Investigating Eating Symptoms in the LGBTQIA+ Population: Do Discrimination and Adverse Conditions Matter?

Abstract

Background:

Eating disorders (EDs) have traditionally been studied among heterosexual cisgender women, but recent research highlights a higher prevalence in LGBTQIA+ individuals.

Aims:

This study aims (1) to investigate the association between different groups based on gender identity and sexual orientation (GISO) and experiencing eating symptoms, and (2) to explore the extent to which self-perceived discrimination and adverse conditions explain this association.

Methods:

We administered an online survey to assess eating symptoms using the Eating Disorder Examination Questionnaire (EDE-Q 6.0) and measures of self-perceived discrimination and adverse conditions. Multistep logistic regressions were employed to analyze the associations between GISO and eating symptoms, initially unadjusted, then adjusted for sociodemographic variables, and finally adjusted for self-perceived discrimination and/or adverse conditions.

Results:

A total of 560 adults aged 30 ± 10.9 years old were included. After adjusting for socio-demographics all groups were more likely to experience eating symptoms compared to heterosexual men, with odds ratios (ORs) of 5.7 [95% CI: 1.3, 24.3] for cisgender heterosexual women, 6.7 [95% CI: 1.5, 29.8] for cisgender non-heterosexual women, and 9.3 [95% CI: 1.8, 47.5] for non-cisgender individuals. After adjusting for self-perceived discrimination and adverse conditions, the associations for women were attenuated, while the associations for non-cisgender individuals were no longer significant.

Conclusion:

This study (1) confirms that sexual and gender minorities may be at higher risk for EDs, and (2) suggests that discrimination and adverse conditions may contribute to the higher prevalence of eating symptoms in this population. Additional research is needed to investigate these minority stressors as they may represent targets for effective interventions to prevent eating symptoms in the LGBTQIA+ community.

Keywords

Eating disorders LGBTQIA+discrimination stigma homophobia

Introduction

Each year, more than 3.3 million healthy life years are globally lost due to eating disorders (EDs), such as anorexia nervosa, bulimia nervosa or binge eating disorder (van Hoeken & Hoek, 2020). Individuals with past or current EDs experience a significant increase in years lived with disability, higher risks of premature mortality, and psychiatric comorbidities including anxiety, depression, and obsessive-compulsive disorder (Casper, 1998; Marcolini et al., 2023; Smink et al., 2012; Tempia Valenta, Campanile, Albert et al., 2024; van Hoeken & Hoek, 2020). Prevalence studies reveal substantial variations based on age and gender, with EDs historically more prevalent among young women (Arija Val et al., 2022). Consequently, research on EDs has predominantly focused on women of Caucasian ethnicity in affluent regions of Western Europe and North America (Coelho et al., 2019; Murray et al., 2021; Pike et al., 2014; Sonneville & Lipson, 2018; Strother et al., 2012).

However, contemporary scientific literature reveals a significant prevalence of EDs within the lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender (LGBTQIA+) population (Diemer et al., 2015; Kamody et al., 2020; Nagata et al., 2020; Silén & Keski-Rahkonen, 2022). In particular recent literature suggests a higher prevalence of eating-related pathology among individuals with transgender identities from Western countries, with approximately 20% to 50% reporting disordered eating and over 30% screening positive for ED symptoms (Coelho et al., 2019; Diemer et al., 2015; Grammer et al., 2021; Keski-Rahkonen, 2023). Nevertheless, research on this matter remains limited within the Italian context, with only few studies suggesting an association between being part of a sexual minority and experiencing symptoms related to EDs (Castellini et al., 2019; Cella et al., 2013; Meneguzzo et al., 2021).

