Treating eating disorders in the LGBTQIA+ adult population: A scoping review

Abstract

Introduction

The lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender (LGBTQIA+) community faces a significantly higher risk of eating disorders (EDs). This review’s primary objective is to explore ED treatments for this population.

Methods

We searched PubMed/MEDLINE and PsycINFO using the keywords “ED,” “LGBTQIA+,” and “therapy,” following the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews 2018 Checklist.

Results

Out of 363 publications, we identified 14 articles and inductively categorized them into two key macro-themes. The primary macro-theme “conventional treatments applied to the LGBTQIA+ population” encompassed both treatment outcomes, which demonstrated overall effectiveness, and self-reported treatment evaluations, which consistently indicated negative experiences. The secondary macro-theme, “specific treatments for the LGBTQIA+ population,” centered on population-targeted treatments, which, while currently limited, displayed promising results, including improvements in ED psychopathology through gender transition.

Conclusions

The existing literature indicates that conventional treatments are effective in symptom relief but occur within a context marked by perceived discrimination based on gender identity and sexual orientation. Concurrently, population-specific interventions hold promise in reducing ED symptoms, with gender transition emerging as a valuable treatment. Further research is needed to develop tailored treatments and address the challenges faced by the LGBTQIA+ community.

Keywords:

• Disordered eating
• body dissatisfaction
• anorexia
• bulimia
• gender dysphoria; gender transition

Introduction

Recent scientific research has highlighted that the lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender (LGBTQIA+) adult population faces a heightened risk of experiencing eating disorders (EDs) and body image dissatisfaction (Arikawa et al., 2021; Coelho et al., 2019; Donahue et al., 2020; McClain & Peebles, 2016; Nagata et al., 2020; Shearer et al., 2015; Thapliyal et al., 2018; Wagner & Stevens, 2017). In particular, the literature reports that gender-diverse communities have 2 to 4 times greater odds of experiencing a DSM-5 ED diagnosis of anorexia nervosa (AN), bulimia nervosa (BN), or binge-eating disorder (BED) compared to cisgender heterosexual adults (Nagata et al., 2018). Body image dissatisfaction is defined as the negative self-appraisal of one’s physical appearance and directly correlates with disordered eating in the general population but assumes a prominent role in sexual and gender minorities, where it may be emphasized by underlying gender dysphoria or dissatisfaction with one’s gender role (Jones et al., 2016).

It is hypothesized that the risk of experiencing EDs and body image dissatisfaction depends on the presence of unique stressors related to the various nuances of gender identity and sexual orientation, such as social prejudice, heterosexist discrimination, concerns related to the sex assigned at birth, and internalized homotransphobia (Avila et al., 2019; Bell et al., 2019; Brewster et al., 2014; Convertino et al., 2021; Geilhufe et al., 2021; Glynn et al., 2016; Grunewald et al., 2021; Parmar et al., 2021; Uniacke et al., 2021). Owing to their gender identity or expression, sexual and gender minorities can experience high levels of gender-based social oppression, including everyday discrimination, family rejection, and hate crimes (Bazargan & Galvan, 2012; Bradford et al., 2013). Stigma and perceived stigma (i.e., an individual’s feelings about the stigma toward them, such as embarrassment or shame, and the individual’s projection of these feelings onto others) can negatively impact both social support and mental health (Valente et al., 2020; Wang & Borders, 2017). Mental disorders triggered by these factors include EDs, often exacerbated by lack of family support, negative affectivity, and social anxiety (Mason & Lewis, 2017).

Additionally, LGBTQIA+ individuals may succumb to ED symptomatology to control their body shape and align with their gender identity by minimizing or hiding their secondary sexual characters (Ålgars et al., 2012; Couturier et al., 2015; Ewan et al., 2014; Jones et al., 2016). Research shows how transgender individuals assigned female at birth (AFAB) can try to reach extreme levels of thinness in order to suppress the hormonal cascade that determines the onset of menstruation and the presence of female secondary sexual characteristics, such as the hips or breasts (Hepp et al., 2004; Hepp & Milos, 2002). Moreover, a reluctance to lose weight can be seen in overweight individuals, as the overweight status makes the hips and breasts appear reduced compared to the abdominal region (Vocks et al., 2009). Transgender individuals assigned male at birth (AMAB) can show a drive toward thinness, possibly dictated by the quest for suppression of masculinity and a specific ideal of feminine beauty, socially and culturally linked to the thin and slender body (Hepp et al., 2004; Hepp & Milos, 2002; Murray et al., 2021).

