGE individuals.

What is needed for eating disorder prevention for transgender and gender diverse young adults? Findings from asynchronous online focus groups

Transgender and gender diverse (TGD) young adults face higher risk of eating disorder (ED) symptoms than cisgender peers. Evidence-based ED prevention programs exist but must be adapted to meet the needs of diverse TGD populations. We conducted eight asynchronous online focus groups in 2019 with 66 ethnically and gender diverse TGD young adults (18-30 years) living in the United States. Participants were recruited online; groups took place over four consecutive days. We conducted inductive thematic analysis of participant responses to three prompts about ED prevention needs and advice for program developers. Findings fell into three domains. In Domain 1: Developing Program Content, themes included (1.1) need to address multiple dimensions of gender; (1.2) intersectional representation matters; (1.3) limitations of ED research; (1.4) being responsive to trauma. Domain 2: Program Delivery Considerations, included preferences for (2.1) group composition, (2.2) intervention modality, and (2.3) program leadership. Domain 3: Cultivating Affirming Spaces included themes addressing the need for programs to (3.1) create judgment-free environments and (3.2) center lived experience. TGD young adults in this study described a range of needs and recommendations for ED prevention content and delivery, with relevance to clinicians, program designers, and ED prevention advocates.

Disordered eating in transgender and gender non-conforming youth: A comparison to community-based and clinical samples

OBJECTIVE

This study investigates eating pathology in transgender and gender non-conforming (TGNC) youth compared to a community-based sample and individuals with eating disorders (EDs).

METHOD

Participants (ages 13-21 years) included TGNC youth from a paediatric gender clinic (N = 97), a demographically matched community-based sample of cisgender males (N = 97) and cisgender females (N = 97), and treatment-seeking patients with EDs (N = 112). The Eating Disorder Examination Questionnaire (EDE-Q) was used to assess ED cognitions and behaviours.

RESULTS

Transgender and gender non-conforming participants reported significantly higher EDE-Q global scores compared to the cisgender samples, but significantly lower than the ED sample. Transgender and gender non-conforming individuals reported a higher likelihood of objective binge episodes (OBEs) than the cisgender groups, albeit lower than youth with EDs. A substantial proportion of TGNC participants scored in elevated ranges on the EDE-Q global score (35% ≥ score of 3, 17% ≥ score of 4), significantly higher than cisgender males (0% ≥ score of 3, 0% ≥ score of 4) and females (9% ≥ score of 3, 3% ≥ score of 4).

CONCLUSIONS

Findings indicate that TGNC youth exhibit increased ED cognitions and OBEs compared to cisgender samples, highlighting the need for screening and addressing ED symptoms in this population.

Roux-en-Y gastric bypass in a transgender patient: a case report

The frequency of transgender individuals seeking gender affirming care is increasing over the last decade. Transgender patients suffer from obesity and psychiatric illness at elevated levels compared with the general population. A 54-year-old male-to-female transition patient presented with morbid obesity, hyperlipidaemia, and weight gain 2 years after their gender-transition and hormonal therapy. She received a Roux-en-Y gastric bypass (RYGB). At 7 months postoperatively, the patient has experienced 49% excess body weight loss, her body dissatisfaction had resolved and has completed further plastic surgery. The RYGB is an effective method for weight loss as well as benefits from cardiovascular disease, cancer, metabolic related conditions, and psychosocial wellbeing. Holistic treatment in conjunction with dietetic and psychology services can help maintain long-term weight management. Bariatric surgery combined with a multidisciplinary care team addressing medical and psychiatric concerns is integral to achieving and maintaining weight loss and gender identity.

[Consenso del grupo de trabajo de los trastornos de la conducta alimentaria de SENPE (GTTCA-SENPE). Evaluación y tratamiento médico-nutricional en la anorexia nerviosa. Actualización 2023]

Anorexia nervosa (AN) is a multifactorial disorder. A possible role of the social network and the gut microbiota in pathogenesis has been added. Exogenous shocks such as the COVID19 pandemic have had a negative impact on patients with AN. The potential medical and nutritional impact of malnutrition and/or compensatory behaviors gives rise to a complex disease with a wide range of severity, the management of which requires a multidisciplinary team with a high level of subject matter expertise. Coordination between levels of care is necessary as well as understanding how to transition the patient from pediatric to adult care is essential. A proper clinical evaluation can detect possible complications, as well as establish the organic risk of the patient. This allows caregivers to tailor the medical-nutritional treatment for each patient. Reestablishing adequate nutritional behaviors is a fundamental pillar of treatment in AN. The design of a personalized nutritional treatment and education program is necessary for this purpose. Depending on the clinical severity, artificial nutrition may be necessary. Although the decision regarding the level of care necessary at diagnosis or during follow-up depends on a number of factors (awareness of the disease, medical stability, complications, suicidal risk, outpatient treatment failure, psychosocial context, etc.), outpatient treatment is the most frequent and most preferred choice. However, more intensive care (total or partial hospitalization) may be necessary in certain cases. In severely malnourished patients, the appearance of refeeding syndrome should be prevented during renourishment. The presence of AN in certain situations (pregnancy, vegetarianism, type 1 diabetes mellitus) requires specific care. Physical activity in these patients must also be addressed correctly.

Emerging Evidence: A Systematic Literature Review of Disordered Eating Among Transgender and Nonbinary Youth

PURPOSE

This systematic literature review explores the evidence base related to the diagnosis and clinical management of eating disorders among transgender and gender nonbinary (TGNB) youth. Through an exploration of the literature, this review highlights key considerations for providers working with this population, including the complex relationship between body image and gender, the assessment of subthreshold eating disorder symptoms, the impact of gender-affirming care on eating disorder treatment outcomes, and available evidence-based metrics, with attention to factors impacting treatment, including family support, psychiatric comorbidities, and community safety.

METHODS

We conducted a search of the databases PubMed and Ovid MEDLINE for articles pertaining to eating disorders and TGNB youth, with forward citation chaining conducted via Google Scholar to provide a review of recent publications. Twenty-six articles published from 2017 to 2022 met the criteria for full-text review.

RESULTS

The selected articles primarily explored data from the United States and varied widely in methodology, including a systematic literature review (n = 1), narrative literature reviews (n = 3), case series (n = 4), case studies (n = 2), cross-sectional population surveys (n = 7), cross-sectional patient surveys (n = 3), other cross-sectional studies (n = 3), retrospective chart reviews (n = 2), and a retrospective longitudinal cohort study (n = 1). Most commonly, researchers sampled patients within the setting of gender clinics. Researchers used a range of validated measures in clinical settings, with the Eating Disorder Examination Questionnaire most frequently reported. The literature highlights several considerations unique to transgender populations, including the complex relationship between gender dysphoria, body dissatisfaction, disordered eating behavior, and gender-affirming care.