In the context of EDs, different authors suggested that individuals from marginalized groups may face an elevated risk of developing these disorders due to the stressors they encounter, which can negatively impact body image, self-esteem, and psychological well-being, ultimately leading to higher risk of EDs (Convertino et al., 2021; Muratore et al., 2022; Parker & Harriger, 2020; Siconolfi et al., 2016; Tempia Valenta, Innella, Bonazzoli et al., 2024; Walloch et al., 2012). For instance, the minority stress model, a prominent theoretical framework in psychology, posits that individuals from marginalized groups endure unique stressors due to their minority status, which can lead to adverse mental health outcomes (Diamond & Alley, 2022; Tan et al., 2020). Among LGBTQIA+ people, these stressors encompass various factors including internalized homophobia, stigma, discrimination, as well as the complexities surrounding the coming out process, familial conflicts, societal attitudes, and the struggles with financial and work-related issues (Castellini et al., 2023; Iwasaki & Ristock, 2007; Meyer, 2015). Furthermore, the influence of antigay politics can exacerbate stress levels (Russell & Richards, 2003). Collectively, external and internal minority stressors, inclusive of discrimination and the internalization of negative cultural attitudes, can significantly amplify mental health difficulties (Frost & Meyer, 2023; Hoy-Ellis, 2023; Levitt et al., 2023).

In Italy factors like discrimination, harassment, violence, economic crisis, and unemployment targeting LGBTQIA+ individuals are still prevalent issues (Callahan & Loscocco, 2023; Mattei et al., 2020; Pelullo et al., 2013). According to a 2023 Ipsos poll, in Italy 9% of the population identified as LGBTQIA+, while egalitarian marriage and adoptions by LGBTA+ couples were endorsed by less than 65%, that is well below the rates in other Countries, such as Netherlands, Spain, Sweden, and Belgium, where support exceeds 80% (Ipsos, 2023). This discrepancy suggests that Italy lags behind in LGBTQIA+ rights, potentially exposing LGBTQIA+ population to higher levels of discrimination compared to other Western nations.

It is important to acknowledge the historical neglect of minorities in research, that leaves a significant gap in our understanding and limits our comprehension of their unique experiences (Goldbach & Castro, 2016; Whaibeh et al., 2020). Within gender identity and sexual orientation (GISO) categories, non-heterosexual and non-cisgender individuals represent sexual and gender minorities. While existing studies on mental health outcomes in these minorities have primarily focused on anxiety, depression, and suicidality, the impact of discrimination and adverse conditions on the onset of EDs remains largely unexplored. Hereby, our research aims (1) to investigate the association between being part of groups based on GISO and experiencing eating symptoms, and (2) to analyze to what extent self-perceived discrimination and adverse conditions affected the association between GISO and eating symptoms. Our hypotheses are that (1) individuals who are part of GISO groups are at higher risk of eating symptoms and (2) self-perceived discrimination and partially explain the higher risk of eating symptoms among these participants.

Methods

Study Design and Recruitment

An ad hoc online survey, written in Italian, was distributed using Qualtrics (Qualtrics, 2018). The dissemination strategy leveraged social media platforms, including Meta and WhatsApp, with a primary focus on the university network in Bologna, Italy. Paper leaflets were distributed in LGBTQIA+ community centers, gay bars, LGBTQIA+ friendly cafes and specialized bookstores in Bologna, Italy. Participants were excluded in this study when they did not meet the following inclusion criteria: (a) being aged 18 years or older, (b) provide digital informed consent for study participation and authorize the use of their data for research purposes, and (c) fill out all sections and questions of the survey. This study adopted a completed cases analysis approach due to the risk of duplication.

Ethical Approval

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Bioethics Committee of University of Bologna, Italy (protocol code 036667, December 6th 2022).

Measures

Socio-demographics

Participants provided information on various demographic variables through a structured questionnaire. Age was self-reported, and respondents were asked to specify their de facto civil status, choosing from options such as single, in a relationship, married or cohabitating, separated or divorced, widowed, or prefer not to disclose. Additionally, participants indicated their living situation, selecting from categories such as living alone, living with family, living with family of origin, living with a partner, living with roommates, or specifying other arrangements. Educational level was assessed by participants disclosing their highest attained qualification, with options including primary school certificate, secondary school certificate, university degree, and master’s or doctoral degree. Finally, participants disclosed their occupational status, choosing from categories such as employed, homemaker, student, retiree, or specifying others.