Despite the relevant correlation between belonging to the LGBTQIA+ population and the risk of EDs, the treatment protocols available today are aimed primarily at the cisgender heterosexual population (Hay, 2020). Conventional treatments include medical management of ED complications, nutritional rehabilitation, psychotherapeutic interventions, and pharmacological approaches (Murphy et al., 2010; Taylor et al., 2021; Treasure et al., 2020; Voderholzer et al., 2020). The choice of the latter depends on the type of disorder and nutritional status of the individual. Growing evidence supports the use of antidepressants for BN and BED, psychostimulants for BED, and antipsychotics, such as olanzapine, for AN (Taylor et al., 2021; Voderholzer et al., 2020).

The therapeutic outcomes of EDs have remained poor even in recent times, presumably due to poor insight into the disease that derives from the ego-syntonic and reinforcing nature of symptomatic behaviors (Abdelbaky et al., 2013; Espel et al., 2016; Fassino et al., 2004; 2009; Roncero et al., 2013). The dropout rate is estimated to be around 70% in outpatient services (Swan-Kremeier et al., 2005) and around 45% in specialized inpatient ED programs (Huas et al., 2011; The EVHAN Group, 2016). These rates tend to be higher among sexual and gender minorities (Duffy et al., 2016). In turn, poor treatment adherence leads to high rates of chronicity; high rates of fasting, purging, or unhealthy diet medical complications; and high rates of death from suicide (Arcelus et al., 2011; Preti et al., 2011; Smink et al., 2012; Steinhausen, 2009; van Hoeken & Hoek, 2020). Our purpose was to explore the existing literature regarding ED treatment options among LGBTQIA+ individuals in order to provide clinicians with a summary of the state of the literature in this under-examined field.

Materials and methods

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018). We applied a narrative data synthesis method and inductively created macro-themes by synthesizing data from the relevant literature. The included articles were summarized using text and tables. Ethical approval was not sought for the present study because it retrieved and synthesized data from already published studies.

Search strategy

Two authors (S.T.V. and F.M.) independently searched PubMed/MEDLINE and PsycINFO databases from 1 through 31 January 2023. Search term lists were developed to describe the three key concepts of “eating disorder,” “LGBTQIA+ population,” and “treatment” (Table 1). In light of the meager literature on the topic, keywords were searched in title, abstract, and text to include every possible therapeutic approach cue.

Table 1. Keyword search terms.

Key concept	Search in	Keyword search terms
Eating disorder	Title, keywords, abstract, and text	eating disorder
LGBTQIA+ population	Title, keywords, abstract, and text	lgbt OR lgbtqia+ OR gay OR lesbian OR bisexual OR transgender OR queer OR sexual minorities OR gender minorities
Treatment	Title, keywords, abstract, and text	treatment OR care OR therapy

LGBTQIA+, lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender.

Eligibility criteria

We included articles (1) addressing the issue of treatment approaches to EDs among LGBTQIA+ adults, (2) published after 1990, (3) peer-reviewed, (4) written in the English language, and (5) available in full-text. Articles were excluded if they involved (1) a non-target population (non-adult, non-ED, non-LGBTQIA+ population), (2) a non-target topic (i.e., descriptive articles about EDs in LGBTQIA+ populations, LGBTQIA+ general health, LGBTQIA+ mood disorder), and (3) a non-target design (i.e., reviews and thesis).

Preliminarily, the abstracts were screened for inclusion and exclusion criteria, and then selected articles were comprehensively examined in full-text. In addition to keyword searching, we used citation chaining in full-text screening to intercept content that the original searches may have missed.

Data extraction and management

Two authors (S.T.V. and F.M.) independently extracted data from the eligible articles following this scheme: sample demographic information, treatment approach, and results. All relevant screened papers were collected using a dedicated Excel spreadsheet. A third reviewer (A.R.A.) resolved any discrepancies. Finally, a flowchart following the PRISMA guidelines was created to summarize the different phases of the selection process (Figure 1) (Moher et al., 2009).

Figure 1. Flowchart of study selection.

