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Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Patterns of Disordered Eating Behavior in Women by Sexual Orientation: A Review of the Literature a
Sarah M. Bankoff & David W. Pantalone
b
a
Psychology Service, VA Boston Healthcare System, Boston, Massachusetts, USA b
Department of Psychology, University of Massachusetts Boston; and The Fenway Institute, Fenway Health, Boston, Massachusetts, USA Published online: 11 Mar 2014.
To cite this article: Sarah M. Bankoff & David W. Pantalone (2014) Patterns of Disordered Eating Behavior in Women by Sexual Orientation: A Review of the Literature, Eating Disorders: The Journal of Treatment & Prevention, 22:3, 261-274, DOI: 10.1080/10640266.2014.890458 To link to this article: http://dx.doi.org/10.1080/10640266.2014.890458
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Eating Disorders, 22:261–274, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2014.890458
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Patterns of Disordered Eating Behavior in Women by Sexual Orientation: A Review of the Literature SARAH M. BANKOFF Psychology Service, VA Boston Healthcare System, Boston, Massachusetts, USA
DAVID W. PANTALONE Department of Psychology, University of Massachusetts Boston; and The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
Most disordered eating research has focused on White, heterosexual women. More empirical work is needed to better understand disordered eating among women of diverse backgrounds. Given evidence of disparities between heterosexual and sexual minority (i.e., non-heterosexual) women in other health behaviors (e.g., tobacco use) and outcomes (e.g., cardiovascular disease), it appears important to study disordered eating behaviors among sexual minority women. In this article, we review the extant literature on disordered eating behaviors in women across sexual orientations, with a focus on research examining potential mechanisms of disparities in disordered eating, including awareness and internalization of sociocultural norms.
The extant literature on disordered eating has focused primarily on examining the phenomenon in White adolescent girls and young women (Brown, Cachelin, & Dohm, 2009). Unfortunately, the sheer quantity of research utilizing clinical samples of White girls and women, with either unreported or primarily heterosexual sexual orientations, has perpetuated myths that disordered eating is less prevalent among ethnic minority (Brown et al., 2009) and sexual minority (Heffernan, 1996) girls and women. Given the disproportionate prevalence of eating disorders among women (vs. men) in
Address correspondence to Sarah M. Bankoff, Psychology Service (116B), VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA 02130, USA. E-mail: [email protected] 261
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general, the literature must move in the direction of better coverage of disordered eating among women of diverse backgrounds—with the ultimate goal of improving and individualizing prevention and treatment efforts through establishing a better understanding of these behaviors in all subgroups. The relatively limited number of published studies that have explored disordered eating specifically in women of minority sexual orientations (i.e., those identifying as non-heterosexual) have yielded mixed and inconclusive results. As such, our understanding of disordered eating among sexual minority women (SMW) remains underdeveloped (MacDonald, 2011; Wilson, Becker & Heffernan, 2003). In this article, we aimed to review the literature on the associations between sexual orientation and disordered eating in women, taking a central or pivotal coverage approach (Cooper, 2003), and have included relevant content featuring examination of these associations with a focus on the potential mechanisms. We searched the electronic databases PsycInfo, PubMed/MEDLINE, and ScienceDirect through November 2013 using various combinations of search terms. We also completed searches for “similar items” once articles were deemed relevant, and reviewed the reference sections of identified articles for other similar work not previously identified. We have focused our review on potential mechanisms of these associations, in an effort to evaluate the critical next steps in the research literature for understanding, and eventually ameliorating, sexual orientation related disparities in disordered eating among women. We begin with an introduction to considerations in studying sexual orientation more generally, and then examine the literature examining prevalence, types, and mechanisms of disordered eating among women of diverse sexual orientations.
METHODOLOGICAL CONSIDERATIONS IN STUDYING SEXUAL ORIENTATION GENERALLY Sexual orientation has historically been inconsistently and insufficiently defined in the literature (e.g., Sell, 1997). In a recent Institute of Medicine (IOM) report, sexual orientation is described as an “inherently relational construct” with the following working definition: “an enduring pattern of or disposition to experience sexual or romantic desires for, and relationships with, people of one’s same sex, the other sex, or both sexes” (IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011, p. 27). Sexual orientation is a complex construct that incorporates psychological (i.e., sexual attractions and desires) and behavioral (i.e., sexual behaviors and experiences) components, among others (Sell, 1997). Given that there are various components involved in one’s sexual identification (i.e., how one understands one’s sexual orientation) each of these components may not be congruent for all individuals.