Eating Symptoms

Eating symptoms, used as a proxy for EDs, were assessed using the Eating Disorder Examination Questionnaire, EDE-Q 6.0. The EDE-Q 6.0 is a self-report questionnaire derived from the EDE, a semistructured interview considered the gold standard for the assessment of ED psychopathology (Fairburn & Beglin, 1994; Luce & Crowther, 1999). The EDE-Q 6.0 consists of 28 questions divided into four subscales (Restraint, Eating Concern, Shape Concern, and Weight Concern), reflecting the main features of EDs psychopathology (Fairburn & Beglin, 1994). Participants are asked to indicate how often they experienced ED core symptoms over the past 28 days with a Likert-scale ranging from 0 (“never”) and 6 (“every day”). The score of each factor is computed as mean. Individuals with a score higher than 2.8 were considered as at high risk of having a clinical ED (Fairburn & Beglin, 1994).

Gender Identity and Sexual Orientation

Respondents were asked to indicate their gender identity with one item asking whether they recognized themselves as cisgender women, cisgender men, transgender assigned male at birth (AMAB), transgender assigned female at birth (AFAB), nonbinary, genderfluid, or agender (definitions for the terms used are provided in Table A of the Supplemental Material). Sexual orientation was investigated asking individuals to indicate whether they recognized themselves as heterosexual, bisexual, gay, lesbian, pansexual, asexual, or other. For both questions, respondents could indicate the preference not to disclose. Gender identity and sexual orientation were subsequently consolidated into five categories: cisgender heterosexual men, cisgender heterosexual women, cisgender non-heterosexual men, cisgender non-heterosexual women, and non-cisgender individuals, aiming to enhance the representation of diverse categories.

Self-perceived Discrimination and Adverse Conditions

Information regarding self-perceived discrimination and adverse conditions was gathered using dichotomous items, which were then combined to classify individuals as having experienced or not experienced self-perceived discrimination and adverse conditions within their family environment and in their city of origin.

Self-perceived discrimination was assessed using two 6-option questions aimed at measuring participants’ perceptions of discriminatory attitudes within their family environment and their city of origin. Items were drawn from established frameworks and validated scales such as the Family Stigma Stress Scale (FSSS; Chang et al., 2019) and the Minority Stress Scale (MSS; Pala et al., 2017) to ensure a comprehensive coverage of relevant constructs and dimensions. Participants were asked to indicate whether they had encountered (score = 1) or not (score = 0) the following forms of discrimination: homobitransphobia (i.e. discrimination, prejudice, or hostility directed toward individuals who identify as homosexual, bisexual, or transgender), discrimination against minorities, marginalization of minorities, and stigma toward minorities, or racism. Additionally, participants could indicate if they had not experienced any of these forms of discrimination.

The experience of adverse conditions was assessed through three questions, each containing different dichotomous items. Participants were asked to indicate whether they had encountered specific challenging circumstances and unfavorable environments, both within their family setting and in their city of origin. Items were selected from well-established frameworks and validated scales such as the Adverse Childhood Experiences (ACE) questionnaire (Felitti et al., 2014), the Early Trauma Inventory (ETI; Bremner et al., 2007), and the Childhood Hunger Identification Project (CHIP; Wehler et al., 1992). Inquiries regarding family-related adversities encompassed experiences of abuse, physical violence, psychological maltreatment, psychiatric disorders, poverty, social isolation, unemployment, and social exclusion. Similarly, participants were prompted to report on adverse conditions in their city of origin, including exposure to adverse childhood social experiences, famine, or malnutrition. Additionally, participants could indicate if they had not experienced any of these forms of adverse conditions.

Statistical Analysis

Descriptive information was summarized as frequencies (N; %) for categorical variables and as mean and standard deviation (SD) for continuous variables. Analyses of continuous variables for skewness, kurtosis, and normality distribution through the Shapiro-Wilk test were performed to test the appropriateness of parametric or non-parametric statistical tests. Additionally, Cronbach’s alpha was calculated to assess the internal consistency of the scales used in the study.