Results

Of the 363 PubMed/MEDLINE and PsycINFO results, 20 met the inclusion criteria for full-text reading. Fourteen articles were included after a full-text review. The most relevant characteristics of the included articles are highlighted in Table 2. Most of the research was conducted in the United States (eight out of 14, 57.1%) (Brown & Keel, 2015; Donahue et al., 2020; Duffy et al., 2016; Ewan et al., 2014; Hartman-Munick et al., 2021; Murray et al., 2021; Nowaskie et al., 2021; Riddle et al., 2022); the others were conducted in Canada (Joy et al., 2022), Japan (Hiraide et al., 2017), Switzerland (Hepp & Milos, 2002), Turkey (Turan et al., 2015), and the UK (Jones et al., 2018; Winston et al., 2004). One was a randomized trial (Brown & Keel, 2015), three were case-control studies (Donahue et al., 2020; Murray et al., 2021; Riddle et al., 2022), two were cross-sectional studies (Jones et al., 2018; Nowaskie et al., 2021), three were observational studies (Duffy et al., 2016; Hartman-Munick et al., 2021; Joy et al., 2022), and five were case reports (Ewan et al., 2014; Hepp & Milos, 2002; Hiraide et al., 2017; Winston et al., 2004). The sample size ranged from 1 to 2,502. The LGBTQIA+ population included transgender AMAB and AFAB individuals, gay men, nonbinary individuals, and gender-diverse persons.

Table 2. Main characteristics of the included articles.

Reference	Country	Study design	LGBTQIA+ population	Sample size	Age (years)	Treatment	Main findings
Theme 1: Conventional treatments applied to the LGBTQIA+ population
Treatment outcomes
Donahue et al., 2020	USA	Case-control study	SM	389 (of whom 79 were SM)	Mean age = 21	Conventional treatment (DH)	SM patients experienced improvement at a faster rate compared to heterosexual patients
Murray et al., 2021	USA	Case-control study	SM women	2502 (of whom 134 were lesbian and 270 were bisexual)	Mean age = 27	Conventional treatment	Despite differences at admission on preoccupation, restriction, fasting, vomiting, shape, and weight concerns, women across groups experienced similar treatment outcomes
Riddle et al., 2022	USA	Case-control study	TG or NB	401 (of whom 25 were TG/NB)	Mean age = 26	Conventional treatment (HLOC)	TG or NB individuals experienced improvement in ED symptoms but less so in depression and suicidality
Self-reported treatment appraisal
Duffy et al., 2016	USA	Observational study	TG	84	Mean age = 22	Conventional treatment	Participants reported deficits in clinicians’ gender competence, resulting in the belief that ED treatment was ineffective and sometimes harmful
Hartman-Munick et al., 2021	USA	Observational study	TG, NB, or another gender different from the assigned at birth	66	Age range = 18–30	Conventional treatment	Respondents discussed the presence of barriers to ED screening/treatment, the complexity of the relationship between ED and gender dysphoria, and the need to educate providers in gender-responsive care practices for ED screening and treatment
Joy et al., 2022	Canada	Observational study	Gender diverse	10	Age range = 21–38	Conventional treatment	Several barriers hinder access to ED treatment, most notably, cisnormative biases and inability to validate the gender-diverse individual’s experience of eating symptoms
Theme 2: Specific treatments for the LGBTQIA+ population
Interventions addressed to the LGBTQIA+ population
Brown & Keel, 2015	USA	Randomized trial	Gay males	87	Age range = 18–30	Cognitive dissonance–based intervention	Decreasing in BID, drive for muscularity, self-objectification, partner-objectification, body-ideal internalization, dietary restraint, and bulimic symptoms
Medical gender transition and its secondary effect on ED symptoms
Hepp & Milos, 2002	Switzerland	Case reports	TG AMAB and AFAB	3	22, 35, and 43	Gender transition (hormonal treatment, SRS)	The preoccupation with body weight and shape did not decrease
Winston et al., 2004	UK	Case reports	AMAB	2	46 and 41	Conventional treatment and gender transition (HLOC, IP, GAS)	The impact of IP can be different in different participants; GAS reduces BID
Ewan et al., 2014	USA	Case report	TG AMAB	1	19	Gender transition (E and/or GnRH agonist)	Addressing GAH along with ED treatment can facilitate medical stabilization and weight restoration
Turan et al., 2015	Turkey	Case report	TG AFAB	1	41	Gender transition (T, SRS)	GAH and GAS result in substantial improvement in the ED
Hiraide et al., 2017	Japan	Case reports	TG AMAB and AFAB	2	35	Gender transition (GAS, E, T)	GAS can reduce BID and improve ED symptoms
Jones et al., 2018	UK	Cross-sectional study	TG AMAB and AFAB	563	Mean age = 29	Gender transition (CHT)	GAH can alleviate ED symptoms by impacting BID, perfectionism, and anxiety and self-esteem
Nowaskie et al., 2021	USA	Cross-sectional study	TG AMAB and AFAB	166	Mean age = 31	Gender transition (GAH, GAS)	GAH and GAS alleviate ED symptomatology; the beneficial effect of GAS is clearer than GAH