DISCUSSION

In clinical settings with TGNB youth, providers may consider implementing validated screening measures to assess for eating disorders. Future research should emphasize a nuanced understanding of the heterogeneity among TGNB patient populations and the impact of gender identity on treatment of eating disorders.

Intersectionality of demographic characteristics in self-reported anorexia nervosa, bulimia nervosa, and probable eating disorders among college students

OBJECTIVE

To investigate associations between identity intersectionality, with a primary focus on minority identity, and probable eating disorders (EDs) within the US college student population.

METHOD

Data consisting of n = 414,299 college students' responses to the American College Health Association's National College Health Assessment between fall 2015 and spring 2019 were utilized for this study. Overall and stratified adjusted odds ratios (aORs) were used to assess the association between different facets of identity (i.e., race/ethnicity, gender identity, and sexual orientation) and probable EDs.

RESULTS

Among all, in our analytic sample, 7.15% reported a probable ED. Interactions between all three identity variables were significant, and thus stratified odds ratios were evaluated. Transgender men were significantly more likely to report probable ED than cisgender male peers within the following racial/ethnic groups: non-Hispanic White (aOR: 3.33; 95% CI: 2.79, 3.96; p < .0001), non-Hispanic Black (aOR: 3.29; 95% CI: 1.72, 6.28; p = .0003), Hispanic (aOR: 2.31; 95% CI: 1.55, 3.43; p < .0001), Asian or Pacific Islander (aOR: 2.19; 95% CI: 1.45, 3.30; p = .0002), Biracial or Multicultural (aOR: 3.36; 95% CI: 2.17, 5.22; p < .0001), and other (aOR: 4.19; 95% CI: 2.25, 7.79; p < .0001).

CONCLUSIONS

This study underscores the importance of increasing our understanding of interactions between marginalized identities and the ways in which minority identity informs ED risk.

PUBLIC SIGNIFICANCE

The impact of multiple marginalized identities on ED outcomes is not well understood. Our study expands on previous ACHA-NCHA studies by addressing identity intersectionality, looking at more than one identity at a time (i.e., specifically race/ethnicity, gender identity, and sexual orientation). Our results contribute unique risk profiles for students who identify with multiple marginalized groups. Further, they indicate that that these associations vary based on the compounded effect of the demographic factors considered.

Eating disorder symptoms among transgender and gender diverse youth

Compared to cisgender peers, transgender and gender diverse (TGD) youth and adults report elevated eating disorder (ED) symptoms likely related to gender dysphoria and attempts to modify their bodies accordingly. Less is known about the impact on gender-affirming care and ED symptoms. This study aimed to expand on extant research and describe ED symptoms in TGD youth seeking gender-affirming care while exploring potential associations between gender-affirming hormone use and ED symptoms. A total of 251 TGD youth completed the Eating Disorders Examination-Questionnaire (EDE-Q) as part of routine clinical care. ANCOVAs and negative binomial regressions examined differences in ED symptoms among transgender females (identifying as female but assigned male at birth) and transgender males (identifying as male but assigned female at birth). ED severity was not significantly different among transgender females versus transgender males, (p = .09), or associated with gender-affirming hormone use (p = .07). Transgender females receiving gender-affirming hormones reported a greater proportion of objective binge eating episodes compared to those who were not (p = .03). Over a quarter of TGD youth reported engagement in ED behaviors suggesting assessment and intervention related to ED behaviors among TGD youth is imperative since adolescence is a particularly vulnerable period for adolescents and engagement in ED behaviors could lead to full ED development and medical risk.

Gender-Affirming Nutrition: An Overview of Eating Disorders in the Transgender Population

PURPOSE OF REVIEW

Transgender individuals are vulnerable to many nutrition-related conditions, especially eating disorders due to gender dysphoria. This review aims to summarize the current literature on eating disorders in transgender individuals. The issues that should be considered in nutrition care for the transgender population are discussed regarding public health.

RECENT FINDINGS

Transgender individuals can exhibit disordered eating behaviors to overcome the stress they experience due to stigma, discrimination, social exclusion, and abuse. Recent studies showed that disordered eating and clinical eating disorders are more prevalent among transgender than cisgender people. It is very important for a multidisciplinary team working in the clinic to understand the epidemiology, etiology, diagnostic criteria, and treatment of eating disorders in the transgender population. However, multidisciplinary nutritional care is limited due to the lack of transgender-specific nutrition guidelines. It is safe to say that adhering to a generally healthy nutritional pattern and using standardized nutrition guidelines. We recommend that health professionals working with patients/clients with eating disorders receive continuing education in transgender health, be empowering and inclusive, address patients/clients with their gender identity nouns and pronouns, and develop nutritional treatment plans that are not gender-specific. Eating disorders are a significant public health problem in the transgender population. Therefore, clinical screening and early intervention are necessary to identify and treat eating disorders in transgender people. Eating disorders in the transgender population should be monitored routinely, and gender-affirming care should be provided as well as treatment of eating disorders.

Body Image and High-Risk Weight and Shape Control Behaviors Among Transgender and Nonbinary Young Adults: The Role of Sexual Assault

Purpose: Transgender and nonbinary (TNB) populations experience disproportionate rates of sexual assault. Despite evidence from cisgender samples linking sexual assault exposure to body image concerns and disordered eating behaviors, such as weight and shape control behaviors (WSCBs), little is known about these relationships in TNB people. The purpose of this study was to assess associations among past-year sexual assault exposure, body areas satisfaction, body weight esteem, and high-risk WSCBs in a sample of TNB young adults. Methods: A sample of 714 participants completed a cross-sectional online survey. Multivariable linear and logistic models were fit to determine associations between constructs of interest. Natural effects mediation analyses assessed for potential mediation of the relationship between sexual assault and WSCBs by body areas satisfaction and body weight esteem. Analyses were stratified by three gender identity categories. Results: Past-year sexual assault exposure was associated with significantly decreased body areas satisfaction, but only for nonbinary participants. No significant association was found between sexual assault and body weight esteem. Sexual assault was associated with significantly increased risk for WSCBs across gender identity categories. No mediation of these relationships by body areas satisfaction and body weight esteem was observed. Conclusion: Findings support clinical consideration of WSCBs in TNB survivors of sexual assault. Results suggest that multiple factors, including body image and sexual assault, may contribute separately to disordered eating behaviors in TNB young adults.

A scoping review of research literature on eating and body image for transgender and nonbinary youth

BACKGROUND

Transgender and nonbinary (TGNB) adolescents and young adults are underrepresented in the literature on eating disorders and body image-related problems, despite increased mental health disparities and emerging research showing high associations between gender dysphoria, body image, and eating disorders among TGNB youth.

AIMS

The scoping review was designed to critically examine the research on TGNB adolescents and young adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this scoping review. The electronic databases of MEDLINE and PsychInfo were used for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for transgender minor children, adolescents, or young adult samples (18 to 25 years old) and address differences in eating/body-related problems by age. The relevant data was extracted and narratively summarized.