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Further, how one understands one’s sexual orientation (i.e., sexual identification), and how one communicates that orientation to others, can vary. Thus, self-reported sexual identification may be less accurate than items addressing attractions or behaviors. Researchers would do well to consider sexual identification, as well as sexual attractions and behaviors, to the extent that each is relevant for a given research question, allowing for comparison with studies operationalizing sexual orientation as sexual attraction (e.g., Austin et al., 2009; French, Story, Remafedi, & Resnick, 1996; Wichstrøm, 2006) and as sexual behaviors (e.g., Boehmer & Bowen, 2009; Bowen, Balsam, & Ender, 2008; Wichstrøm, 2006), in addition to the majority of studies that report self-identified sexual orientation.
DISORDERED EATING AMONG SEXUAL MINORITY WOMEN In the literature to date that examines disordered eating, sexual minority men (SMM) have received considerably more attention than SMW (Moore & Keel, 2003). Findings regarding disordered eating among SMM have also been clearer and more consistent, with general consensus across studies that SMM are at increased risk of disordered eating when compared to heterosexually identified men (e.g., Feldman & Meyer, 2007). In contrast, findings regarding disordered eating among SMW have been mixed and remain inconclusive (e.g., MacDonald, 2011). Early research reviewed in the field suggested that a lesbian sexual orientation may serve as a protective factor against disordered eating—an assumption which was based on empirical findings that lesbian women demonstrate lower levels of investment in societal norms of attractiveness (Heffernan, 1994). This conceptualization has since been identified as a misconception lacking empirical support, as prevalence rates of eating disorders and disordered eating behaviors among SMW are not available in the literature (e.g., MacDonald, 2011; Wilson et al., 2003). However, findings from multiple studies do corroborate the notion that lesbian women are less likely than heterosexual women to report both body dissatisfaction and negative attitudes about eating and weight (e.g., Brand, Rothblum, & Solomon, 1992; French et al., 1996; Owens, Hughes, & Owens-Nicholson, 2003; Polimeni, Austin, & Kavanagh, 2009). Some researchers have speculated that these disparities may exist because heterosexual women aim to attract men, who tend to place greater emphasis on physical appearance of their romantic partners (e.g., Brand et al., 1992), or because lesbian women tend to place less emphasis on physical appearance compared to heterosexual women (e.g., Polimeni et al., 2009). Other studies, however, have found no or few differences in body dissatisfaction among heterosexual, bisexual, and lesbian women (Davids & Green, 2011; Morrison, Morrison & Sager, 2004). For example, in a metaanalysis of 27 studies (N = 5,220), heterosexual and lesbian women did not
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differ on body dissatisfaction, except in a small subset of studies in which lesbian women reported greater body satisfaction compared to heterosexual women of equivalent body weights (Morrison et al., 2004). Given this evidence that suggests lesbian (vs. heterosexual) women report less body dissatisfaction, a variable that has been linked empirically to disordered eating (Moore & Keel, 2003; Share & Mintz, 2002), some researchers have suggested that lesbian women may also be at decreased risk of restricting and purging behaviors. Some studies have found more similarities than differences in disordered eating among women across sexual orientations (e.g., Feldman & Meyer, 2007; Maloch, Bieschke, McAleavey, & Locke, 2013; Moore & Keel, 2003; Share & Mintz, 2002). In an ethnically diverse sample, no differences in eating disorder prevalence were revealed among lesbian, bisexual, and heterosexual women (Feldman & Meyer, 2007). Other studies have confirmed the finding that disordered eating (Share & Mintz, 2002), and bulimic symptoms, specifically (Moore & Keel, 2003), do not seem to differ between heterosexual and lesbian women. Additionally, some studies have revealed no differences between heterosexual and lesbian women on several psychosocial variables related to disordered eating risk, including body esteem, body dissatisfaction, weight concern, and awareness of cultural standards (Epel, Spanakos, Kasl-Godley, & Brownell, 1996; Heffernan, 1999; Moore & Keel, 2003; Share & Mintz, 2002). Other findings even suggest that lesbian (vs. heterosexual) women may possess protective factors against disordered eating, such as better body esteem, lower drive for thinness, and decreased internalization of cultural standards (Moore & Keel, 2003; Share & Mintz, 2002). In contrast, other evidence suggests SMW may be at increased risk of certain disordered eating behaviors. For instance, some studies have found increased prevalence of body weight in the overweight or obese range among lesbian women, specifically (Boehmer, Bowen, & Bauer, 2007), and SMW, in general (Boehmer & Bowen, 2009). These results are supported by a literature review that examined obesity and related issues among SMW compared to heterosexual women (Bowen et al., 2008). Of 19 studies reviewed, nine found higher weight (ranging from 1–5 pounds) or obesity rates among lesbian as opposed to heterosexual or control participants, five found no differences, and four did not report between-group comparisons (Bowen et al., 2008). Binge eating has been found to be more prevalent among adolescent girls identifying a minority sexual orientation, compared to heterosexual girls (Austin et al., 2009). Increased risk of a range of disordered eating behaviors has also been demonstrated in women identifying as bisexual and primarily heterosexual, compared to women identifying as exclusively heterosexual (Polimeni et al., 2009). One study of high school students found that same-sex sexual experiences predicted future bulimic symptoms (Wichstrøm, 2006). Another study
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found that bisexual women were more than twice as likely as lesbian women to report a past or present eating disorder diagnosis, while “out” bisexual women were more likely than heterosexual women to report an eating disorder (Koh & Ross, 2006). As such, bisexual women may be at greater risk of disordered eating, potentially accounted for in part by experiences of isolation and stigmatization after coming out. Considering the evidence that sexual minority girls and women may be at higher, or at least equivalent, risk of disordered eating compared to heterosexual women, it is imperative to better understand mechanisms and correlates of maladaptive eating attitudes, behaviors, and diagnoses among SMW.