AMAB, assigned male at birth; AFAB, assigned female at birth; BID, body image dissatisfaction; CHT, cross-sex hormone therapy; DH, day hospital; E, estrogen; ED, eating disorder; GAH, gender-affirming hormones; GAS, gender-affirming surgeries; GnRH agonist, gonadotropin-releasing hormone agonist; HLOC, higher levels of care; IP, individual psychotherapy; LGBTQIA+, lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual/aromantic/agender; NB, nonbinary; SM, sexual minorities; SRS, sex reassignment surgery; T, testosterone; TG, transgender.

We identified two macro-themes: conventional treatments applied to the LGBTQIA+ population (theme 1) and specific treatments for the LGBTQIA+ population (theme 2). Theme 1 identified sub-themes were Treatment outcomes (Donahue et al., 2020; Murray et al., 2021; Riddle et al., 2022) and Self-reported treatment appraisal (Duffy et al., 2016; Hartman-Munick et al., 2021; Joy et al., 2022). Theme 2 identified sub-themes were Interventions addressed to the LGBTQIA+ population (Brown & Keel, 2015) and Medical gender transition and its secondary effect on ED symptoms (Ewan et al., 2014; Hepp & Milos, 2002; Hiraide et al., 2017; Jones et al., 2018; Nowaskie et al., 2021; Turan et al., 2015; Winston et al., 2004). This organization is illustrated in Figure 2. The two main macro-themes and their respective sub-themes are described in the following sections.

Figure 2. Macro-themes and respective sub-themes.

Theme 1: Conventional treatments applied in the LGBTQIA+ population

Treatment outcomes

A U.S. case-control study published in 2020 compared the psychopathological outcomes of 310 heterosexual patients and 79 patients identified as sexual minorities (Donahue et al., 2020). They were all referred to an ED day hospital service where healthcare personnel were trained to interact appropriately with persons with varying gender and sexual identities (Donahue et al., 2020). Although these patients initially had more pronounced ED symptomatology, they improved faster (Donahue et al., 2020). However, these disparities were minimized throughout treatment and follow-up at a higher level of care for EDs (Donahue et al., 2020). Similarly, a U.S. cross-sectional study from 2021 examined a large sample of more than 2,500 women, of whom about a quarter identified themselves as sexual minorities (Murray et al., 2021). Despite some significant differences in the initial ED symptomatology, all groups achieved similar overall treatment outcomes (Murray et al., 2021). One exception is bisexual and lesbian/gay women’s reports of self-induced vomiting, suggesting that this may be a significant treatment target (Murray et al., 2021). Another U.S. case-control study from 2022 compared the outcomes of 376 cisgender heterosexual participants and 25 transgender or nonbinary participants receiving treatment for EDs at higher levels of care (Riddle et al., 2022). The study showed that transgender or nonbinary individuals had similar improvements in ED symptoms compared to cisgender individuals, but they had more resistant depression and higher suicidality (Riddle et al., 2022).

Self-reported treatment appraisal

A U.S. observational study published in 2016 examined the treatment experiences of transgender individuals with EDs by administering an online questionnaire to 84 individuals from this population (Duffy et al., 2016). The respondents reported a cultural gap regarding the issue of gender identity, resulting in resistance to validating and accommodating clients’ gender identity (Duffy et al., 2016). As a direct result, participants described their ED treatment assistance as ineffective and sometimes harmful (Duffy et al., 2016). Similarly, a U.S. observational study in 2021 administered an online questionnaire regarding ED screening and treatment appraisal in transgender and gender-diverse young adults (Hartman-Munick et al., 2021). In this case, respondents recalled the presence of barriers to receiving screening, accessing care pathways, and protecting gender-affirming therapies (Hartman-Munick et al., 2021). Also, the study emphasized the need for more training by health professionals by reporting a severe shortage of physicians who understood and supported both ED care and gender-affirming care (Hartman-Munick et al., 2021). Moreover, a Canadian observational study published in 2022 investigated ED treatment experiences in a gender-diverse population and, even in this context, participants noted several barriers to seeking ED treatment (Joy et al., 2022). In particular, they reported the presence of systemic stigma, cisnormative biases, and failure to validate their experience of eating symptoms and thus declared the adopted therapeutic strategies damaging (Joy et al., 2022).