RESULTS

49 studies were identified, data extracted, and analyzed. Increased prevalence of eating disorders and body image problems were identified for TGNB youth. Body-gender congruence through gender affirming social and medical interventions (e.g., hormone therapy) were noted as significant for alleviating body image problems and facilitating eating disorder treatment. Family and social factors were not well understood in the literature and a need for increased study of TGNB youth from varied racial/ethnic, neurodiverse, and within specific identities (e.g., nonbinary) and families and cultural contexts is still needed.

CONCLUSIONS

Future research should consider the use of developmental and family theories for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups, neurodiversity, and varied gender identities (e.g., nonbinary and gender queer) for identifying important differences.

A Longitudinal Study on Disordered Eating in Transgender and Nonbinary Adolescents

OBJECTIVE

We longitudinally explored frequency of disordered eating among transgender and nonbinary (TGNB) adolescents and explored trends by gender identity and gender-affirming care.

METHODS

Participants completed an abbreviated version of the Eating Disorder Examination Questionnaire (EDE-Q) at baseline, 3, 6, and 12 months after establishing care in a gender clinic. We analyzed descriptive statistics and multivariate linear regression analyses.

RESULTS

Of the 91 TGNB adolescent participants, 61% were transmasculine, 30% transfeminine, and 7% nonbinary/gender-fluid. Among TGNB adolescents, disordered eating thoughts/behaviors were frequently endorsed with 26% of participants engaging in any occurrence of binge eating, 27% limiting the amount of food they ate, and 30% excluding foods from their diet. Forty percent of participants reported any occurrence of at least 1 disordered eating behavior and 17% at least 3 behaviors. Abbreviated EDE-Q responses did not differ significantly by sex assigned at birth, gender identity, gender-affirming medications, or time spent receiving gender-affirming care. There was a significant effect of age (P value = .003) on abbreviated EDE-Q scores.

CONCLUSIONS

There were no significant changes in disordered eating after initiating gender-affirming medical care, possibly due to the limited study time frame of 12 months. Given the high prevalence of disordered eating behaviors, clinicians should consider screening all TGNB adolescents for disordered eating thoughts/behaviors throughout gender-affirming care. Future longitudinal research should recruit larger samples with a diverse range of gender identities and survey disordered eating thoughts/behaviors at least one year after starting gender-affirming medications.

Orthorexia nervosa symptomatology in the LGBTQ community: Gender and sexual orientation differences

This study investigated whether gender and sexual minority groups exhibit differences in orthorexia nervosa (ON) symptomatology compared to cisgender, straight individuals. A sample of 441 non-clinical participants (65 % White, mean age = 27) reported their gender (104 cisgender men, 229 cisgender women, 28 transgender men, 27 transgender women, 53 nonbinary) and sexual orientation (144 straight, 45 gay, 54 lesbian, 105 bisexual/pansexual, 68 queer), and completed the Orthorexia Nervosa Inventory. The LGBTQ group exhibited greater ON symptomatology compared to the cisgender, straight group. ANOVAs demonstrated significant group differences according to gender and sexual orientation. Post-hoc tests revealed that transgender women exhibited greater ON symptomatology than cisgender men and cisgender women. However, nonbinary individuals exhibited lower ON symptomatology than cisgender women, transgender men, and transgender women. Additionally, lesbians exhibited greater ON symptomatology than straight individuals. Our findings suggest that individuals with an LGBTQ identity, particularly transgender women and lesbians, may experience greater ON symptomatology than cisgender, straight individuals. However, nonbinary individuals appear to experience lower ON symptomatology, which may relate to a lack of alignment with masculine or feminine ideals, such that these individuals may feel a lack of need to conform to a certain appearance ideal based on gender norms.

Validation of the adolescent binge eating disorder measure (ADO-BED) among transgender youth and young adults

BACKGROUND

Transgender youth and young adults are at increased risk for eating disorders, including binge eating disorder, yet few measures have been validated for screening purposes with the transgender population.

METHODS

The purpose of this study was to provide initial evidence for the internal consistency and convergent validity of the Adolescent Binge Eating Disorder questionnaire (ADO-BED) in a sample of transgender youth and young adults. 208 participants completed the ADO-BED as part of a routine nutrition screening protocol at a gender center. Exploratory factor analysis and confirmatory factor analysis was used to establish the factor structure of the ADO-BED. Relationships between the ADO-BED, Sick, Control, One Stone, Fat, Food (SCOFF), Nine Item Avoidant/restrictive Intake Disorder (NIAS), Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), and demographic characteristics were explored.

RESULTS

Analyses revealed a one-factor structure of the ADO-BED with good fit to the data in the present sample. The ADO-BED was shown to be significantly related to all convergent validity variables, except the NIAS.

CONCLUSIONS

The ADO-BED is a valid measure to screen for BED among transgender youth and young adults. Healthcare professionals can screen all transgender patients for BED, regardless of body size, in order to effectively identify and manage binge eating concerns.

Disordered eating and considerations for the transgender community: a review of the literature and clinical guidance for assessment and treatment

BACKGROUND

It has been well established that individuals who identify as lesbian, gay, bisexual, transgender, and queer are at increased risk for mental health pathology, including eating disorders/disordered eating behaviors (ED/DEB). However, less is understood about the unique experiences of transgender and gender diverse (TGD) people who struggle with ED/DEB.

AIMS

The purpose of this literature review is to examine the literature regarding the unique risk factors for TGD individuals who experience ED/DEB through a lens informed by the minority stress model. Additionally, guidance around the assessment and clinical management of eating disorders for TGD individuals will be presented.

RESULTS

TGD people are at increased risk for developing ED/DEB due to a number of factors including: gender dysphoria, minority stress, the desire to pass, and barriers to gender affirming care.

CONCLUSION

While guidance around assessment and treatment of ED/DEB for TGD individuals is still limited, adhering to a gender affirmative care model is essential.

Understanding the Complex Relationship Between One's Body, Eating, Exercise, and Gender-Affirming Medical Care Among Transgender and Nonbinary Adolescents and Young Adults

Purpose

Gender dysphoria has been linked to body dissatisfaction, which can affect an individual's eating and exercise habits and increase their risk for disordered eating. The prevalence of eating disorders among transgender and nonbinary (TGNB) adolescents and young adults (AYA) ranges from 5% to 18% and studies have found a higher risk of disordered eating among these AYA in comparison to their cisgender peers. However, there is minimal research on why TGNB AYA are at higher risk. The aim of this study is to understand unique factors that define a TGNB AYA's relationship between their body and food, how this relationship may be affected by gender-affirming medical care, and how these relationships may contribute to disordered eating.

Methods

A total of 23 TGNB AYA were recruited from a multidisciplinary gender-affirming clinic to participate in semistructured interviews. Transcripts were analyzed using Braun and Clarke's theory of thematic analysis (2006).

