Article Contributed by Sharon McConville, MB, BCh, BAO
It has been widely demonstrated that people who identify as belonging to the lesbian, gay, bisexual and transgender (LGBT) community have a greater susceptibility to mental health problems including suicide attempts, anxiety and depression1. They are also specifically at a higher risk of developing eating disorders including anorexia and bulimia2. According to the National Eating Disorders Association, this may be due to their difficulties around the time of coming out, such as fear of rejection, internalised negative beliefs because of their sexual orientation, problems with discrimination or bullying, discordance between biological sex and gender identity, and homelessness (which is more likely to happen to people from the LGBT community)3. But, are there specific risk factors which predispose to eating psychopathology, and are lesbians, gay and transsexual people affected in the same ways? This paper will examine the evidence.
It has been known for some time that eating disorders are more common in gay men than in heterosexual men. In the United States, approximately 3% of men identify as being gay or bisexual; however, studies show that up to 42% of men who present with eating disorders identify as being gay or bisexual4. The story is somewhat different with lesbian women, who generally rate their appearance as feminine, androgynous, or masculine. Lesbians who consider themselves to be feminine have a similar risk of developing an eating disorder to their heterosexual peers; however, an interesting phenomenon emerges with androgynous or masculine lesbians, with studies showing their gender identity to be protective against eating disorders5.
Why do gay men get eating disorders while lesbian women are relatively protected? The main theory promulgated by researchers relates to the “socio-cultural perspective”, or the view that the community and media environment in which gay men live their lives can be toxic as far as their body image is concerned4,6. Gay and bisexual men hope to attract men, and therefore experience similar cultural pressures to those experienced by heterosexual women, who are already known to be at risk of developing eating disorders at least in part because of a societal expectation of thinness4. Indeed, gay men are more likely than their heterosexual counterparts to perceive their bodies as sexual objects and for this reason are more likely to report body dissatisfaction7.
Because of bombardment with media advertising which increasingly presents the ideal male body as being youthful, toned and muscular, all men – regardless of sexual orientation – tend to report a degree of unhappiness with their bodies; however, gay men are affected more than heterosexual men, with single gay men affected most of all6. Men’s magazines, often full of pictures of men with ‘ideal’ body shapes, have more influence than any other media outlet on gay male body image6. The media does not constitute the only pressure on gay men, however, as peer group influences have also been shown to affect their body satisfaction6. Many studies have suggested that the values and expectations of the gay community, which places a heightened emphasis on physical appearance, influence gay male body image4. The evidence is somewhat conflicted, though, because belonging to the gay community and feeling accepted by it may be protective against developing disordered eating4.
Younger gay men (and lesbians who identify as feminine) are more susceptible to these socio-cultural pressures than older gay men3, which may be due to less exposure to the media or to the fact that older gay men are more likely to be in a stable relationship. Being in a relationship has been shown to be a protective factor against restrictive disordered eating in gay men2. When looking for a partner, men, regardless of sexual orientation, seek out attractiveness and thinness2. Single gay men, therefore, feel pressure to be thin. Heterosexual men do not experience this pressure because women place less emphasis on physical features when looking for a mate and do not perceive thinness as the aesthetic ideal2. Interestingly, gay men also place a higher emphasis on physical attractiveness than heterosexual men do when they evaluate their own characteristics2.
Although restrictive disordered eating is common in single gay men, it turns out that bulimic symptoms are actually more frequent in gay men who are in a relationship2. It is postulated that these bulimic symptoms arise not so much because of a pressure to be thin as because of psycho-social difficulties within relationships2. Because of this, one research group have suggested that single gay men should have cognitive dissonance-based therapy to challenge socio-cultural pressures to be thin, while gay men in partnerships who have bulimic symptoms should have interpersonal psychotherapy to improve their psychosocial functioning2.
Lesbians, on the other hand, have higher levels of self-esteem regarding their body and sexual attractiveness8. They also have a decreased tendency to internalize cultural standards for physical appearance8. In particular, androgynous and masculine identifying lesbians are more experienced at accepting themselves as being different from societal and media-represented norms5. Additionally, lesbian women who have mostly lesbian and bisexual friends have greater body satisfaction than lesbians who have mostly heterosexual friends5. This is likely to be because the latter group experience mainstream perceptions of what the female body should look like to a greater extent5. Although we have seen that most lesbians are no more susceptible to eating disorders than their heterosexual counterparts, and that some are protected to a degree from restrictive disordered eating, it has been shown that in women – as in men – any same-sex sexual experience, no matter how infrequent, is predictive of bulimic symptoms1. Again, this is thought to be due to problems with psychosocial functioning rather than pressures to be thin1.