Theme 2: Specific treatments for the LGBTQIA+ population

Interventions addressed to the LGBTQIA+ population

In 2015, a U.S.-based study introduced a cognitive dissonance–based intervention specifically designed for gay males, aiming to challenge prevailing sociocultural ideals around body image (Brown & Keel, 2015). This intervention implemented in a randomized trial with 87 participants and resulted in significant reductions in ED risk factors and bulimic symptoms (Brown & Keel, 2015). It addressed issues such as body dissatisfaction, the pursuit of muscularity, self-objectification, partner-objectification, internalization of body ideals, and dietary restraint, underscoring the potential benefits of tailored interventions in addressing the unique challenges within LGBTQIA+ populations facing EDs (Brown & Keel, 2015).

Medical gender transition and its secondary effect on ED symptoms

The first study in chronological order, conducted in Switzerland in 2002, focused on clinical cases involving three transgender individuals with EDs and discussed the relationship among eating behavior, body image dissatisfaction, and gender identity (Hepp & Milos, 2002). After the reported interventions (i.e., hormonal treatment and sex reassignment surgery when possible), the preoccupation with body shape and weight did not decrease, and the patients still reported disturbed eating behavior and body image dissatisfaction (Hepp & Milos, 2002). Two years later, a UK case report published in 2004 presented the clinical cases of two patients AMAB with gender identity disorder (Winston et al., 2004). One patient had a complicated clinical course and required inpatient treatment; the other had a good response to outpatient psychotherapy and could experience gender-affirming surgeries, which led to an increase in body shape satisfaction (Winston et al., 2004).

A decade later, a U.S. article from 2014 described the clinical case of a transgender AMAB individual in which medical gender-affirming treatment with gonadotropin-releasing hormone agonist therapy with spironolactone was initiated with the rationale to suppress unwanted natal sex phenotypic changes in the inpatient ED treatment setting (Ewan et al., 2014). In this case, this kind of intervention effectively facilitated medical stabilization and weight restoration consistent with the patient’s identified gender (Ewan et al., 2014). A Turkish case report published in 2015 delved into the case of a transgender AMAB patient with AN (Turan et al., 2015). After finding a strong association between gender dysphoria and eating symptoms, hormonal and surgical treatments were shown to lead to substantial improvement in EDs (Turan et al., 2015). Similarly, a Japanese study from 2017 dealt with the clinical case of two transgender patients with ED and gender dysphoria (Hiraide et al., 2017). It investigated the clinical course after gender transition, particularly gender-affirming surgeries, reported to reduce body image dissatisfaction and improve ED symptoms (Hiraide et al., 2017).

Results in alignment with case reports were identified in two extensive cross-sectional studies, encompassing a combined participant pool of more than 700 individuals (Jones et al., 2018; Nowaskie et al., 2021). A UK study published in 2018, including a sample of 563 transgender AMAB and AFAB individuals, demonstrated the role of gender-affirming hormones in increasing self-esteem and alleviating body image dissatisfaction, perfectionism, and anxiety symptoms, thereby leading to an improvement in ED symptoms (Jones et al., 2018). Likewise, a more recent U.S. study in 2021 aimed to investigate the relationship among gender identity; gender-affirming interventions, such as hormones and surgeries; and ED symptomatology in a sample of 166 transgender AMAB and AFAB patients (Nowaskie et al., 2021). Both gender-affirming hormones and gender-affirming surgeries proved to be effective interventions to support gender affirmation and thereby alleviate ED symptomatology, with a clearer effect from the gender-affirming surgical intervention (Nowaskie et al., 2021).