Multistep logistic regressions were performed to investigate: (1) the association between being part of GISO categories and experiencing eating symptoms, and (2) to what extent self-perceived discrimination and adverse conditions explained the association between GISO and eating symptoms. In model 1, the unadjusted association of GISO for eating symptoms was estimated to respond to the first research question. In model 2, socio-demographics were also included. In model 3 self-perceived discrimination and adverse conditions were added to model 2 to respond to the second research question. Odds Ratios (ORs) with 95% confidence intervals (IC) were calculated for each eating symptom (i.e. food concerns, weight phobia, shape concerns, and restriction) and for the total score. Heterosexual cisgender men were used as the reference group, guided by existing literature indicating that this group tends to exhibit a comparatively lower absolute risk (Dahlenburg et al., 2020; Peplau et al., 2009).

All analyses were performed using Statistical Package for Social Science for MacOS (SPSS) software, Version 24.0 (IBM Corp, 2016).

Results

Sample Characteristics

The results of the descriptive analysis, detailing socio-demographic characteristics, are summarized in Table 1. The questionnaire was opened 723 times. A total of 560 respondents (mean age = 30; SD = 10.9) filled in the cross-sectional online survey. Cisgender women and cisgender men accounted respectively for 71.1% and 22.9% of the sample, while 0.4% and 0.2% of respondents identified as transgender AMAB and transgender AFAB. The remaining 5.5% identified as nonbinary, genderfluid, or with another gender identity. Concerning sexual orientation, 66.8% identified as heterosexual, 17.5% as bisexual, 10.0% as gay or lesbian, and 5.8% with pansexual, asexual, or other orientations. The intersection of gender identity and sexual orientation revealed five categories: cisgender heterosexual men (n = 88; 15.7%), cisgender heterosexual women (n = 282; 50.4%), cisgender non-heterosexual men (n = 40; 7.1%), cisgender non-heterosexual women (n = 116; 20.7%), and non-cisgender individuals (n = 34; 6.1%).

Table 1.

Descriptive Information of Socio-demographics Characteristics, Self-perceived Discrimination and Adverse Conditions Among a Sample of Adults (N = 560).

Variable	Answer	n	% of total sample
GISO	Cisgender heterosexual man	88	15.7
	Cisgender heterosexual woman	282	50.4
	Cisgender non-heterosexual man	40	7.1
	Cisgender non-heterosexual woman	116	20.7
	Non-cisgender individuals	34	6.1
Nationality	Italian	525	93.8
	Other	35	6.3
De facto civil status	Single	204	36.4
	In a relationship	226	40.4
	Married or cohabitating	102	18.2
	Separated or divorced	3	0.6
	Widowed	7	1.3
	Prefer not to disclose	18	3.2
Living situation	Living alone	80	14.3
	Living with the family	137	24.5
	Living with the family of origin	69	12.3
	Living with a partner	111	19.8
	Living with roommates	151	27.0
	Other	12	2.1
Educational level	Middle school certificate	15	2.7
	High school certificate	203	36.3
	University degree	192	34.3
	Master’s or doctoral degree	150	26.8
Occupation	Employed	284	50.7
	Homemaker	14	2.5
	Student	217	38.8
	Retiree	27	4.8
	Other	18	3.2
Presence of self-perceived discrimination and/or adverse conditions		n	% within each GISO category
Cisgender heterosexual men		52	59.1
Cisgender heterosexual women		216	76.6
Cisgender non-heterosexual men		34	85.0
Cisgender non-heterosexual women		101	87.1
Non-cisgender individuals		33	97.1

Note. GISO = gender identity and sexual orientation; Self-perceived discrimination, homophobia, biphobia, transphobia, discrimination against minorities, marginalization of minorities, or stigma toward minorities; Adverse conditions, abuse, physical violence, psychological maltreatment, psychiatric disorders, poverty, social isolation, unemployment, social exclusion, exposure to adverse childhood social experiences, famine, or malnutrition; SD = standard deviation.