FACTORS EXPLAINING DIFFERENCES IN DISORDERED EATING BY SEXUAL ORIENTATION Although some researchers have proposed a wide variety of psychosocial (e.g., social support) and individual (e.g., stress) factors that may explain differences in disordered eating by sexual orientation, such factors have been understudied in the empirical literature and remain largely speculative. A few previously studied potential factors with empirical support include sexual attraction, gender-related traits, and feminist beliefs. For instance, results from previous studies suggest that efforts to sexually attract men (Siever, 1994) and intrasexual competition (Li, Smith, Griskevicius, Cason, & Bryan, 2010) may explain greater body dissatisfaction, emphasis on thinness, and poorer eating-related attitudes among heterosexual women and gay men compared to lesbian women and heterosexual men. Additionally, gender-related traits such as masculinity and femininity may be associated with disordered eating, as evidence indicates that femininity predicts eating pathology in men and women irrespective of sexual orientation (Lakkis, Ricciardelli, & Williams, 1999; Meyer, Blissett, & Oldfield, 2001), while masculinity seems to be associated with relatively healthy eating-related attitudes and behaviors (Meyer et al., 2001). Further research in this area suggests that androgyny (i.e., high levels of femininity & masculinity) among women is associated with fewer disordered eating behaviors (Hepp, Spindler, & Milos, 2005). Other evidence suggests that feminist beliefs may protect against disordered eating among lesbian women (Guille & Chrisler, 1999); indeed, according to a recent meta-analysis, feminist beliefs may serve to protect women of all sexual orientations from body image problems (Murnen & Smolak, 2009). Given the range of potential mechanisms in the association between disordered eating and sexual orientation, additional research is needed. Preliminary findings suggest the potential importance of women’s awareness and internalization of sociocultural norms, specifically those regarding weight and sexual orientation, and warrant further research exploring these psychosocial and individual factors.
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Awareness and Internalization of Sociocultural Norms Research demonstrates that awareness and internalization of sociocultural norms regarding appearance, specifically valuing thinness, are associated with disordered eating in women (Kiang & Harter, 2006). Research also suggests that lesbian women may be less likely to internalize these values of appearance, dieting, and thinness (Bowen, Balsam, Diergaarde, Russo, & Escamilla, 2006). The tendency to adhere to sociocultural norms and hold negative attitudes about obesity may explain in part disparities in disordered eating in women by sexual orientation. Further, internalized heterosexism (i.e., negative thoughts and feelings about one’s sexual minority orientation) has been found to be related in gay men to disordered eating, appearance satisfaction, and self-esteem (Reilly & Rudd, 2006; Williamson & Spence, 2001). Thus, we might speculate that internalized negative attitudes regarding one’s sexual orientation may also explain in part disordered eating in SMW. Previous research has examined attitudes regarding weight among study participants of different genders and weights. Findings demonstrate that overweight men and women experience weight-based prejudice, as compared to average-weight men and women (Brochu & Morrison, 2007). In general, men tend to show more negative attitudes than women toward overweight individuals (Brochu & Morrison, 2007), but both men and women express anti-fat attitudes (Grover, Keel, & Mitchell, 2003). However, while men tend to implicitly (i.e., automatically) identify as “light” regardless of their actual weight status, the implicit weight identity of women is associated with their actual weight, explicit (i.e., self-reported) weight appraisal, and implicit self-esteem—a difference that may explain in part increased rates of eating disorders among women compared to men (Grover et al., 2003). Thus, women seem to more accurately perceive their body weight, possibly increasing their risk of disordered eating. Among many individuals who engage in restricting and purging behaviors, obesity is a feared condition (Jáuregui Lobera, Polo, González, & Millán, 2008). Patients diagnosed with the restricting subtype of anorexia show strong automatic and self-reported negative evaluations of body weights in the overweight range (Cserjési et al., 2010). A study of undergraduate women found implicit negative attitudes toward obesity among restrained and unrestrained eaters, but stronger explicit negative attitudes among restrained eaters (Vartanian, Herman, & Polivy, 2005). In another study of young women (sexual orientations unreported), thin-ideal implicit attitudes did not sufficiently predict body dissatisfaction, as being overweight was viewed negatively across all participants (Ahern & Hetherington, 2006). A more recent study of undergraduate women showed that implicit attitudes were able to predict drive for thinness, with this association moderated by attitude importance (Ahern, Bennett, & Hetherington, 2008). Thus, evidence suggests that attitudes regarding overweight individuals may be assessed to help to
