Understanding Pre-obesity and Overweight in the LGBTQ+ Community

LGBTQ, which stands for lesbian, gay, bisexual, transgender, and questioning, as the acronym suggests, is a large minority group in the United States that also includes groups such as transexual, queer, intersex, asexual, and pansexual. As one would expect with any minority group, those who self-identify within the LGBTQ spectrum encounter societal oppression daily. Less discussed, however, is how oppression, in its various forms, impacts social determinants of health. Dr. Niranjan defines social determinants of health as “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risk.” Substance use, financial resource strain, transportation issues, chronic stress, intimate partner violence, housing instability, food insecurity, lack of social connection, and impaired mental health are all broad categories that negatively impact the LGBTQ community in study after study. We have known for quite some time that these social determinants are also linked with excess weight and the LGBTQ community is no exception.

One study has shown that women who identify as lesbian and bisexual in the United Kingdom are 14 percent more likely to have pre-obesity or obesity than their heterosexual counterparts, while other studies have shown women of sexual minorities have up to 2x the increased risk of having pre-obesity or obesity than their cisgender heterosexual counterparts. ^{1,3, 19} Bisexual women alone have been shown to have higher risk of eating disorders than heterosexual women.¹⁶ Although college students as a whole are not known for having the healthiest diets, it appears the separation of eating patterns between healthy and less healthy dietary habits among lesbian and bisexual-identifying women compared to heterosexual-identifying women clearly begins to diverge starting at college age. ^{22, 20} These patterns of divergence are likely driven by psychological factors such as depression and minority stress that can interfere with healthy eating and exercise. ¹⁵ One form of stressor can come in the form of discrimination, both overt and concealed, and has been shown in studies to also affect weight in lesbian-identifying women. ¹¹ One form of coping mechanism to manage the psychosocial pressure of discrimination and stigma by engaging in patterns of disordered eating, such as binge-eating disorder. Sadly, internalized homophobia is a risk factor for binge-eating as well and may be compounded with high-risk sexual activity and substance abuse. ^{10, 5, 11}

Disordered eating is not unique to women who identify as lesbian and bisexual, but is also found in bisexual and gay-identifying men, with those being between the ages of 18-29 being the most at risk. ⁷ Gay men are likely to use derogatory verbiage like “gayfer” for “gay-heffer” or “gay fat” for an individual that is within normal weight parameters but without chiseled abs or a muscular build. In one study, “gay and bisexual boys reported being significantly more likely to have fasted, vomited, or taken laxatives or diet pills to control their weight in the last 30 days. Gay Males were 7 times more likely to report binging and 12 times more likely to report purging than heterosexual males.” Gay men are more likely to have body image disturbances and 42% of men with eating disorders identify as gay. ¹³ While ethnic minorities often have higher rates of adverse health outcomes compared to the white majority, when it comes to disordered eating, Black and Latino LGB individuals have at least as high a prevalence rate as those that are White LGB. As mentioned above, stigma, discrimination, and internal homophobia can increase risk of disordered eating, but studies have also shown that individuals who have a sense of “connectedness to the gay community” have a protective effect against the development of eating disorders. ¹³

Individuals who identify as transgender also experience higher rates of disordered eating, but gender-affirming therapies are associated with lower rates of these disorders. ^{13, 9} Aside from disordered eating, there is also increased prevalence of obesity. One study showed that 46% of trans masculine patients, that is patients who were assigned female at birth but present with a male or masculine phenotype, reported having obesity. ² The divergence in outcomes likely begins early for transgender students with transgender students demonstrating an increased likelihood of developing underweight or obesity and to be less likely to match physical activity and screen time standards than age-matched cis-gendered peers. ²¹ Some of the challenges with body size and gender identity are unique to the transgender community. For example, sexual minority young men (assigned female at birth) may focus eating patterns traditionally associated with men, such as eating more protein to “bulk up”. Male transgender patients (assigned female at birth) are also less likely to be screened for eating disorders, despite the fact they are at increased risk of body dysmorphia, binge eating, purging, and restriction. Female transgender patients (assigned male at birth) may fall to the same societal norms that all women are held to and engage in restrictive eating patterns to have an idealized thin physique. ^{12, 8}

It is important to recognize the effects of shame, stigma, and internalized homophobia on the LGBT community, and how these affects can adversely affect health outcomes in the form of disordered eating and/or unhealthy BMI. By recognizing that these community-specific risks exist, health care professionals can adequately screen and counsel patients. Several therapeutic modalities have been shown to improve psychological stress that can contribute to weight including enhanced cognitive behavioral therapy (CBT-E), family based therapy (FBT), interpersonal psychotherapy (IPT), and dialectical behavior therapy (DBT). ^{6, 4, 14, 17} In addition, there are programs, such as the one provided by the National LGBT Health Education Center, that help health care professions to apply 4 main principles: normalize, facilitate acceptance, emotional regulation, and support relationships. More information can be found on their website LGBTQIAHealthEducation.org.¹⁴