Among the participants, 29.1% reported instances of family discrimination, while 68.1% indicated experiencing social discrimination. Adverse conditions within family settings were reported by 38.6%, compared to 12.7% within social environment. Among cisgender non-heterosexual women, 49.1% reported self-perceived discrimination within their families, while 84.5% reported self-perceived discrimination within society. Non-cisgender individuals reported the rates of self-perceived discrimination of 67.6% within family context and of 94.1% within societal context. In terms of adverse conditions within family settings, cisgender non-heterosexual women reported a prevalence of 51.7% and non-cisgender individuals of 79.4%. More details in Table B of the Supplemental Material.

Internal Consistency of the Scales

The internal consistency of the scales was evaluated using Cronbach’s alpha. The Cronbach’s alpha for the EDE-Q was α = .95, indicating excellent reliability. For the discrimination scale the Cronbach’s alpha was α = .79 and for the adverse conditions scale it was α = .71, reflecting good reliability.

Associations Between GISO Categories and Eating Symptoms

Cisgender heterosexual women, cisgender non-heterosexual women, and non-cisgender individuals showed elevated odds across all eating symptoms compared to cisgender heterosexual men. Among the more notable results, cisgender heterosexual women exhibited significantly higher odds of experiencing weight phobia (OR: 4.1, 95% CI: [2.2, 7.7]) and shape concerns (OR: 2.8, 95% CI: [1.6, 4.8]). Cisgender non-heterosexual women showed significantly higher odds of experiencing weight phobia (OR: 5.2, 95% CI: [2.6, 10.4]) and shape concerns (OR: 4.0, 95% CI: [2.2, 7.3]). Non-cisgender individuals exhibited relevant odds of all eating symptoms, with significant associations for food concerns (OR: 6.0, 95% CI: [1.8, 19.5]), weight phobia (OR: 8.2, 95% CI: [3.3, 20.3]), shape concerns (OR: 4.8, 95% CI: [2.1, 11.3]), and restriction (OR: 4.2, 95% CI: [1.5, 11.7]). In contrast, cisgender non-heterosexual men did not show significant associations with any eating symptoms. Details in Table 2.

Table 2.

Associations Between Different GISO Categories and Eating Symptoms Among 560 Adults.

Eating symptoms^a
	Food concerns	Weight phobia	Shape concerns	Restriction
	OR [95% CI]	OR [95% CI]	OR [95% CI]	OR [95% CI]
Cisgender heterosexual men (n = 88)	1	1	1	1
Cisgender heterosexual women (n = 282)	2.7* [1.0, 7.2]	4.1*** [2.2, 7.7]	2.8*** [1.6, 4.8]	2.6* [1.2, 5.8]
Cisgender non-heterosexual men (n = 40)	0.9 [0.2, 4.7]	1.9 [0.8, 4.9]	1.6 [0.7, 3.6]	0.8 [0.2, 3.2]
Cisgender non-heterosexual women (n = 116)	4.3** [1.6, 11.9]	5.2*** [2.6, 10.4]	4.0*** [2.2, 7.3]	3.6** [1.6, 8.4]
Non-cisgender individuals (n = 34)	6.0** [1.8, 19.5]	8.2*** [3.3, 20.3]	4.8*** [2.1, 11.3]	4.2** [1.5, 11.7]

Eating symptoms were assessed using the eating disorder examination questionnaire, (EDE-Q 6.0).

p < .05. **p < .01. ***p < .001.

Regarding total scores for eating symptoms, cisgender heterosexual women (OR: 5.5, 95% CI: [1.3, 23.5]), cisgender non-heterosexual women (OR: 7.9, 95% CI: [1.8, 35.0]), and non-cisgender individuals (OR: 11.1, 95% CI: [2.2, 56.9]) were more likely to experience eating symptoms compared to cisgender heterosexual men [model 1]. These associations remained consistent with slight modifications after adjusting for socio-demographic variables [model 2]. After adjusting for self-perceived discrimination and adverse conditions, the ORs were attenuated [model 3]. The OR for cisgender heterosexual women decreased to 4.7 (95% CI: [1.1, 20.4]) and for cisgender non-heterosexual women it decreased to 4.8 (95% CI: [1.1, 22.0]). Notably, the significant associations for non-cisgender individuals with any eating symptoms were no longer observed. More details are provided in Table 3.