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identify disordered eating behaviors, which are often marked by high levels of secrecy. Negative attitudes toward overweight individuals are highly prevalent in the U.S., with individuals of both genders (Grover et al., 2003) demonstrating such attitudes. Evidence suggests that individuals engaging in restricting and purging behaviors may reveal more extreme negative attitudes regarding obesity (Vartanian et al., 2005). No studies identified to date have compared women of different sexual orientations on their attitudes regarding weight. However, evidence suggests that women aiming to sexually attract women (vs. men) may hold less negative views of obesity (e.g., Boehmer & Bowen, 2009)—a finding which appears to be consistent with the assumption that SMW may be at decreased risk of restricting and purging behaviors, compared to heterosexual women. As such, it could be important to determine whether SMW truly hold less negative attitudes regarding obesity compared to heterosexual women and, if so, to explore the role these attitude differences may play in influencing eating behaviors by sexual orientation. Findings also point to the importance of considering the role of attitudes regarding sexual orientation in relation to disordered eating. First, internalized heterosexism has been linked with maladaptive eating attitudes among gay men (Williamson & Spence, 2001). Also among gay men, negative attitudes regarding one’s own minority sexual orientation have been associated with poorer appearance satisfaction and self-esteem, while negative attitudes regarding others’ gay orientations have been associated with bulimic behaviors (Reilly & Rudd, 2006). Further, in a recent meta-analysis, internalized heterosexism was linked to internalizing mental health problems among gay and lesbian individuals in multiple studies reviewed (Newcomb & Mustanski, 2010). In the literature identified to date, attitudes regarding sexual orientation have not been examined as a potential factor influencing the association between sexual orientation and disordered eating among women. Existing findings suggest that women’s attitudes toward lesbian and heterosexual women are equally positive (Steffens, 2005). Although women in general may evaluate lesbian women as positively as heterosexual women, we know little about how SMW evaluate their own sexual orientations and the orientations of other SMW.
CLINICAL IMPLICATIONS Although our empirical understanding of disordered eating among SMW remains equivocal, findings indicate that disordered eating is not experienced identically in women of all sexual orientations and, therefore, reveal an important issue requiring attention in clinical practice. Clinicians can be instrumental in eating disorder prevention, assessment, and treatment efforts for all women, irrespective of sexual orientation. Eating disorder prevention
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efforts may be targeted both for women generally and for SMW specifically. Given evidence of connections between sociocultural norms valuing thinness and disordered eating (e.g., Vartanian et al., 2005), educational programming and campaigns should continue to raise awareness of the dangers of glorifying unhealthy body types in the media. As demonstrated by a review of eating disorder interventions, a media literacy approach appears beneficial in preventing eating disorder symptoms among college students (Yager & O’Dea, 2008). Providers could assist in communicating these important messages in their practices, through providing information and educational materials to patients and their family members. Evidence of associations between internalized heterosexism and disordered eating (e.g., Williamson & Spence, 2001) suggest that, for SMW, prevention efforts may also necessitate ongoing policy work aimed to increase equal rights of sexual minority individuals in today’s society (e.g., Mathy & Lehmann, 2004). Given the unfortunately long-term nature of this goal, in the meantime, individual providers may assist in minimizing health disparities with advocacy efforts on a smaller scale. To begin, providers should strive to create culturally competent practices where SMW feel comfortable seeking healthcare (IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011), especially given evidence that SMW may not be receiving the services they need even in the context of health disparities (IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011). Assessment efforts appear to be critically important, especially in considering the historical assumption that restricting and purging behaviors are less prevalent among SMW compared to heterosexual women (e.g., Heffernan, 1994), thus presenting the potential risk of these behaviors being overlooked in this demographic group (e.g., Wilson et al., 2003). Observations of similar disordered eating behaviors among women of all sexual orientations presented here (e.g., Feldman & Meyer, 2007; Maloch et al., 2013; Moore & Keel, 2003; Share & Mintz, 2002) should serve to caution clinicians against overlooking or underestimating these dangerous, potentially life-threatening, behaviors (e.g., Keel, 2010) in SMW. Given the inherent secrecy and shame surrounding disordered eating behaviors, it may be especially difficult to identify them in clients who present with problems other than eating disorders, and clinicians operating under the unsupported assumption that SMW are less likely to engage in such behaviors may be at a further disadvantage. Thus, clinicians should remain aware that all women—regardless of orientation—appear to be at increased risk of disordered eating behaviors compared to men, and they should routinely conduct a thorough assessment of these behaviors. For a review of relevant assessment measures, see Túry, Güleç, and Kohls (2010); clinicians may consider choosing a complete measure or selection of items to incorporate a self-report of eating disorder symptoms into their typical intake procedures. Clinicians could also