Results

The average age of participants was 16.9 years. Forty-four percent of participants identified as having a transfeminine gender identity, 39% transmasculine, and 17% nonbinary/gender fluid. Five themes emerged regarding TGNB participants' relationship to food and exercise: gender dysphoria and control over one's body, societal expectations of gender, mental health and safety concerns, emotional and physical changes with gender-affirming medical care, and recommended resources for TGNB AYA.

Conclusion

By understanding these unique factors, clinicians can provide targeted and sensitive care when screening and managing disordered eating among TGNB AYA.

Validation of the Nine-Item Avoidant/Restrictive Food Intake Disorder Screen Among Transgender and Nonbinary Youth and Young Adults

Purpose

The purpose of the study was to provide initial evidence for the internal consistency and convergent validity of the nine-item avoidant/restrictive food intake disorder screen (NIAS) in a sample of transgender and nonbinary (TGNB) youth and young adults.

Methods

Returning patients at a Midwestern gender clinic (n=164) ages 12-23 completed the NIAS, sick, control, one stone, fat, food (SCOFF), patient health questionnaire 9 (PHQ-9), and generalized anxiety disorder 7 (GAD-7) during their clinic visit. Age, sex assigned at birth, gender identity, weight, and height were also collected. Confirmatory factor analysis was used to establish the hypothesized three-factor structure of the NIAS in this sample. Relationships between the NIAS subscales and anthropometric data, SCOFF, PHQ-9, GAD-7, and sex assigned at birth were explored for convergent and divergent validity, and proposed screening cutoff scores were used to identify the prevalence of likely avoidant/restrictive food intake disorder (ARFID) in this population.

Results

The three-factor structure of the NIAS was an excellent fit to the current data. Approximately one in five (22%) of the participants screened positive for ARFID. Approximately one in four participants scored above the picky eating (27.4%) or appetite (23.9%) cutoffs. Assigned female at birth participants scored significantly higher on the NIAS-Total, Appetite, and Fear subscales than those assigned male at birth. NIAS-Total was significantly related to all convergent validity variables other than age, with a moderate-strong correlation with other symptom screeners (SCOFF, PHQ-9, GAD-7), and a small negative correlation with body mass index percentile.

Conclusions

Evidence supports the NIAS as a valid measure to screen for ARFID among TGNB youth and young adults.

"How Do I Exist in This Body…That's Outside of the Norm?" Trans and Nonbinary Experiences of Conformity, Coping, and Connection in Atypical Anorexia

Addressing eating disorders (EDs) within trans and nonbinary (TNB) populations is a growing concern, as TNB individuals are two to four times more likely to experience EDs than cisgender women. This study explored the lived experiences of TNB people with atypical anorexia by examining how gender identity impacted experiences of ED illness and (potential) recovery. Nine TNB adults with atypical anorexia were followed for one year and completed semi-structured, in-depth, longitudinal qualitative interviews at baseline, 6 months, and 12 months. Interviews were coded using Braun and Clark's thematic analysis procedures. Four themes, along with subthemes, emerged regarding the intersection of gender identity and ED experiences: (1) Conforming, (2) Coping, (3) Connecting, and (4) Critiquing. In Conforming, participants highlighted how societal pressures around gender contributed to ED vulnerability. In Coping, participants explained that their EDs represented attempts to cope with the overlapping influences of body dissatisfaction, gender dysphoria, and body disconnection. In Connecting, participants described ED recovery as a process of connecting to self, others, and communities that welcomed and affirmed their diverse identities. In Critiquing, participants described how current ED treatment settings were often unwelcoming of or unprepared for non-cisgender patients. Overall, participants viewed their EDs as intricately linked to their gender identity and experiences of social pressure and discrimination. This study suggests the need for targeted ED prevention and intervention efforts within TNB communities, and the ethical imperative to meaningfully address the needs of TNB patients in ED treatment settings.

Eating disorders and substance use: Examining associations among US college students

OBJECTIVE

To investigate associations between reported eating disorder (ED) diagnosis and substance use disorder (SUD) diagnosis, substance misuse, and illicit drug use among US college students.

METHOD

Data consisting of n = 414,299 students' responses to the National College Health Assessment survey conducted by the American College Health Association between fall 2015 and spring 2019 were utilized for this study. Unadjusted and adjusted odds ratios were used to determine the association of reported ED diagnosis with reported SUD diagnosis, misuse of cigarettes, e-cigarettes, alcohol, marijuana, cocaine/methamphetamine, sedatives, hallucinogens, opiates, inhalants, MDMA, and other club drugs, as well as illicit use of prescription pain killers, prescription sedatives, and prescription stimulants. A sensitivity analysis investigating associations between reported anorexia nervosa (AN), bulimia nervosa (BN), and each substance use outcome was also conducted.

RESULTS

Among all in our analytic cohort, 7.15% reported receiving an ED diagnosis or being treated for an ED in the last 12 months. Students with ED indications were significantly more likely to report each of the substance use outcomes investigated in this study, including SUD diagnosis (aOR: 7.43; 95% CI: 6.98, 7.92; p < .0001), opiate misuse (aOR: 8.35; 95% CI: 7.38, 9.45; p < .0001), and misuse of other club drugs (aOR: 10.37; 95% CI: 9.10, 11.81; p < .0001) than peers without reported EDs. Both AN and BN were associated with an increased likelihood of SUD diagnosis.

DISCUSSION

These findings demonstrate strong associations between EDs and the most extensive list of substance use outcomes explored in the context of college setting ED research to date.

Transgender and other gender diverse adolescents with eating disorders requiring medical stabilization

BACKGROUND

Despite the high prevalence of eating disorders in gender diverse adolescents, little is known about the characteristics of gender diverse youth with eating disorders who require inpatient medical stabilization. The primary objective of this study was to describe the medical, anthropometric, and psychiatric characteristics of gender diverse adolescents hospitalized for eating disorders and compare these characteristics to cisgender peers hospitalized for eating disorders. The secondary objective was to evaluate percent median body mass index as one marker of malnutrition and treatment goal body mass index as a recovery metric between patients' birth-assigned sex and affirmed gender using standardized clinical growth charts.

METHODS

A retrospective chart review was conducted of 463 patients admitted to an inpatient eating disorders medical unit between 2012 and 2020. To compare medical, anthropometric, and psychiatric data between gender diverse and cisgender patients, chi-square/Fisher's exact and t-tests were used. Clinical growth charts matching the patients' birth-assigned sex and affirmed gender identity were used to assess percent of median body mass index and treatment goal body mass index.