Discussion

The findings of this study shed light on the complex landscape of treatments for individuals within the LGBTQIA+ community facing ED and related psychopathologies. The study, which distilled its insights from a comprehensive review of 363 publications, offers valuable perspectives on two overarching macro-themes. The first of these themes delves into the application of conventional treatments to LGBTQIA+ populations, revealing a paradoxical situation where these treatments appear effective in addressing symptoms, yet they are uniformly evaluated negatively by the individuals undergoing them. This incongruity raises critical questions about the experiences and needs of LGBTQIA+ individuals in the context of ED treatment, especially considering the pervasive discrimination they face due to their gender identity or sexual orientation. The second macro-theme explores specific treatments tailored for the LGBTQIA+ community, which, though currently limited in scope, show promise in delivering positive results. Moreover, the study underscores the significant impact of gender transition on reducing ED psychopathology, further emphasizing the importance of addressing the unique challenges faced by LGBTQIA+ individuals in the context of their ED treatment. In this discussion, we delve deeper into these macro-themes, emphasizing the implications of these findings and their significance for future research and clinical practice.

Regarding the outcomes of conventional treatments, a detailed analysis of three large population-based case-control studies, including a collective sample of almost 3,300 patients, indicated that there was a similarity in the effectiveness of conventional ED treatments between cisgender-heterosexual and LGBTQIA+ populations (Donahue et al., 2020; Murray et al., 2021; Riddle et al., 2022). However, the results took a different turn when examining outcomes concerning depression and suicidality, as these issues were found to be more severe and resistant in the LGBTQIA+ community (Riddle et al., 2022). A noteworthy aspect that emerged from the study by Donahue et al. was the observation that LGBTQIA+ patients experiences more rapid improvement compared to their heterosexual counterparts (Donahue et al., 2020). According to Mensinger et al., this improved outcome might be attributed to the specific training that the healthcare personnel had received (Mensinger et al., 2020). Indeed, training healthcare professionals to affirm different gender and sexual identities could enhance the quality of the patient–provider relationship (Keo-Meier & Ehrensaft, 2018). Over the past decade, several theoretical models have been developed to guide clinicians in interacting with the gender-diverse community (Hendricks & Testa, 2012; Keo-Meier & Ehrensaft, 2018). These models promote a culturally sensitive approach to fostering a therapeutic relationship that encourages the expression of one’s identity and takes into account internal and external stressors, such as self-acceptance issues or societal discrimination (Hendricks & Testa, 2012; Keo-Meier & Ehrensaft, 2018).

In terms of the self-reported evaluation of conventional treatments, all three studies consistently yielded negative feedback from transgender individuals who had received treatment for ED (Duffy et al., 2016; Hartman-Munick et al., 2021; Joy et al., 2022). These patients expressed a significant cultural resistance on the part of the healthcare professionals, who appeared to be burdened with cisnormative biases. These biases, in turn, resulted in difficulties in accommodating the participants’ gender identity and validating their experience of ED symptomatology, which was still often perceived as a “young girl” condition (Duffy et al., 2016; Hartman-Munick et al., 2021; Joy et al., 2022). An illustrative example of this cultural resistance was observed when the healthcare staff displayed discomfort in assigning bed allocations or using proper pronouns (Hartman-Munick et al., 2021; Joy et al., 2022). Respondents further described several barriers to accessing screening, treatment, and safeguarding gender-affirming therapies (Hartman-Munick et al., 2021; Joy et al., 2022). In fact, two of the studies went so far as to characterize the therapeutic strategies adopted as damaging (Duffy et al., 2016; Joy et al., 2022). These findings echo earlier reports by transgender individuals who shared similar challenges and negative experiences when seeking and approaching mental health services for the first time (Benson, 2013; Institute of Medicine (U.S.), 2011).

When it comes to LGBTQIA+-specific treatments, we encountered a notable dearth of literature concerning treatments designed specifically for this population. In fact, we located only one article proposing a treatment tailored to this group. This singular contribution, authored by Brown and Keel in 2015, introduced a cognitive dissonance–based intervention focused on deconstructing the notion of the “ideal” body, with a unique emphasis on the population of gay males (Brown & Keel, 2015). Remarkably, this intervention demonstrated its effectiveness in challenging and reversing the internalized sociocultural ideal body model. As a result, it led to a reduction in bulimic symptoms and mitigated various eating-related risk factors, including body dissatisfaction, the pursuit of muscularity, self-objectification, partner-objectification, internalization of the body ideal, and dietary restraint (Brown & Keel, 2015).