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capitalize on knowledge of the link between attitudes regarding obesity and restricting behaviors by implementing measures of attitudes into their assessment or screening protocols. While individuals engaging in restricting behaviors may not be willing or motivated to disclose disordered eating behaviors to providers, incorporating self-report measures to assess awareness and internalization of norms valuing thinness could allow clinicians to identify patients at potentially increased risk of these dangerous behaviors. In establishing culturally competent practices, providers should include items assessing for sexual orientation with their regular intake materials. Providers could also consider screening for internalized heterosexism (for several brief measures recommended for use in clinical practice, see Szymanski, Kashubeck-West, & Meyer, 2008) with their sexual minority patients to identify individuals at potentially increased risk of disordered eating behaviors, among other mental health concerns (Newcomb & Mustanski, 2010). In terms of eating disorder treatment efforts, providers might consider addressing internalized sociocultural norms when relevant. For example, cognitive-behavioral intervention efforts might address negative attitudes regarding obesity by targeting cognitive distortions. Future quantitative research will be necessary to test the effectiveness of different components (e.g., cognitive restructuring) of these intervention efforts incorporating techniques to minimize disordered eating behaviors by targeting maladaptive attitudes and beliefs about weight among women of all sexual orientations. Consideration should also be given to adapting cognitive-behavioral interventions to populations of SMW (e.g., Pantalone, Iwamasa, & Martell, 2009), who may also possess other marginalized identities. Culturally competent interventions are essential for addressing disordered eating behaviors— which appear to be associated with internalized heterosexism—among SMW, and trained clinicians are needed to carry out these interventions. This may require training technically and culturally competent therapists, who are skilled both at treating disordered eating and in working with non-heterosexual clients.
RECOMMENDATIONS FOR FUTURE RESEARCH Investigators in this area must address some potential limitations in studying disordered eating and differences by sexual orientation. First, researchers face the challenge of conceptualizing the construct of disordered eating (Túry et al., 2010). While some studies have examined eating disorder diagnoses (e.g., Feldman & Meyer, 2007), others consider specific attitudes (e.g., body dissatisfaction, drive for thinness) and behaviors (e.g., restricting, purging, binge eating) associated with disordered eating (e.g., Moore & Keel, 2003; Share & Mintz, 2002). Given this variety of predictor variables, comparisons across studies can be difficult (Túry et al., 2010). Second, in the
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research literature in general, a lack of consistency exists in measuring sexual orientation (e.g., IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011; Sell, 1997). Some significant challenges in conducting health disparity research include the barriers of relatively small populations of sexual minority individuals, and of participants’ willingness to identify a sexual minority orientation, due to issues of stigma and privacy, among other concerns (IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011). Often small sample sizes force exclusion of “questioning” participants, or other participants who do not identify clearly as heterosexual or lesbian, from statistical analyses because they are underpowered to use the group as a reliable comparator on its own. In operationalizing sexual orientation, researchers might consider assessing multiple components of the construct (e.g., attractions, behaviors, identification), and base decisions about which components to utilize in analyses on relevance to the research questions and other constructs being examined. The present state of the literature in this area remains inconclusive, owing in part to challenges investigators face in comparing across studies. Future research could facilitate cross-study comparisons by offering clear and uniform operationalization of variables and examining differences across all sexual orientations.
CONCLUSION Additional research is warranted to better understand disparities—and mechanisms accounting for these disparities—in disordered eating in women of different sexual orientations. Large, longitudinal studies, incorporating comprehensive assessments of sexual orientation and disordered eating, would help us learn whether rates of disordered eating behaviors and eating disorder diagnoses significantly differ among women of different sexual orientations, by allowing for examination of ways in which the developmental processes of understanding one’s sexual identity and coming out may influence disordered eating among SMW. In the meantime, clinicians and other healthcare providers should remain cognizant of the historical assumption that SMW may be at decreased risk of disordered eating compared to heterosexual women is not supported by empirical evidence, and carefully screen for disordered eating in women patients of all sexual orientations.