RESULTS

Ten patients (2.2%) identified as gender diverse and were younger than cisgender patients [13.6 (1.5) years vs. 15.6 (2.7) years, p = 0.017]. Gender diverse patients were hospitalized with a higher percent median body mass index compared to cisgender peers [97.1% (14.8) vs. 87.9% (13.7), p = 0.037], yet demonstrated equally severe vital sign instability such as bradycardia [44 (8.8) beats per minute vs. 46 (10.6) beats per minute, p = 0.501], systolic hypotension [84 (7.1) mmHg vs. 84 (9.7) mmHg, p = 0.995], and diastolic hypotension [46 (5.8) mmHg vs. 45 (7.3) mmHg, p = 0.884]. Gender diverse patients had a higher prevalence of reported anxiety symptoms compared to cisgender patients (60% vs. 28%, p = 0.037).

CONCLUSIONS

Gender diverse patients demonstrated complications of malnutrition including vital sign instability despite presenting with a higher weight. This is consistent with a greater proportion of gender diverse patients diagnosed with atypical anorexia nervosa compared to cisgender peers. Additionally, psychiatric comorbidities were present among both groups, with a larger percentage of gender diverse patients endorsing anxiety compared to cisgender patients.

Medical considerations in the care of transgender and gender diverse patients with eating disorders

Transgender and gender diverse (TGD) individuals are at increased risk for the development of eating disorders, but very little has been published with regards to the unique aspects of their medical care in eating disorder treatment. Providing gender affirming care is a critical component of culturally competent eating disorder treatment. This includes knowledge of gender affirming medical and surgical interventions and how such interventions may be impacted by eating disordered behaviors, as well as the role of such interventions in eating disorder treatment and recovery. TGD individuals face barriers to care, and one of these can be provider knowledge. By better understanding these needs, clinicians can actively reduce barriers and ensure TGD individuals are provided with appropriate care. This review synthesizes the available literature regarding the medical care of TGD patients and those of patients with eating disorders and highlights areas for further research.

Bone density and bone marrow composition in transgender girls prior to pubertal blockade: A case series

PURPOSE

To determine bone mineral density (BMD) of transgender girls before pubertal blockade, and correlate with lifestyle and clinical variables.

METHODS

Six transfemale peri-pubertal girls had knee magnetic resonance imaging (MRI) with T1-weighted images and single-voxel proton magnetic resonance spectroscopy (MRS). BMD measurements were obtained via dual-energy X-ray absorptiometry. Questionnaires about physical activity, diet, and the Eating Attitudes Test (EAT-26) were completed. The T2 relaxation rate of water (R2 = 1/T2 in s -1) was correlated with scores on surveys.

RESULTS

Three participants (50 %) had a low bone mineral density for age based on total body less head Z-score less than -2; two participants (33 %) had a low BMD for age at lumbar spine. All had EAT-26 scores below threshold for clinical concern. All participants self-reported regular exercise. Bone marrow MR variables (T1, fat fraction, unsaturation index and R2 of water) were not correlated with DXA measures.

CONCLUSIONS

Participants had low BMD on beginning pubertal blockade. Clinicians should consider monitoring BMD among youth AMAB, a group at potential risk for poor bone health.

Screening, assessment and diagnosis in the eating disorders: findings from a rapid review

BACKGROUND

Limited screening practices, minimal eating disorder training in the healthcare professions, and barriers related to help-seeking contribute to persistent low rates of eating disorder detection, significant unmet treatment need, and appreciable associated disease burden. The current review sought to broadly summarise the literature and identify gaps relating to the screening, assessment, and diagnosis of eating disorders within Western healthcare systems.

METHODS

This paper forms part of a Rapid Review series scoping the evidence base for the field of eating disorders, conducted to inform the Australian National Eating Disorders Research and Translation Strategy 2021-2031, funded and released by the Australian Government. ScienceDirect, PubMed and Ovid/Medline were searched for studies published between 2009 and mid 2021 in English. High-level evidence such as meta-analyses, large population studies and Randomised Control Trials were prioritised through purposive sampling. Data from selected studies relating to Screening, Assessment and Diagnosis of eating disorders were synthesised and are disseminated in the current review.

RESULTS

Eighty seven studies were identified, 38% relating to screening and 62% to assessment and diagnosis. The majority of screening studies were conducted in university student samples, showing high prevalence but only modest improvements in help-seeking in those studies that followed up post-screen. In healthcare settings, clinicians continue to have difficulty identifying eating disorder presentations, particularly Binge Eating Disorder, Other Specified Feeding or Eating Disorders, and sub-threshold eating disorders. This is preceded by inadequate and frequently homogenous screening mechanisms and exacerbated by considerable personal and health-system barriers, including self-stigma and lack of resourcing. While all groups are at risk of delayed or no diagnosis, those at particular risk include LGBTQ+ and gender diverse individuals, individuals living in larger bodies, and males.

CONCLUSIONS

A majority of individuals with eating disorders remain undiagnosed and untreated despite a high prevalence of these conditions and increased advocacy in recent years. Research into improving detection and clinician diagnostic skill is extremely limited. Innovative empirical research is strongly recommended to address significant individual and health-system barriers currently preventing appropriate and timely intervention for many. Limited screening in healthcare settings and low rates of eating disorder training in the healthcare professions are just some of the barriers to help-seeking which may contribute to delayed intervention and diagnosis in the eating disorders. This has significant impacts, prolonging treatment when it is finally received, and increasing healthcare costs for both the individual and the healthcare system. The current review is part of a larger Rapid Review series conducted to inform the development of Australia's National Eating Disorders Research and Translation Strategy 2021-2031. A Rapid Review is designed to comprehensively summarise a body of literature in a short timeframe, often to guide policy-making and address urgent health concerns. The Rapid Review synthesises the current evidence-base and identifies gaps in eating disorder research and care, in order to guide decision making and address urgent health concerns. This paper gives a critical overview of the scientific literature relating to the current state of screening, assessment, and diagnosis of eating disorders within Western healthcare systems that may inform health policy and research in an Australian context. It covers screening initiatives in both general and high-risk populations; personal, clinician and healthcare system challenges relating to help-seeking; and obstacles to accurate and timely clinical diagnosis across the eating disorders.

Weight Status, Medication Use, and Recreational Activities of Treatment-Naïve Transgender Youth

Background: Studies of transgender/gender diverse (TGD) youth indicate a high prevalence of overweight/obesity and concern for unhealthy weight management behavior. This study describes the association of weight status with medication use and recreational activities among treatment-naïve, pediatric TGD patients. Methods: This study is a chart review of 277 patients [aged 9-18 years, 79.1% female sex assigned at birth (SAB), and 86.3% white] seen at a medical center from 2017 to 2020. BMI was calculated by age and SAB using CDC growth charts. BMI percentile (BMI%) and BMI z-score (BMIz) were used to define weight status. Results: By BMI% category, 3.6% patients were in the underweight range (BMI <5%); 50.5% had BMI >85%; and 30.3% had BMI >95%. Overweight and obesity rates were higher than national norms (χ² = 15.152, p < 0.01). Female SAB participants had higher BMIz values than male SAB participants. Youth who reported watching/listening to media (t = 3.50, p < 0.01) and parent-reported creative arts involvement (t = 1.97, p = 0.05) were associated with higher BMIz values. Conversely, spending time with friends and family was associated with a lower BMIz. Over half of the patients were prescribed medications, and those patients taking medications had higher BMIz values than those not taking medications (t = -1.96, p < 0.05). Female SAB, involvement in sedentary recreational activities, and taking medications to treat gastrointestinal conditions were associated with elevated BMIz. Conclusions: Overweight/obesity is a common problem among TGD youth. TGD youth should be considered a high-risk group and targeted in obesity prevention and treatment efforts. Interventions to decrease sedentary activities and improve connections with friends and family are promising strategies to address overweight and obesity among TGD youth.