Table 3.

Associations Between Different Gender Identity and Sexual Orientation Categories and Eating Symptoms Among 560 Adults.

Eating symptoms^a
	Model 1: Unadjusted	Model 2: Model 1 adj for SD	Model 3: Model 2 adj for SPD and AC
	OR [95% CI]	OR [95% CI]	OR [95% CI]
Cisgender heterosexual men (n = 88)	1	1	1
Cisgender heterosexual women (n = 282)	5.5* [1.3, 23.5]	5.7* [1.3, 24.3]	4.7* [1.1, 20.4]
Cisgender non-heterosexual men (n = 40)	2.3 [0.3, 16.7]	2.1 [0.3, 15.4]	1.7 [0.2, 12.7]
Cisgender non-heterosexual women (n = 116)	7.9** [1.8, 35.0]	6.7* [1.5, 29.8]	4.8* [1.1, 22.0]
Non-cisgender individuals (n = 34)	11.1** [2.2, 56.9]	9.3** [1.8, 47.5]	5.0 [0.9, 26.9]

Note. Adj = adjusted; AC = adverse conditions; SD = socio-demographic; SPD = self-perceived discrimination.

Eating symptoms were assessed using the Eating Disorder Examination Questionnaire, (EDE-Q 6.0).

p < .05. **p < .01. ***p < .001.

Discussion

This study investigated the association between different GISO categories with eating symptoms in a cohort of 560 respondents, examining the influence of self-perceived discrimination and adverse conditions on such relationship. Our analyses revealed a significant association between GISO categories and eating symptoms, primarily impacting women and non-cisgender individuals in comparison with cisgender heterosexual men. While most associations retained statistical significance post-adjustment for self-perceived discrimination and adverse conditions, their strength diminished, revealing a partial explanatory role for these factors. Notably, the associations for non-cisgender individuals ceased to be statistically significant.

In line with previous literature, our study showed a higher risk of eating symptoms in both heterosexual and non-heterosexual women compared to heterosexual cisgender men. Historically the burden of body dissatisfaction and its consequences has disproportionately affected the female population (Alpern, 1990; Brumberg, 1985). Throughout ancient and contemporary societies, the female body has been imbued with symbolic meanings linked to fertility, motherhood, and societal ideals of beauty (Behjati-Ardakani et al., 2016; Neto et al., 2019). Women have often faced intense societal pressures to conform to unreachable standards of appearance, perpetuated by cultural norms, historical expectations, and media culture (Ramati-Ziber et al., 2020; Silvestrini, 2020). This longstanding cultural emphasis on women’s bodies as objects of reproduction and beauty has contributed significantly to the prevalence of body dissatisfaction and subsequent vulnerability to EDs in this population (Dakanalis et al., 2017; McCarthy, 1990; Morris & Katzman, 2003). Conversely, societal pressures on the male body have been less pronounced, with men generally experiencing fewer expectations and less scrutiny regarding their physical appearance (Gruszka et al., 2022; Quittkat et al., 2019). As a result, EDs have traditionally been more prevalent among women than men (Breton & Booij, 2023; Diemer et al., 2015; Qian et al., 2022). However, recent trends suggest an increasing incidence of EDs among men, highlighting evolving societal norms and changing attitudes toward body image across genders (Gorrell & Murray, 2019; Manzato & Gravina, 2018; Valente et al., 2017).

