Parker and Harriger Journal of Eating Disorders (2020) 8:51 https://doi.org/10.1186/s40337-020-00327-y REVIEW Open Access Eating disorders and disordered eating behaviors in the LGBT population: a review of the literature Lacie L. Parker1* and Jennifer A. Harriger2 Abstract Background: According to past research, lesbian, gay, bisexual, and transgender (LGBT) individuals experience a higher prevalence of psychopathology, which is attributable to the increased stress (i.e., stigma and prejudice) that they experience, as detailed by the minority stress model (MSM). Main: This current literature review examined the empirical literature regarding the rates and types of, and risk factors for eating disorders and disordered eating behaviors in LGBT adults and adolescents, in addition to each individual subgroup (i.e., lesbians, gay males, bisexuals, transgender and gender-nonconforming individuals). Conclusion: LGBT adults and adolescents experience greater incidence of eating disorders and disordered eating behaviors than their heterosexual and cisgender counterparts. Additionally, gay, bisexual, and transgender adults and adolescents were all at increased risk for eating disorders and disordered eating behaviors. Mixed results were found for lesbian adults and adolescents. Results are discussed within the framework of the MSM. Keywords: Eating disorders, Disordered eating behaviors, LGBT, Sexual minority, Lesbian, Gay, Bisexual, Transgender Plain English summary Background It has been found that lesbian, gay, bisexual, and trans- While eating disorders and disordered eating behaviors gender (LGBT) adults and adolescents are more likely to can affect individuals with various identities, it has been suffer from mental illness due to experiencing greater found that disparities exist in certain marginalized stress, caused by stigma and prejudice. This literature groups, such as sexual and gender minorities [145]. The review examines past research findings regarding eating purpose of this research is to review the literature re- disorders and disordered eating behaviors for lesbian, garding eating disorders and disordered eating behaviors gay, bisexual, transgender and gender non-conforming within lesbian, gay, bisexual, and transgender (LGBT) adults and adolescents as a whole, as well as each indi- adults and adolescents in comparison to their heterosex- vidual group. Overall, it was found that lesbian, gay, ual and cisgender counterparts. Additionally, we exam- bisexual, and transgender adults and adolescents are ined four specific LGBT subgroups (lesbian adults and more likely to experience eating disorders and disordered adolescents; gay adults and adolescents; bisexual, mostly eating behaviors. Additionally, unique risk factors were heterosexual, and questioning adults and adolescents; identified for each lesbian, gay, bisexual, and transgender transgender and gender non-conforming adults and ado- adult and adolescent group. lescents), as well as risk factors for each subgroup. The minority stress model (MSM) is often used to * Correspondence: [email protected] explain mental health disparities in sexual [121] and gender 1Department of Psychology, Loma Linda University, 11130 Anderson Street, Suite 106, Loma Linda, CA 92350, USA minority [76] groups. Minority stress models posit that in- Full list of author information is available at the end of the article dividuals from LGBT populations experience unique distal © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Parker and Harriger Journal of Eating Disorders (2020) 8:51 Page 2 of 20 stressors, such as stigma and discrimination, and proximal significantly different from heterosexual and cisgender stressors, such as internalized homophobia or transphobia females [37, 44, 120, 145, 151]. Adult sexual minorities and concealment of sexual or gender identity [122]which also were almost twice as likely to experience food in turn lead to increased risk for the development of addiction (defined as the application of the criteria of physical and mental health issues [26, 101, 118, 121, 122]. substance use disorder to highly rewarding foods) For example, one study found that sexual minority adoles- compared to heterosexuals, which was aggravated by cents reported various forms of stress from the original heterosexist harassment [135], and sexual minorities model [121] including distal (discrimination and have reported higher rates of weight discrimination than victimization), proximal (expectations of rejection and in- heterosexual peers, even after controlling for body mass ternalized stigma such as homophobia), and disclosure index (BMI) and race [145]. Other studies indicated that (concealment stress), as well as violence and social and LGBT youth engaged in disordered eating behaviors, verbal victimization [59]. It has also been found that sexual such as purging, fasting, dieting with intention of weight minority youth report higher levels of sexual minority- loss, and taking diet pills at higher rates compared to specific victimization, depressive symptoms, and suicidality heterosexual youth [5, 67, 84, 113, 154, 167], putting compared to their heterosexual peers [30]. Additionally, them at greater risk for developing an eating disorder research has found that individuals from sexual and gender [31]. Further, the results of one study indicated that over minority groups that perceive higher levels of stigma are half of sexual and gender minority youth experienced more likely to report eating disorder symptoms [14, 110], weight-based victimization from family members and and that shame, concealment of one’s sexual identity, and peers, which in turn was associated with increased rates discrimination increases the risk of eating disorders in sex- of binge eating, dieting, and other unhealthy weight- ual minority men and women [12, 163, 166]. Finally, minor- control behaviors, in addition to stress, exercise avoid- ity stress is related to binge-eating in lesbian and bisexual ance, less physical activity, and poorer sleep [79]. women [106] and body dissatisfaction in gay males [94]. Gordon et al. [61] also found that their young adult While minority stress is only one of the frameworks from and adolescent participants indicated that their appear- which to understand eating disorder risk in sexual and ance ideals came from traditional media, social media, gender minorities, it is important to examine research on LGBT-specific media, dating apps, and family, suggesting LGBT individuals through the lens of minority stress. that LGBT appearance ideals only slightly differs from Indeed, it has been reported that both clinical eating heterosexual and cisgender appearance ideals, with the disorders and eating disorder behaviors occur more exception of the influence of LGBT-specific media. Four frequently in LGBT individuals compared to their themes emerged regarding the participants’ experiences heterosexual and cisgender counterparts [10, 32, 44, 73, with these appearance ideals: (1) appearance ideals 145, 160]. Further research has indicated that approxi- tended to interrelate with one’s sexual and/or gender mately 54% of LGBT adolescents have been diagnosed identity development, in that respondents constructed with a full-syndrome eating disorder during their life- their own ideal from a wide variety of sources, especially time, with an additional 21% suspecting that they had an from sources that aligned with their own sexual and/or eating disorder at some point during their life [157]. gender identity; (2) appearance ideals and LGBT stereo- Additionally, 60.9% of LGBT adolescents in one study types were intertwined, in that others expected them to reported engaging in at least one disordered eating have a certain appearance based on the stereotype of behavior within the past year [61]. Transgender youth their sexual and/or gender identity (e.g., gay men stereo- were more likely to report eating disorder behaviors typically have a lean and muscular body); (3) gender iden- compared to cisgender populations [44, 66, 169]. Finally, tity, sexual orientation, and race/ethnicity all uniquely a recent study examining participants upon admission to contributed to the pressure one felt to appear a certain eating disorder treatment reported that sexual and way; and (4) LGBT-specific community spaces had the gender minority participants had more acute eating potential to be either affirming or constraining to one’s disorder symptoms and higher rates of abuse compared appearance,