In the realm of gender transition, a discernible trend emerges as studies consistently reveal a noteworthy aspect: Gender transition therapies yield positive outcomes, including a notable improvement in eating symptoms, across the majority of investigations (Ewan et al., 2014; Hepp & Milos, 2002; Hiraide et al., 2017; Jones et al., 2018; Nowaskie et al., 2021; Turan et al., 2015; Winston et al., 2004). These therapeutic approaches encompass a spectrum, ranging from hormones, including puberty blockers (i.e., gonadotropin-releasing hormone agonist) and gender-affirming hormones (i.e., estrogen and testosterone) to surgical procedures, including both genital (i.e., penectomy and vaginoplasty or penis and scrotum reconstruction) and nongenital surgeries (i.e., mastoplasty or mastectomy, plastic surgery, voice surgery) (Ewan et al., 2014; Hepp & Milos, 2002; Hiraide et al., 2017; Jones et al., 2018; Nowaskie et al., 2021; Turan et al., 2015; Winston et al., 2004).

The impact of both hormone treatments (Ewan et al., 2014; Hiraide et al., 2017; Jones et al., 2018; Nowaskie et al., 2021; Turan et al., 2015) and surgical interventions (Hiraide et al., 2017; Nowaskie et al., 2021; Turan et al., 2015) on reducing ED symptoms (Hiraide et al., 2017; Turan et al., 2015), mitigating body image dissatisfaction (Hiraide et al., 2017; Jones et al., 2018), increasing self-esteem (Hiraide et al., 2017; Turan et al., 2015), facilitating medical stabilization, and promoting weight restoration (Ewan et al., 2014) is evident in the findings. Furthermore, some interventions were found to alleviate anxiety symptoms (Jones et al., 2018). However, it is important to note that one case report involving three patients demonstrated no improvement in eating symptoms, a result that may be attributed to the age of the intervention, which occurred more than 2 decades ago, and the advanced age of the individuals involved (Hepp & Milos, 2002). Indeed, it is widely recognized that delayed interventions generally yield fewer mental health benefits than early transition (Cohen-Kettenis et al., 2011; Wong et al., 2019). On the other hand, two large cross-sectional studies, including more than 700 patients in total, underscored the overall positive impact of gender transition on eating symptoms (Jones et al., 2018; Nowaskie et al., 2021). Consequently, it was suggested that medical transition appears to be more effective than ED-specific interventions (Ewan et al., 2014).

The complexity of the psychological dynamics experienced by individuals with gender dysphoria is further elucidated in the literature, as they grapple with a dual conflict related to basic gender identity and gender role identity (Hiraide et al., 2017; Wester et al., 2010). Prolonged gender role conflict, coupled with difficulties in disclosing gender dysphoria or facing social stigma, may result in persistent eating symptoms despite undergoing gender transition (Hiraide et al., 2017). The role of social acceptance is critical in this context. Recent cross-national research has demonstrated that the association between sexual minority status and psychiatric morbidity can be mediated by perceived family approval (Gmelin et al., 2022). Similarly, eating psychopathology can benefit from family and social acceptance (Gmelin et al., 2022; Roberts et al., 2022). Along the same line, research on LGBTQIA+ adolescents shows that treatments involving family support prove more effective than individual treatment models in addressing eating symptoms (McClain & Peebles, 2016). Moreover, supporting social transition in gender-diverse children and adolescents has been shown to lead to improved psychological functioning (Connolly et al., 2016). It is imperative that further research be conducted among the adult population to develop treatment paradigms that encompass both family and social dimensions.

The extensive findings of our study underscore the pressing need for clinical recommendations aimed at improving the quality of care for individuals within the LGBTQIA+ community facing EDs and related psychopathologies. An essential aspect involves offering culturally competent training to healthcare professionals that emphasizes the understanding and affirmation of diverse gender and sexual identities. Such training can enhance the patient-provider relationship, making it more inclusive and accepting. Early intervention in gender transition therapies is also paramount, as it can lead to more favorable outcomes, including a reduction in ED symptoms. Tailored treatment approaches specific to the LGBTQIA+ community are essential, given the limited existing literature on this topic. Clinicians should remain open to adapting existing therapeutic models to better suit the unique needs and experiences of LGBTQIA+ individuals with EDs. Moreover, family and social support should be actively encouraged, as these factors have a profound positive impact on both gender transition and ED outcomes. Addressing cultural resistance, cisnormative biases, and stigma within healthcare settings is crucial. Healthcare professionals should actively combat these issues, including the use of proper pronouns, addressing identity expression, and facilitating access to gender-affirming therapies. Finally, continued research is essential to expand our understanding of LGBTQIA+ healthcare and ED treatment, with a focus on developing treatment paradigms that encompass both family and social dimensions. In implementing these recommendations, healthcare providers can work toward creating a more inclusive, culturally sensitive, and supportive healthcare environment for LGBTQIA+ individuals with EDs.