Variability in Eating Disorder Risk and Diagnosis in Transgender and Gender Diverse College Students

PURPOSE

To examine differences in elevated eating disorder risk and self-reported eating disorder diagnosis across subgroups of transgender and gender diverse (TGD) college students.

METHODS

Data from 5057 TGD college students participating in the national Healthy Minds Study between 2014-2019 were analyzed. Chi-square tests and logistic regression analyses examined heterogeneity in prevalence and odds of elevated eating disorder risk, as measured by the SCOFF, and self-reported eating disorder diagnosis by gender, as well as by intersecting gender and sexual orientation identities.

RESULTS

Genderqueer/non-conforming college students reported the highest prevalence of elevated eating disorder risk (38.8%) relative to gender expansive students. Genderqueer/non-conforming (11.1%), gender expansive (12.3%), and trans men/transmasculine students (10.5%) reported higher prevalence of a self-reported eating disorder diagnosis relative to trans women/transfeminine students (6.3%). Heterosexual or straight trans men had lower odds of eating disorder risk and self-reported diagnosis relative to trans men with a minoritized sexual orientation.

CONCLUSIONS

Genderqueer/non-conforming college students may be at heightened eating disorder risk. Moreover, a heterosexual/straight sexual orientation was associated with lower odds of elevated eating disorder risk and self-reported eating disorder diagnoses among trans men and genderqueer/non-conforming college students, but this finding did not hold for other groups. College campuses should aim to reduce eating disorder risk among TGD students.

Expanding the limits of sex: a systematic review concerning food and nutrition in transgender populations

OBJECTIVE

To examine the literature and identify main themes, methods and results of studies concerning food and nutrition addressed in research on transgender populations.

DESIGN

A systematic review conducted through July 2020 in the MedLine/PubMed, Scopus and Web of Science databases.

RESULTS

Of the 778 studies identified in the databases, we selected thirty-seven. The studies were recent, most of them published after 2015, being produced in Global North countries. The most often used study design was cross-sectional; the least frequently used study design was ethnographic. Body image and weight control were predominant themes (n 25), followed by food and nutrition security (n 5), nutritional status (n 5), nutritional health assistance (n 1) and emic visions of healthy eating (n 1).

CONCLUSIONS

The transgender community presents body, food and nutritional relationships traversed by its unique gender experience, which challenges dietary and nutritional recommendations based on the traditional division by sex (male and female). We need to complete the lacking research and understand contexts in the Global South, strategically investing in exploratory-ethnographic research, to develop categories of analysis and recommendations that consider the transgender experience.

Eating disorder symptomatology in transgender patients: Differences across gender identity and gender affirmation

OBJECTIVE

Past studies have reported high rates of eating disorder (ED) symptomatology among transgender people, yet without consideration of gender affirmation. The primary objective of this study was to evaluate the relationship between gender identity, gender affirming interventions such as gender affirming hormones (GAH) and gender affirming surgeries (GAS), and ED symptomatology.

METHOD

Transgender patients at a primary care outpatient gender health program in the United States completed a survey consisting of demographics, medical history, and clinical variables, including the Eating Disorder Examination Questionnaire (EDE-Q). Multivariate analyses of covariance were conducted to compare EDE-Q scores across gender identity and gender affirmation.

RESULTS

Compared to transgender men (n = 79), transgender women (n = 87) reported higher EDE-Q scores and significantly higher Eating Concern. Compared to hormone/surgery-naïve and hormone-experienced/surgery-naïve patients, hormone/surgery-experienced patients had lower EDE-Q scores. Hormone/surgery-experienced patients reported significantly lower Shape Concern and marginally lower Global Score and Weight Concern than hormone-experienced/surgery-naïve patients. There were no differences in EDE-Q scores between hormone/surgery-naïve and hormone-experienced/surgery-naïve patients.

DISCUSSION

Transgender patients report high levels of ED symptomatology. There are subtle, yet important, differences in ED between gender identities and gender affirmations. High ED prevalence may result from the dual pathways of sociocultural pressures as well as gender dysphoria. Both GAH and GAS may be effective interventions to support gender affirmation and thereby alleviate ED symptomatology. While the potential positive benefits of GAS on ED are more apparent, the effects of GAH are less clear.

Disparities in disordered eating between gender minority and cisgender adolescents

OBJECTIVE

Adolescence is a developmental period of increased risk for disordered eating. Gender minority adolescents (GMAs), or those whose gender identity does not align with their sex assigned at birth, may experience body image concerns related to unique gender-related stressors. GMAs may use disordered eating to affirm a feminine, masculine, or nonbinary gender identity. However, little is known about differences in disordered eating between GMAs and cisgender adolescents. Therefore, this study had two primary goals: (a) to compare disordered eating between GMAs and cisgender adolescents by examining the role of gender identity and sex assigned at birth; and (b) within GMAs, to examine associations between gender identity congruence and disordered eating.

METHOD

A large U.S. sample of GMAs and cisgender adolescents (n = 1,191 GMAs; 919 cisgender; M_age = 15.93 years) reported their disordered eating on an anonymous online survey.

RESULTS

A MANOVA revealed a significant interaction between gender identity and sex assigned at birth. Follow-up ANOVAs demonstrated that purging, caloric restriction, excessive exercise, and muscle building differed as a function of gender identity and sex assigned at birth. Among GMAs, a multiple multivariate regression model demonstrated that disordered eating was lower among participants who reported greater gender identity congruence.

DISCUSSION

GMAs should not be considered a homogenous group, as differences in gender identity may lead to the internalization of different appearance ideals and disparate eating disorder symptomatology. Results suggest that clinicians working with GMAs consider the unique body image concerns that could accompany a specific gender identity.

