Adolescence is a crucial period for emerging sexual orientation and gender identity and also body image disturbance and disordered eating. Body image distortion and disordered eating are important pediatric problems affecting individuals along the sexual orientation and gender identity spectrum. Lesbian, gay, bisexual, transgender (LGBT) youth are at risk for eating disorders and body dissatisfaction. Disordered eating in LGBT and gender variant youth may be associated with poorer quality of life and mental health outcomes. Pediatricians should know that these problems occur more frequently in LGBT youth. There is evidence that newer treatment paradigms involving family support are more effective than individual models of care.
Key points
- •
Current studies suggest that sexual minority males have increased body shape and weight dissatisfaction, anorexic and bulimic symptoms, and may consider physical appearance to be critical to their sense of self.
- •
Studies have shown that transgender youth and young adults report elevated rates of compensatory behaviors (eg, vomiting, laxative use, or diet pill use) and higher rates of past-year self-reported eating disorders.
- •
Transgender adults may be at increased risk for eating disorders, so screening and early recognition of disordered eating are critical in youth.
- •
Although further research is needed to examine the relationships among disordered eating, gender identity, and sexual orientation, current literature suggests that sexual minority youth of both genders may be more likely to engage in dangerous weight control behaviors.
Introduction
Adolescence is a crucial period for emerging sexual orientation and gender identity, and body image disturbance and disordered eating. Eating disorders are serious mental illnesses with the potential for life-threatening medical complications and death. Although previously body image distortion and disordered eating were considered to affect only a small subset of society, largely affluent females, they are now recognized to impact millions, including all individuals along the sexual orientation and gender identity spectrum. However, most research on eating disorders and body image has focused on heterosexual, cisgender individuals. The limited amount of research on sexual minority adolescents and gender variant youth suggests associations between sexual orientation and gender identity and eating-related pathology. Eating disorders in youth have recently been shown to be highly associated with the future development of serious psychiatric conditions, such as anxiety disorders, depression, drug use, and self-harm behaviors in young adulthood. It is of paramount importance that health care providers recognize the importance of eating and body image issues and that these may affect the lesbian, gay, bisexual, transgender (LGBT) population in unique ways, and may confer future risk toward adverse health outcomes. An American Academy of Pediatrics’ statement in the office-based care for LGBT youth has called for additional research in this area, highlighting eating disorders as an underresearched, critical, and emerging issue for LGBT youth.
Introduction
Adolescence is a crucial period for emerging sexual orientation and gender identity, and body image disturbance and disordered eating. Eating disorders are serious mental illnesses with the potential for life-threatening medical complications and death. Although previously body image distortion and disordered eating were considered to affect only a small subset of society, largely affluent females, they are now recognized to impact millions, including all individuals along the sexual orientation and gender identity spectrum. However, most research on eating disorders and body image has focused on heterosexual, cisgender individuals. The limited amount of research on sexual minority adolescents and gender variant youth suggests associations between sexual orientation and gender identity and eating-related pathology. Eating disorders in youth have recently been shown to be highly associated with the future development of serious psychiatric conditions, such as anxiety disorders, depression, drug use, and self-harm behaviors in young adulthood. It is of paramount importance that health care providers recognize the importance of eating and body image issues and that these may affect the lesbian, gay, bisexual, transgender (LGBT) population in unique ways, and may confer future risk toward adverse health outcomes. An American Academy of Pediatrics’ statement in the office-based care for LGBT youth has called for additional research in this area, highlighting eating disorders as an underresearched, critical, and emerging issue for LGBT youth.
Overview of eating disorders and body image
Eating disorders are common and potentially deadly conditions. They affect millions of males and females in the United States, with some estimates up to 30 million Americans, with increasing incidence and prevalence, and with adolescents diagnosed with increasing frequency. The precise cause of these disorders is not known. It is most likely that they are multifactorial in origin, with evidence for neurobiologic predispositions and gene-environment interactions. Among the wide spectrum of mental illness, eating disorders have the highest rate of mortality, making them a considerable public health concern. These facts are particularly important for LGBT adolescents who are at elevated risk for certain other psychiatric comorbidities. Therefore, it is of critical importance that providers are aware of how to detect these disorders in LGBT youth.