Moreover, in line with the literature, our study found that non-cisgender and non-heterosexual individuals are more likely to experience eating symptoms. The LGBTQIA+ population faces higher risks of EDs compared to heterosexual and cisgender individuals, with factors such as body non-acceptance and social discrimination playing a significant role (Cella et al., 2010, 2013; Mason et al., 2021; Meneguzzo et al., 2021; Parker & Harriger, 2020). Within the LGBTQIA+ community, variations in the prevalence of EDs exist among different subgroups (Calzo et al., 2017). Among individuals in the transgender community, body non-acceptance is particularly pronounced, contributing to a higher risk of EDs (Hartman-Munick et al., 2021; Rasmussen et al., 2023). Transgender individuals can experience body dissatisfaction stemming from gender dysphoria resulting from the incongruence between their assigned gender features and authentic gender identity (Nagata et al., 2020). Consequently, individuals may engage in disordered eating behaviors and excessive exercise to suppress characteristics associated with their assigned gender while emphasizing those aligned with their gender identity (Coelho et al., 2019; Jones et al., 2016). This phenomenon is notably pronounced among transgender youth who may manipulate weight to affirm their gender identity, particularly during adolescence when the development of sexual characteristics can intensify challenges associated with gender dysphoria (Avila et al., 2019). Gender affirmation processes have been observed to positively impact mental health outcomes, potentially leading to the resolution of EDs (Tempia Valenta, Marcolini, Martone et al., 2024). In line with previous findings, non-heterosexual men were more likely to experience EDs compared to heterosexual men, possibly influenced by societal ideals that prioritize thinness and muscularity (Fogarty & Walker, 2022; Schmidt et al., 2022). Research findings on EDs among non-heterosexual women present conflicting results, with some studies suggesting lower levels of body discomfort compared to heterosexual counterparts, while others indicate higher levels of body dissatisfaction within this population (Dotan et al., 2021; Mor et al., 2015; Parker & Harriger, 2020). In our study, both non-heterosexual men and women showed higher levels of eating symptoms compared to heterosexual cisgender men, possibly reflecting cultural influences on these differences.

Offering a new contribution to existing research, our findings suggest that adjusting for self-perceived discrimination and adverse conditions may weaken the relationship between identifying as non-heterosexual or non-cisgender and experiencing eating symptoms. This aligns with previous research indicating that social discrimination within the LGBTQIA+ community significantly contributes to the development of eating disorders, body dissatisfaction, and other mental health issues (Bostwick et al., 2014; Fish, 2020; Lothwell et al., 2020; Moagi et al., 2021; Parker & Harriger, 2020). Globally, members of the queer community face ongoing stigma, isolation, and discrimination (Bayrakdar & King, 2023; Mara et al., 2021; Meyer, 2015). These disparities in mental health outcomes are frequently linked to experiences of minority stress, encompassing bullying, victimization, discrimination, and internalized homobitransphobia (Choukas-Bradley & Thoma, 2022). Consequently, marginalized or stigmatized groups within the LGBTQIA+ community, including lesbian, gay, bisexual, and transgender individuals, racial and ethnic minorities, and individuals with obesity, exhibit an increased susceptibility to developing disordered eating compared to non-marginalized counterparts (Copeland et al., 2015; Hudson et al., 2007; Lie et al., 2019; Mason et al., 2021; Mason & Lewis, 2017; Striegel-Moore et al., 2002).

The study should be interpreted in light of its strengths and limitations. This novel contribution fills an important gap in the literature on LGBTQIA+ population and eating symptoms specific to an Italian context. To our knowledge, this is the first study to evaluate the role of self-perceived discrimination and adverse conditions in relation to eating symptoms within different GISO categories. The relatively high representation of individuals from non-heterosexual and non-cisgender communities, comprising nearly 40% of the total sample or almost four times the expected proportion in the general population, raises concerns about the broader applicability of the results. However, due to the study’s focus on this minority population, specific recruitment methods were tailored to target individuals within LGBTQIA+ culture-aware environments. This approach may have influenced the sample size and overall composition, resulting in a higher proportion of LGBTQIA+ individuals who are potentially more politically liberal or open-minded and sensitized to these issues. Despite this, such recruitment method ensured the representation of diverse GISO categories and a level of homogeneity within the sample. While the questionnaire drew from existing literature, the absence of a specifically validated tool for these assessments may introduce biases or limitations in data accuracy. Additionally, although the theoretical background allows us to reasonably suggest the existence of causal associations between GISO and eating symptoms, the cross-sectional design of the study restricts our ability to establish causality between variables. Moreover, the study’s monocentric design limits its representativeness of the broader Italian population. Furthermore, relying on selfreported measures and eating symptoms as proxies for EDs may not fully capture clinical severity.