Disordered Eating, Food Insecurity, and Weight Status Among Transgender and Gender Nonbinary Youth and Young Adults: A Cross-Sectional Study Using a Nutrition Screening Protocol

Purpose: The purpose of this study was to describe the prevalence of and relationships among disordered eating, food insecurity, and weight status among transgender and gender nonbinary youth and young adults. Methods: This cross-sectional study involved a screening protocol to assess disordered eating and food insecurity risk from September to December of 2019 at a gender clinic using five validated measures: (1) previous eating disorder diagnosis (yes/no); (2) Sick, Control, One Stone, Fat, Food Questionnaire (SCOFF); (3) Adolescent Binge Eating Disorder Questionnaire (ADO-BED); (4) Nine-Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS); and (5) Hunger Vital Sign. Age, assigned sex at birth, gender identity, stage of medical transition, and body mass index were collected. Pearson's r correlation coefficients, between-groups t-tests, one-way analysis of variance tests, and Tukey's honest significant difference test were used to characterize the relationships between variables. Results: A total of 164 participants ages 12-23 years completed the screener. Using assigned sex at birth, 1.8% were underweight, 53% were a healthy weight, 17.1% were overweight, and 28.0% were obese. An estimated 8.7% reported a previous eating disorder diagnosis, 28.0% screened positive on the SCOFF, 9.1% on the ADO-BED, 75.0% on the NIAS, and 21.2% on the Hunger Vital Sign. Transgender males scored higher on the NIAS than transgender females (p = 0.03). Those with a previous eating disorder diagnosis scored significantly higher on the Hunger Vital Sign (p < 0.05). Conclusion: Gender clinics should routinely screen for disordered eating, food insecurity, overweight, and obesity to identify patients in need of further evaluation and referral.

Eating Disorders in Children and Adolescents: A Practical Review and Update for Pediatric Gynecologists

Eating disorders (EDs) are common among female adolescents and young adults and can have serious and diverse health consequences. Pediatric gynecology providers have the opportunity to play a vital role in the recognition of EDs in this population. Early medical detection and referral for appropriate evidence-based treatment can lead to better health outcomes for youth. In this article we aim to increase the awareness of the pediatric gynecologist of typical and subtle presentations of EDs, provide guidance for screening, discuss common and serious medical complications, and review treatment considerations for gynecologic issues in patients with EDs.

Eating disorder screening and treatment experiences in transgender and gender diverse young adults

Transgender and gender diverse (TGD) young adults have elevated risk for disordered eating, unhealthy weight control behaviors, and eating disorders (EDs). Little is known about TGD young adult experiences with ED screening and treatment; this qualitative study aimed to address this gap. This study used data from eight asynchronous online focus groups, a dynamic online bulletin board method (N = 66). Participants posted responses to moderator-posed questions over a 4-day period. Participants were TGD young adults ages 18-30 years old, were recruited using social media and outreach to community organizations, and resided in 25 US states. We conducted inductive thematic analysis of all focus group excerpts that described experiences with ED screening or treatment (n = 32). Participants were of diverse gender identities (25% transgender woman, 41% transgender man, 28% non-binary, 6% another gender) and racial/ethnic identities (62% White, 13% Latinx, 13% Multiracial, 6% Asian, 6% Black). Three major themes emerged from the analysis: (1) Barriers to ED screening/treatment; (2) Complexity of the relationship between EDs and gender dysphoria; (3) Need for provider education in gender affirming care practices for ED screening and treatment. Results indicate an ongoing need for gender affirming care for TGD young adults in ED screening and treatment. Health care systems must address barriers to screening and treatment for TGD young adults, including enhancing understanding of the intersection of gender dysphoria and eating disorders as well as improvements in health care provider training.

Gender-affirmation surgery and bariatric surgery in transgender individuals in The Netherlands: Considerations, surgical techniques and outcomes

INTRODUCTION

The number of transgender individuals seeking medical and surgical care has increased over the last years. Within the transgender population overweight and obesity is more frequently observed when compared to the general population. Little is known on the prevalence of bariatric surgery in the transgender population and the effects on the surgical gender transition path of the individual transgender with overweight or obesity.

MATERIAL AND METHODS

All transgender individuals who underwent gender-affirming surgery (GAS) between 1980 and 2020 were retrospectively identified from our hospital registry. Those with a history of bariatric surgery were selected. A retrospective chart study was conducted, recording gender identity, bariatric surgery specifications, gender surgery specifications, complications, reoperations and clinical follow-up time.

RESULTS

A total of 15 transgender individuals (11 transgender men, 4 transgender women) who underwent bariatric surgery were identified. All individuals underwent bariatric surgery before any GAS procedure, except for one transgender man. At the first GAS procedure, all individuals experienced significant weight loss when compared to their weight at bariatric surgery (mean 13.1 ± 3.8 BMI points lost for transgender men, mean BMI points lost 14.3 ± 2.8 for transgender women, p < 0.01). Obesity was still frequently prevalent in transgender men after bariatric surgery. All included transgender men underwent mastectomy via the double incision with free nipple grafting technique. Only one transgender man underwent genital GAS. All transgender women underwent penile-inversion vaginoplasty, one in combination with prosthesis-based augmentation mammoplasty.

CONCLUSION

Surgical gender transition is possible after massive weight loss after bariatric surgery. Specific surgical subtechniques will be more prevalent in this population.

Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among gender-expansive populations

PURPOSE

Gender-expansive individuals (i.e., those who identify outside of the binary system of man or woman) are a marginalized group that faces discrimination and have a high burden of mental health problems, but there is a paucity of research on eating disorders in this population. This study aimed to describe the community norms for the Eating Disorder Examination Questionnaire (EDE-Q) in gender-expansive populations.

METHODS

The participants were 988 gender-expansive individuals (defined as neither exclusively cisgender nor binary transgender) from The PRIDE study, an existing longitudinal cohort study of health outcomes in sexual and gender minority people.

RESULTS

We present the mean scores, standard deviations, and percentile ranks for the Global score and four subscale scores of the EDE-Q in this group as a whole and stratified by sex assigned at birth. Gender-expansive individuals reported any occurrence (≥1/28 days) of dietary restraint (23.0%), objective binge episodes (12.9%), excessive exercise (7.4%), self-induced vomiting (1.4%), or laxative misuse (1.2%). We found no statistically significant differences by sex assigned at birth. Compared to a prior study of transgender men and women, there were no significant differences in eating attitudes or disordered eating behaviors noted between gender-expansive individuals and transgender men. Transgender women reported higher Restraint and Shape Concern subscale scores compared to gender-expansive individuals. Compared to a prior study of presumed cisgender men 18-26 years, our age-matched gender-expansive sample had higher Eating, Weight, and Shape Concern subscales and Global Score, but reported a lower frequency of objective binge episodes and excessive exercise. Compared to a prior study of presumed cisgender women 18-25 years, our age-matched gender-expansive sample had a higher Shape Concern subscale score, a lower Restraint subscale score, and lower frequencies of self-induced vomiting, laxative misuse, and excessive exercise.