Previously, eating disorders were divided into three major subgroups: (1) anorexia nervosa (AN), (2) bulimia nervosa (BN), and (3) eating disorder not otherwise specified. However, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has broadened the diagnostic criteria in a more inclusive manner to reduce the need for eating disorder not otherwise specified. Other diagnoses described in the DSM-5 include: pica, rumination disorder, avoidant/restrictive food intake disorder (ARFID), binge-eating disorder, other specified feeding or eating disorder, and unspecified feeding or eating disorder. Estimates show that AN affects up to 1% of adolescents and young adults, whereas BN has a prevalence of 3%. Although some individuals may not meet the full criteria for an eating disorder diagnosis, many adolescents engage in eating disordered behaviors, with up to 25% of high school aged girls and 11% of high school aged boys reporting disordered eating severe enough to need evaluation, and 9% of high school girls and 4% of boys reporting daily vomiting to control their weight.
In contrast to eating disorders, body image is less strictly defined and less extensively studied. Body image can loosely be defined as how individuals perceive themselves when they picture themselves in their minds or see themselves in the mirror. Body image includes how one feels about not only their body, but also their height, weight, and shape. This article looks at disturbances or distortions in body image, often described as body dissatisfaction.
It is important to notice that the DSM-5 allows not only distortions in how body weight or shape are experienced as a feature defining eating disorders diagnostically, but also allows behaviors that sabotage weight gain as a criterion. This is important, because many pediatric and adolescent patients do not report body image disturbances as part of their eating disorder, and are less able to identify cognitive changes brought on by their disease.
Finally, it is critical to note that for the most part, most sexual minority youth have positive body image and lack eating concerns. This article discusses associations found in the literature between sexual minority youth and eating disorders or body image disturbances.
Clinical presentation, screening, and treatment
A patient with weight loss, inability to gain weight, restrictive thoughts about weight or shape, unexplained vomiting, or abnormal behaviors around eating warrants a consideration of the diagnosis of an eating disorder. AN typically presents with a refusal to maintain a minimally normal body weight, or behaviors that consistently sabotage weight gain even in the absence of overt cognitions surrounding weight and/or shape. Pediatric patients may present with failure to gain weight over time as normally expected, and sometimes with linear growth stunting, rather than weight loss. BN typically presents as recurrent episodes of binge eating followed by compensatory behaviors to avoid weight gain, such as laxative use, induced vomiting, fasting, or purging with exercise. Finally, ARFID is another common disorder that presents with nonorganic, often anxiety-mediated causes of poor growth and feeding resulting in impairments in physical health, growth, and/or psychosocial functioning. Patients with ARFID do not have concerns about their weight or shape that can be identified, but nonetheless have difficulty eating adequately.
Some presentations of eating disorders, however, are less obvious, and include chronic abdominal pain, syncope, orthostatic hypotension, chest pain, menstrual irregularities or other symptoms of hypogonadism, and constipation. Eating disorders are not always clear on initial presentation and a high index of suspicion is warranted if these signs are present. In fact, patients with dangerous eating disorders may be overweight or obese, and may therefore not be recognized. Similarly, eating disorders are often missed in adolescent and young adult males at first presentation, and it is important to consider these diseases when males present with symptoms that may reflect an eating disorder.
When assessing a patient with a suspected eating disorder, the provider must first determine the patient’s current weight, examine a weight and growth history, and compare the current weight with an expected body weight or body mass index (BMI). A comprehensive history and physical examination should be completed. Caregivers and patients should be interviewed, because some adolescents and young adults with eating disorders can significantly underreport their symptoms. In addition to common history questions, questions about diet, body image, weight-control measures, and psychiatric conditions should be assessed. Suggested screening questions are listed in Box 1 .
Have you done anything in the past 6 months to change your weight?
What do you think you ought to weigh?
How much do you exercise?
How do you feel if you miss a workout?
What is your self-image (thin or fat)?
Are there any particular areas of your body that bother you?
The diagnosis of an eating disorder is a clinical diagnosis and there is not confirmatory laboratory testing. However, some laboratory and ancillary testing may be helpful in the evaluation of a patient with an eating disorder ( Box 2 ). The purpose of such testing is to exclude other organic etiologies, detect complications of malnutrition or vomiting, and initially assess the effects of nutritional rehabilitation.