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women. Journal of Gay and Lesbian Social Services, 23, 452–464. doi:10.1080/ 10538720.2011.611100 Maloch, J. K., Bieschke, K. J., McAleavey, A. A., & Locke, B. D. (2013). Eating concerns in college women across sexual orientation identities. Journal of College Counseling 16, 275–288. doi:10.1002/j.2161-1882.2013.00042.x Mathy, R. M., & Lehmann, B. A. (2004). Public health consequences of the Defense of Marriage Act for lesbian and bisexual women: Suicidality, behavioral difficulties, and psychiatric treatment. Feminism and Psychology, 14, 187–194. doi:10.1177/ 0959-353504040322 Meyer, C., Blissett, J., & Oldfield, C. (2001). Sexual orientation and eating psychopathology: The role of masculinity and femininity. International Journal of Eating Disorders, 29, 314–318. doi:10.1002/eat.1024 Moore, F., & Keel, P. K. (2003). Influence of sexual orientation and age on disordered eating attitudes and behaviors in women. International Journal of Eating Disorders, 34, 370–374. doi:10.1002/eat.10198 Morrison, M. A., Morrison, T. G., & Sager, C. L. (2004). Does body satisfaction differ between gay men and lesbian women and heterosexual men and women? A meta-analytic review. Body Image, 1, 127–138. doi:10.1016/ j.bodyim.2004.01.002 Murnen, S. K., & Smolak, L. (2009). Are feminist women protected from body image problems? A meta-analytic review of relevant research. Sex Roles, 60, 186–197. doi:10.1007/s11199-008-9523-2 Newcomb, M. E., & Mustanski, B. (2010). Internalized homophobia and internalizing mental health problems: A meta-analytic review. Clinical Psychology Review, 30, 1019–1029. doi:10.1016/j.cpr.2010.07.003 Owens, L. K., Hughes, T. L., & Owens-Nicholson, D. (2003). The effects of sexual orientation on body image and attitudes about eating and weight. Journal of Lesbian Studies, 7, 15–33. doi:10.1300/J155v07n01_02 Pantalone, D. W., Iwamasa, G. Y., & Martell, C. R. (2009). Adapting cognitivebehavioral therapies to diverse populations. In K. S. Dobson (Ed.), Handbook of cognitive-behavioral therapies (3d ed., pp. 445–464). New York, NY: Guilford Press. Polimeni, A. M., Austin, S. B., & Kavanagh, A. M. (2009). Sexual orientation and weight, body image, and weight control practices among young Australian women. Journal of Women’s Health, 18, 355–362. doi:10.1089/jwh.2007.0765 Reilly, A., & Rudd, N. A. (2006). Is internalized homonegativity related to body image? Family and Consumer Sciences Research Journal, 35, 58–73. doi:10.1177/1077727X06289430 Sell, R. L. (1997). Defining and measuring sexual orientation: A review. Archives of Sexual Behavior, 26, 643–658. doi:10.1023/A:1024528427013 Share, T. L., & Mintz, L. B. (2002). Differences between lesbians and heterosexual women in disordered eating and related attitudes. Journal of Homosexuality, 42, 89–106. doi:10.1300/J082v42n04_06 Siever, M. (1994). Sexual orientation and gender as factors in socioculturally acquired vulnerability to body dissatisfaction and eating disorders. Journal of Consulting and Clinical Psychology, 62, 252–260. doi:10.1037/0022-006X.62.2.252
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Steffens, M. C. (2005). Implicit and explicit attitudes towards lesbians and gay men. Journal of Homosexuality, 49, 39–66. doi:10.1300/J082v49n02_03 Szymanski, D. M., Kashubeck-West, S., & Meyer, J. (2008). Internalized heterosexism: Measurement, psychosocial correlates, and research directions. The Counseling Psychologist, 36, 525–574. doi: 10.1177/0011000007309489 Túry, F., Güleç, H., & Kohls, E. (2010). Assessment methods for eating disorders and body image disorders. Journal of Psychosomatic Research, 69, 601–611. doi:10.1016/j.jpsychores.2009.05.012 Vartanian, L. R., Herman, C. P., & Polivy, J. (2005). Implicit and explicit attitudes toward fatness and thinness: The role of the internalization of societal standards. Body Image, 2, 373–381. doi:10.1016/j.bodyim.2005.08.002 Wichstrøm, L. (2006). Sexual orientation as a risk factor for bulimic symptoms. International Journal of Eating Disorders, 39, 448–453. doi:10.1002/eat.20286 Williamson, I., & Spence, K. (2001). Towards an understanding of risk factors for eating disturbance amongst gay men. Health Education, 101, 217–227. doi:10.1108/EUM0000000005645 Wilson, G. T., Becker, C. B., & Heffernan, K. (2003). Eating disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (2nd ed., pp. 687–715). New York, NY: Guilford Press. Yager, Z., & O’Dea, J. A. (2008). Prevention programs for body image and eating disorders on university campuses: A review of large, controlled interventions. Health Promotion International, 23, 173–189. doi:10.1093/heapro/dan004
Eating Disorders: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uedi20
Patterns of Disordered Eating Behavior in Women by Sexual Orientation: A Review of the Literature a
Sarah M. Bankoff & David W. Pantalone
b
a
Psychology Service, VA Boston Healthcare System, Boston, Massachusetts, USA b
Department of Psychology, University of Massachusetts Boston; and The Fenway Institute, Fenway Health, Boston, Massachusetts, USA Published online: 11 Mar 2014.