CONCLUSIONS

Gender-expansive individuals reported lower Restraint and Shape Concern scores than transgender women; higher Eating, Weight, and Shape Concern scores than presumed cisgender men; and lower Restraint but higher Shape Concern scores than presumed cisgender women. These norms can help clinicians in treating this population and interpreting the EDE-Q scores of their gender-expansive patients.

Emerging trends in eating disorders among sexual and gender minorities

PURPOSE OF REVIEW

To review the recent literature on eating disorders, disordered eating behaviors (DEB), and body image dissatisfaction among sexual and gender minority populations, including, but not limited to, gay, lesbian, bisexual, and transgender people.

RECENT FINDINGS

Overall, eating disorders, DEB, and body dissatisfaction are common among sexual and gender minority populations. Lifetime prevalence for anorexia nervosa (1.7%), bulimia nervosa (1.3%), and binge-eating disorder (2.2%) diagnoses are higher among sexual minority adults compared with cisgender heterosexual adults in the United States. Lifetime prevalence of eating disorders by self-report of a healthcare provider's diagnosis are 10.5% for transgender men and 8.1% for transgender women in the United States, including anorexia nervosa (4.2 and 4.1%) and bulimia nervosa (3.2 and 2.9%), respectively. DEB may be perpetuated by minority stress and discrimination experienced by these individuals. Body dissatisfaction may be a core stressor experienced by transgender people; gender dysphoria treatment has been shown to increase body satisfaction. A particular clinical challenge in caring for transgender youth with eating disorders is the standard use of growth charts based on sex.

SUMMARY

Novel research demonstrates that sexual and gender minorities with eating disorders have unique concerns with regards to disordered eating and body image.

A Descriptive Study of Transgender Active Duty Service Members in the U.S. Military

Purpose: Department of Defense policy prohibits, with limited exceptions, transgender individuals from serving in their affirmed gender in the U.S. Military, citing potential impact on unit cohesion and military readiness. To date, however, little is known about the sociodemographic profile and health of transgender military personnel. Methods: U.S. Military personnel who self-identified as transgender completed anonymous online measures of demographics and military service. Participants also completed measures of health, mood, eating pathology, and risk behaviors. Results: One hundred ninety-five service members (mean age: 28.9±7.2 years, 48.7% transmale, 70.3% non-Hispanic White, 7.83±5.9 years in service) completed the survey. The majority of respondents first identified as transgender before military accession. Most had disclosed their gender identity to their command and providers, and had undertaken steps toward gender affirmation. The sample as a whole reported above average physical health, with mood symptoms within normal ranges and few reported risk behaviors. Analyses of covariance indicated that transmales reported significantly better mental health and psychosocial functioning compared with transfemales. Conclusion: In light of current policy that precludes, with limited exceptions, transgender individuals from serving in the U.S. Military in their affirmed gender, the current study provides an initial sociodemographic profile of this understudied population and indicates that transgender service members report above average physical health and few risk behaviors. Preliminary analyses indicated that transfemales in the military may be at higher risk for mental health concerns, compared with transmales. Additional research is needed to elucidate risk and protective factors among transgender service members.

Disordered Eating Among Trans-Masculine Youth: Considerations Through a Developmental Lens

As with male populations more generally, eating disorder symptom expression among trans-masculine youth is understudied. Gender minority individuals are at increased risk for eating disorders; however, culturally responsive and developmentally tailored research is limited. Although all gender minority individuals may experience elevated risk for developing eating disorders, the focus of this article is trans-masculine youth. We provide a theoretical conceptualization of eating disorder symptom expression among this understudied group, and propose novel directions for research, particularly for youth at pubertal onset. Adolescence as a critical developmental period for intervention is highlighted.

Community norms for the Eating Disorder Examination Questionnaire (EDE-Q) among transgender men and women

Transgender men and women may be at risk for eating disorders, but prior community norms of the Eating Disorders Examination Questionnaire (EDE-Q) are based on presumed cisgender men and woman and have not intentionally included transgender people. The objective of this study was to develop community norms for eating disorder attitudes and disordered eating behaviors in transgender men and women using the EDE-Q. Participants were 312 transgender men and 172 transgender women participants in The PRIDE Study, an existing cohort study of sexual and gender minority people. We present mean scores, standard deviations, and percentile ranks for the Global score and four subscale scores of the EDE-Q in transgender men and women. Transgender men and women reported any occurrence (≥1/week) of dietary restraint (25.0% and 27.9%), objective binge episodes (11.2% and 12.8%), excessive exercise (8.0% and 8.1%), self-induced vomiting (1.6% and 1.7%), and laxative misuse (.3% and .6%), respectively. Compared to a prior study of presumed cisgender men 18-26 years (Lavender, De Young, & Anderson, 2010), our age-matched subsample of transgender men reported lower rates of objective binge episodes and excessive exercise. Compared to a prior study of presumed cisgender women 18-42 years (Mond, Hay, Rodgers, & Owen, 2006), we found that an age-matched sample of transgender women reported higher rates of dietary restraint but lower rates of excessive exercise. These norms should aid clinicians in applying and researchers in investigating and interpreting the EDE-Q scores of transgender men and women.

Sexual and gender minority individuals report higher rates of abuse and more severe eating disorder symptoms than cisgender heterosexual individuals at admission to eating disorder treatment

Eating disorders (EDs) occur at higher rates among sexual/gender minorities (SGMs). We currently know little about the risk factor profile of SGMs entering ED specialty care.

OBJECTIVE

To (a) compare history of abuse-related risk in SGMs to cisgender heterosexuals (CHs) when entering treatment, (b) determine if SGMs enter and exit treatment with more severe ED symptoms than CHs, and (c) determine if SGMs have different rates of improvement in ED symptoms during treatment compared to CHs.

METHOD

We analyzed data from 2,818 individuals treated at a large, US-based, ED center, 471 (17%) of whom identified as SGM. Objective 1 was tested using logistic regression and Objectives 2 and 3 used mixed-effects models.

RESULTS

SGMs had higher prevalence of sexual abuse (OR = 2.10, 95% CI = 1.71, 2.58), other trauma (e.g., verbal/physical/emotional abuse; OR = 2.07, 95% CI = 1.68, 2.54), and bullying (OR = 2.13, 95% CI = 1.73, 2.62) histories. SGMs had higher global EDE-Q scores than CHs at admission (γ = 0.42, SE = 0.08, p < .001) but improved faster early in treatment (γ = 0.316, SE = 0.12, p = .008). By discharge, EDE-Q scores did not differ between SGMs and CHs.

DISCUSSION

Our main hypothesis of greater abuse histories among SGMs was supported and could be one explanation of their more severe ED symptoms at treatment admission compared to CHs. In addition, elevated symptom severity in SGMs at admission coincides with greater delay between ED onset and treatment initiation among SGMs-possibly a consequence of difficulties with ED recognition in SGMs by healthcare providers. We recommend increased training for providers on identifying EDs in SGMs to reduce barriers to early intervention.