Complete blood count
Erythrocyte sedimentation rate or C-reactive protein
Comprehensive metabolic panel, phosphorus, magnesium
Thyroid studies
Celiac panel
25-OH Vitamin D
Ferritin, iron studies
Thiamine, B 12 levels
Estradiol or testosterone
Follicle-stimulating hormone and luteinizing hormone
Prolactin
Pregnancy testing
If liver function elevated, consider Wilson disease, porphyria
Once an eating disorder has been suspected or diagnosed by a provider, depending on their comfort level, they may want to refer patients for further evaluation and management. Eating disorders are complex and are ideally treated by an experienced multidisciplinary team of medical, nutrition, and mental health professionals. Many inpatient facilities that treat patients with eating disorders use specific protocols. Inpatient treatment is appropriate for patients who are medically unstable (eg, because of bradycardia, hypotension, hypothermia, electrolyte abnormalities, arrhythmias) or psychiatrically unstable (concurrent suicidality, severe self-injury, or other dangerousness to self or others), or for patients who cannot otherwise be treated in a home setting.
Although family acceptance is a special issue for LGBT youth (See Sabra Katz-Wise and colleagues article, “ LGBT Youth and Family Acceptance ,” in this issue), when feasible, treatment paradigms have shifted away from individualized therapy for most adolescents and young adults, to family-based therapy. Family-based therapy is an outpatient intervention with a multidisciplinary team that places parental involvement at the center of care and is critical to the therapeutic success of the adolescent. When feasible, family-based therapy is currently the gold standard and is the most effective treatment of AN and BN. Individual treatment paradigms on general populations are less successful in randomized trials. If family members cannot be leveraged to help support the adolescent, thought should be given to involving other caretakers or adults in treatment, because it seems that full recovery is much more challenging when done without a strong support system.
Practical tips in managing eating disorders
Treatment paradigms have shifted dramatically. This is caused by improved understanding that eating disorders can be conceptualized as brain disorders that respond best to weight restoration and normalization of eating behaviors. These disorders are now widely accepted to have strong genetic links in families, and occur in young people with genetic and neurobiologic vulnerability. Family members are critical to supporting a patient in recovery.
It is helpful when treating a patient with an eating disorder to focus on reversing maladaptive eating behaviors that have developed and restoring weight, rather than diverting time and effort to speculation about causation that cannot be substantiated. Although a risk factor, sexual orientation or gender identity concerns are clearly neither necessary nor sufficient to cause eating disorder, because most sexual minority or transgender youth never develop an eating disorder. If they do, this is likely influenced by the same genetic and neurobiologic vulnerabilities as in nonsexual and gender minority peers.
Weight restoration to a goal that is consistent with the patient’s prior, premorbid growth trajectories earlier in childhood is important. Obviously, not all patients are meant to live at the fiftieth percentile for BMI. Some may need to be higher or lower, consistent with their premorbid BMI.
Because eating disorders can be chronic and are associated with significant morbidity and mortality, providers should discuss their concerns with patients and families early and refer to experienced teams for treatment. Evidence-based treatment that involves families should be prioritized if available and feasible. These illnesses should be recognized as treatable, and full recovery should be the goal, because they do not need to be chronic. Box 3 provides treatment recommendations.
- 1.
Have a high index of suspicion. These are common illnesses in adolescence.
- 2.
Make the diagnosis and have the discussion with your patient and his/her family. Do not be afraid of upsetting the family, and do not wait for a large medical work-up to be complete before discussing openly that an eating disorder is a likely cause of your patient’s symptoms. This conversation can be initiated while completing the necessary medical work-up, rather than after. This will help your patient feel more supported early on.
- 3.
Instill hope. These disorders can be fully treated, and full recovery should be the goal.
- 4.
Impress an appropriate sense of medical urgency. Treatment should not be delayed, and will not get easier in time. These are life-threatening illnesses if they go untreated.
- 5.
Target behaviors. If weight gain needs to occur, that should be the initial focus. If other behaviors are more important, such as purging, work with a team of professionals to target those.
- 6.
Set accurate weight goals that align with your patient’s prior growth history. Not everyone is meant to weigh less than the fiftieth percentile.
- 7.
Refer to qualified providers with demonstrated track records of success for treatment. This is more important than providers who are close to home or have convenient schedules. Just as with any other serious illness, the quality and background of the treating specialist is important to reach success.
- 8.
Support the family. Patients should not be treated in isolation. Embrace the involvement of family members or friends if they are able to be structured and supportive in targeting the treatment goals. These illnesses are best fought with caregivers who can help.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