To cite this article: Sarah M. Bankoff & David W. Pantalone (2014) Patterns of Disordered Eating Behavior in Women by Sexual Orientation: A Review of the Literature, Eating Disorders: The Journal of Treatment & Prevention, 22:3, 261-274, DOI: 10.1080/10640266.2014.890458 To link to this article: http://dx.doi.org/10.1080/10640266.2014.890458
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Eating Disorders, 22:261–274, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1064-0266 print/1532-530X online DOI: 10.1080/10640266.2014.890458
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Patterns of Disordered Eating Behavior in Women by Sexual Orientation: A Review of the Literature SARAH M. BANKOFF Psychology Service, VA Boston Healthcare System, Boston, Massachusetts, USA
DAVID W. PANTALONE Department of Psychology, University of Massachusetts Boston; and The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
Most disordered eating research has focused on White, heterosexual women. More empirical work is needed to better understand disordered eating among women of diverse backgrounds. Given evidence of disparities between heterosexual and sexual minority (i.e., non-heterosexual) women in other health behaviors (e.g., tobacco use) and outcomes (e.g., cardiovascular disease), it appears important to study disordered eating behaviors among sexual minority women. In this article, we review the extant literature on disordered eating behaviors in women across sexual orientations, with a focus on research examining potential mechanisms of disparities in disordered eating, including awareness and internalization of sociocultural norms.
The extant literature on disordered eating has focused primarily on examining the phenomenon in White adolescent girls and young women (Brown, Cachelin, & Dohm, 2009). Unfortunately, the sheer quantity of research utilizing clinical samples of White girls and women, with either unreported or primarily heterosexual sexual orientations, has perpetuated myths that disordered eating is less prevalent among ethnic minority (Brown et al., 2009) and sexual minority (Heffernan, 1996) girls and women. Given the disproportionate prevalence of eating disorders among women (vs. men) in
Address correspondence to Sarah M. Bankoff, Psychology Service (116B), VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA 02130, USA. E-mail: [email protected] 261
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general, the literature must move in the direction of better coverage of disordered eating among women of diverse backgrounds—with the ultimate goal of improving and individualizing prevention and treatment efforts through establishing a better understanding of these behaviors in all subgroups. The relatively limited number of published studies that have explored disordered eating specifically in women of minority sexual orientations (i.e., those identifying as non-heterosexual) have yielded mixed and inconclusive results. As such, our understanding of disordered eating among sexual minority women (SMW) remains underdeveloped (MacDonald, 2011; Wilson, Becker & Heffernan, 2003). In this article, we aimed to review the literature on the associations between sexual orientation and disordered eating in women, taking a central or pivotal coverage approach (Cooper, 2003), and have included relevant content featuring examination of these associations with a focus on the potential mechanisms. We searched the electronic databases PsycInfo, PubMed/MEDLINE, and ScienceDirect through November 2013 using various combinations of search terms. We also completed searches for “similar items” once articles were deemed relevant, and reviewed the reference sections of identified articles for other similar work not previously identified. We have focused our review on potential mechanisms of these associations, in an effort to evaluate the critical next steps in the research literature for understanding, and eventually ameliorating, sexual orientation related disparities in disordered eating among women. We begin with an introduction to considerations in studying sexual orientation more generally, and then examine the literature examining prevalence, types, and mechanisms of disordered eating among women of diverse sexual orientations.
METHODOLOGICAL CONSIDERATIONS IN STUDYING SEXUAL ORIENTATION GENERALLY Sexual orientation has historically been inconsistently and insufficiently defined in the literature (e.g., Sell, 1997). In a recent Institute of Medicine (IOM) report, sexual orientation is described as an “inherently relational construct” with the following working definition: “an enduring pattern of or disposition to experience sexual or romantic desires for, and relationships with, people of one’s same sex, the other sex, or both sexes” (IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011, p. 27). Sexual orientation is a complex construct that incorporates psychological (i.e., sexual attractions and desires) and behavioral (i.e., sexual behaviors and experiences) components, among others (Sell, 1997). Given that there are various components involved in one’s sexual identification (i.e., how one understands one’s sexual orientation) each of these components may not be congruent for all individuals.
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Further, how one understands one’s sexual orientation (i.e., sexual identification), and how one communicates that orientation to others, can vary. Thus, self-reported sexual identification may be less accurate than items addressing attractions or behaviors. Researchers would do well to consider sexual identification, as well as sexual attractions and behaviors, to the extent that each is relevant for a given research question, allowing for comparison with studies operationalizing sexual orientation as sexual attraction (e.g., Austin et al., 2009; French, Story, Remafedi, & Resnick, 1996; Wichstrøm, 2006) and as sexual behaviors (e.g., Boehmer & Bowen, 2009; Bowen, Balsam, & Ender, 2008; Wichstrøm, 2006), in addition to the majority of studies that report self-identified sexual orientation.