Our comprehensive review, while offering valuable insights, is not without its limitations. Firstly, the absence of comparable outcomes in the literature prevented us from providing quantitative-based clinical indications, which would have enabled a systematic literature review and meta-analysis. This limitation underscores the need for more standardized research in the field to facilitate evidence-based clinical recommendations. A notable omission in our review is the inclusion of muscle dysmorphia, a condition of increasing interest, particularly within the gay community. The DSM-5 currently categorizes muscle dysmorphia within the obsessive-compulsive and related disorder spectrum, rather than within the spectrum of EDs. This exclusion may have resulted in the oversight of a portion of treatments relevant to the LGBTQIA+ community. Future research should consider the interplay between muscle dysmorphia and EDs, especially concerning LGBTQIA+ individuals. Additionally, our review lacked detailed information on the ethnoracial and socioeconomic backgrounds of the research participants. The absence of this crucial demographic data hinders a complete understanding of how these factors may impact the development and outcomes of EDs. Future studies and case reports should aim to incorporate these variables to provide a more holistic view of the subject. Finally, we limited our search to peer-reviewed publications to ensure the quality and reliability of the studies included, given the sensitive nature of our research. However, it is important to acknowledge that this strict criterion may have excluded valuable insights from non–peer-reviewed sources. Our choice to focus on peer-reviewed publications represents a tradeoff between rigor and comprehensiveness, recognizing that relevant information may exist beyond this scope.

In conclusion, it seems evident that the long-standing stereotype associating EDs with affluent heterosexual White women has historically shaped the nature of interventions in this field (Grabe et al., 2008; Hoek & van Hoeken, 2003; Mitchison et al., 2014). This review attempted to identify contemporary approaches to ED care within the LGBTQIA+ population, serving as a synthesis of the currently available literature for clinicians. Our results highlight the paradox within conventional therapies, which, while yielding symptomatic improvement, operate within a cultural backdrop of perceived discrimination (Donahue et al., 2020; Duffy et al., 2016; Hartman-Munick et al., 2021; Joy et al., 2022; Murray et al., 2021; Riddle et al., 2022). To address this challenge, it is imperative that mental health professionals receive extensive training to better understand the unique needs of the LGBTQIA+ community and to validate their experiences.

Notably, our results underscore the effectiveness of treatments that prioritize alleviating discomfort related to one’s gender identity. Gender transition therapies, including hormone interventions and surgery, have demonstrated a consistent reduction in ED symptoms (Ewan et al., 2014; Hepp & Milos, 2002; Hiraide et al., 2017; Jones et al., 2018; Nowaskie et al., 2021; Turan et al., 2015; Winston et al., 2004). However, it is crucial to acknowledge that the body of literature on population-specific approaches, although showing promise, remains limited. Expanding and deepening these tailored interventions to better meet the needs of the LGBTQIA+ community should be a priority in future research (Brown & Keel, 2015).

Looking ahead, there is a clear path for the development of a more holistic approach to ED treatment within the LGBTQIA+ population. This should integrate conventional ED treatments with specific interventions that take into account the unique body experiences of LGBTQIA+ individuals, including mental health, medical necessity, and psychosocial perspectives. By doing so, we can work toward a more inclusive and effective framework for addressing EDs in the LGBTQIA+ community, ensuring that their specific needs are both acknowledged and met.

Ethics statement

Considering the nature of this review, which synthesizes data from previously published studies, ethical approval was not deemed necessary.

Author contributions

Conceptualization, S.T.V. and A.R.A.; methodology, S.T.V. and A.R.A.; data curation, S.T.V., A.R.A., and F.M.; writing–original draft preparation, S.T.V., F.M., and A.M.; writing–review and editing, A.R.A.; supervision, D.D.R. All authors have read and agreed to the published version of the manuscript.

Disclosure statement

The authors declare no conflict of interest.

Data availability statement

Not applicable.

Additional information

Funding

The research received no external funding.