Future research should explore longitudinal approaches to gain more robust insights into the complex associations examined in this study. Additionally, future investigations should discuss the mediating effects of discrimination and adverse conditions to better understand the pathways influencing eating symptoms among different GISO categories. Methodologically, it is important for upcoming studies to prioritize the validation of scales like the EDE-Q within LGBTQIA+ populations and to develop dedicated tools specifically designed to measure discrimination experienced by individuals within this community. This study offers preliminary evidence suggesting that the model focusing on self-perceived discrimination and adverse conditions is applicable in the context of eating symptoms among LGBTQIA+ populations, highlighting the importance of further tailored investigations.

Conclusion

In conclusion, our findings show a significant association between GISO categories and eating symptoms, with women and non-cisgender individuals experiencing higher risk of EDs compared to cisgender heterosexual men. Discrimination and adverse conditions seem to partially explain the association between GISO categories and eating symptoms. Our study confirms the higher vulnerability of the LGBTQIA+ population to EDs in an Italian sample (Cella et al., 2010, 2013; Meneguzzo et al., 2021), and suggests that this higher risk of EDs may be due to the convergence of intrinsic factors related to body non-acceptance and external environmental factors such as discrimination and adverse conditions. LGBTQIA+ emerged as a vulnerable population in relation to EDs, hence understanding these complex dynamics is necessary to develop targeted interventions and support strategies aimed at mitigating the impact of discrimination and adverse conditions on the mental well-being of LGBTQIA+ individuals. By addressing both internal and external factors contributing to EDs within this population, healthcare professionals and policymakers can work toward promoting acceptance, inclusivity, and positive mental health outcomes.

Supplemental Material

sj-docx-1-isp-10.1177_00207640241300969 – Supplemental material for Investigating Eating Symptoms in the LGBTQIA+ Population: Do Discrimination and Adverse Conditions Matter?

Supplemental material, sj-docx-1-isp-10.1177_00207640241300969 for Investigating Eating Symptoms in the LGBTQIA+ Population: Do Discrimination and Adverse Conditions Matter? by Silvia Tempia Valenta, Fabio Porru, Anna Bornioli, Matteo Di Vincenzo, Andrea Fiorillo, Diana De Ronchi and Anna Rita Atti in International Journal of Social Psychiatry

Footnotes

Author contributions

Conceptualization, S.T.V. and A.R.A.; methodology, S.T.V., F.P., and A.B.; formal analysis, S.T.V., F.P., and A.B.; investigation, S.T.V., F.P., and A.B.; data curation, S.T.V.; writing—original draft preparation, S.T.V., F.P., and A.B.; writing—review and editing, A.R.A. and M.D.V.; supervision, A.F. and D.D.R. All the authors have read and approved the final manuscript.

Acknowledgment of language assistance

The authors acknowledge the use of OpenAI’s ChatGPT to enhance the clarity and quality of the English language in the manuscript. The tool was utilized solely for improving language expression and grammar, with no influence on the scientific content, analyses, or conclusions of the study.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics approval

This study complied with the Declaration of Helsinki and with the Italian privacy law, specifically the “Code on the Protection of Personal Data (Legislative Decree 196/2003), updated with the new legislative decree (Legislative Decree 101/2018).” The statistical evaluation of collected data was carried out after complete anonymization. The study was approved by the local Institutional Review Board. The research protocol with the identification number 036667 was officially approved on December 6th 2022.

Data availability statement

The dataset analyzed in this study is available at the following link:

ORCID iD

Silvia Tempia Valenta

Supplemental material

Supplemental material for this article is available online.

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(2020). Reducing the treatment gap for LGBT mental health needs: The potential of telepsychiatry. Journal of Behavioral Health Services & Research, 47(3), 424–431. https://doi.org/10.1007/s11414-019-09677-1

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