In general, the presence of any psychiatric disorder in someone from the LGBT community is a risk factor for the development of an eating disorder9. Gay and bisexual men with eating disorders are more likely to have an anxiety or substance abuse disorder than gay and bisexual men without eating disorders, whereas lesbian and bisexual women with eating disorders are more likely to have mood disorders than lesbian and bisexual women without eating disorders9. The onset of the co-morbid psychiatric disorder generally predates the onset of the eating disorder, which means that gay and bisexual men, and lesbian and bisexual women with psychiatric disorders should be monitored for the development of eating pathology9.
There have been fewer studies relating to transsexual people and eating disorders but the studies that exist suggest that this group has an especially high risk of developing anorexia or bulimia. This is because both biologic males and biologic females who are transgender experience severe body dissatisfaction10. Biologically male transsexuals aspire to be ‘super-female’, accentuating their feminine characteristics10. They also equate femininity with slimness10. Biologically female transsexuals, on the other hand, recognise that low weight suppresses menstruation and secondary sexual characteristics. It is therefore not a drive for thinness – which is not perceived to be a particularly masculine trait – but a desire to lose feminine characteristics which causes dietary restriction10. In general then, both biologic males and biologic females aspire to thinness in order to suppress their biological gender and emphasise features of their desired gender11. Gender reassignment has therefore been proposed as an appropriate treatment to alleviate the symptoms of eating disorders in transsexuals11.
In summary, we have seen that most members of the LGBT community are at increased risk of developing eating disorders, with anorexia being commoner in single gay men and transsexuals, and bulimia being commoner in gay men in relationships and women who have engaged in same-sex experiences. Health professionals should be aware of this risk when working with the LGBT community and should be educated in how to identify the signs of eating disorders. Eating disorder practitioners should be sensitive to the particular needs of gay and bisexual men, lesbian and bisexual women, and transsexual men and women. Efforts should also be made to work with the LGBT community to modify their risk by educating them about the effects of the “toxic environment” or social and media influences, and give them skills which will help to protect them from body dissatisfaction and its consequences.
- Wichstrom, L: Sexual orientation as a risk factor for bulimic symptoms. International Journal of Eating Disorders 2006;39:448-453
- Brown, TA and Keel, PK: The impact of relationships in the association between sexual orientation and disordered eating in men. International Journal of Eating Disorders 2012;45:792-799
- NEDA: Eating disorders in LGBT (lesbian, gay, bisexual and transgender) populations. www.nationaleatingdisorders.org/sites/default/files/ResourceHandouts/LGBTQ.pdf Accessed May 21st, 2013
- Feldman, MB and Meyer, IH: Eating disorders in diverse lesbian, gay and bisexual populations. International Journal of Eating Disorders 2007;40:218-226
- Ludwig, ML and Brownell, KD: Lesbians, bisexual women and body image: an investigation of gender roles and social group affiliation. International Journal of Eating Disorders 1999;25:89-97
- Morgan, JF and Acelus, J: Body image in gay and straight men: a qualitative study. European Eating Disorders Review 2009;17:435-443
- Siever, MD: Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders. Journal of Consulting and Clinical Psychology 1994;62:252-260
- Share, TL and Mintz, LB: Differences between lesbians and heterosexual women in disordered eating and related attitudes. Journal of Homosexuality 2002;4:89-106
- Feldman, MB and Meyer, IH: Comorbidity and age of onset of eating disorders in gay men, lesbians and bisexuals. Psychiatry Research 2010;180:126-131
- Hepp, U and Milos, G: Gender identity disorder and eating disorders. International Jounral of Eating Disorders 2002;32:473-478
- Algars, M et al: Disordered eating and gender identity disorder: a qualitative study. Eating Disorders 2012;20:300-311
Last Reviewed By: Jacquelyn Ekern, MS, LPC on June 25, 2013
Page last updated: June 25, 2013
Published on EatingDisorderHope.com, Resources for Eating Disorder Information