DISORDERED EATING AMONG SEXUAL MINORITY WOMEN In the literature to date that examines disordered eating, sexual minority men (SMM) have received considerably more attention than SMW (Moore & Keel, 2003). Findings regarding disordered eating among SMM have also been clearer and more consistent, with general consensus across studies that SMM are at increased risk of disordered eating when compared to heterosexually identified men (e.g., Feldman & Meyer, 2007). In contrast, findings regarding disordered eating among SMW have been mixed and remain inconclusive (e.g., MacDonald, 2011). Early research reviewed in the field suggested that a lesbian sexual orientation may serve as a protective factor against disordered eating—an assumption which was based on empirical findings that lesbian women demonstrate lower levels of investment in societal norms of attractiveness (Heffernan, 1994). This conceptualization has since been identified as a misconception lacking empirical support, as prevalence rates of eating disorders and disordered eating behaviors among SMW are not available in the literature (e.g., MacDonald, 2011; Wilson et al., 2003). However, findings from multiple studies do corroborate the notion that lesbian women are less likely than heterosexual women to report both body dissatisfaction and negative attitudes about eating and weight (e.g., Brand, Rothblum, & Solomon, 1992; French et al., 1996; Owens, Hughes, & Owens-Nicholson, 2003; Polimeni, Austin, & Kavanagh, 2009). Some researchers have speculated that these disparities may exist because heterosexual women aim to attract men, who tend to place greater emphasis on physical appearance of their romantic partners (e.g., Brand et al., 1992), or because lesbian women tend to place less emphasis on physical appearance compared to heterosexual women (e.g., Polimeni et al., 2009). Other studies, however, have found no or few differences in body dissatisfaction among heterosexual, bisexual, and lesbian women (Davids & Green, 2011; Morrison, Morrison & Sager, 2004). For example, in a metaanalysis of 27 studies (N = 5,220), heterosexual and lesbian women did not
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differ on body dissatisfaction, except in a small subset of studies in which lesbian women reported greater body satisfaction compared to heterosexual women of equivalent body weights (Morrison et al., 2004). Given this evidence that suggests lesbian (vs. heterosexual) women report less body dissatisfaction, a variable that has been linked empirically to disordered eating (Moore & Keel, 2003; Share & Mintz, 2002), some researchers have suggested that lesbian women may also be at decreased risk of restricting and purging behaviors. Some studies have found more similarities than differences in disordered eating among women across sexual orientations (e.g., Feldman & Meyer, 2007; Maloch, Bieschke, McAleavey, & Locke, 2013; Moore & Keel, 2003; Share & Mintz, 2002). In an ethnically diverse sample, no differences in eating disorder prevalence were revealed among lesbian, bisexual, and heterosexual women (Feldman & Meyer, 2007). Other studies have confirmed the finding that disordered eating (Share & Mintz, 2002), and bulimic symptoms, specifically (Moore & Keel, 2003), do not seem to differ between heterosexual and lesbian women. Additionally, some studies have revealed no differences between heterosexual and lesbian women on several psychosocial variables related to disordered eating risk, including body esteem, body dissatisfaction, weight concern, and awareness of cultural standards (Epel, Spanakos, Kasl-Godley, & Brownell, 1996; Heffernan, 1999; Moore & Keel, 2003; Share & Mintz, 2002). Other findings even suggest that lesbian (vs. heterosexual) women may possess protective factors against disordered eating, such as better body esteem, lower drive for thinness, and decreased internalization of cultural standards (Moore & Keel, 2003; Share & Mintz, 2002). In contrast, other evidence suggests SMW may be at increased risk of certain disordered eating behaviors. For instance, some studies have found increased prevalence of body weight in the overweight or obese range among lesbian women, specifically (Boehmer, Bowen, & Bauer, 2007), and SMW, in general (Boehmer & Bowen, 2009). These results are supported by a literature review that examined obesity and related issues among SMW compared to heterosexual women (Bowen et al., 2008). Of 19 studies reviewed, nine found higher weight (ranging from 1–5 pounds) or obesity rates among lesbian as opposed to heterosexual or control participants, five found no differences, and four did not report between-group comparisons (Bowen et al., 2008). Binge eating has been found to be more prevalent among adolescent girls identifying a minority sexual orientation, compared to heterosexual girls (Austin et al., 2009). Increased risk of a range of disordered eating behaviors has also been demonstrated in women identifying as bisexual and primarily heterosexual, compared to women identifying as exclusively heterosexual (Polimeni et al., 2009). One study of high school students found that same-sex sexual experiences predicted future bulimic symptoms (Wichstrøm, 2006). Another study
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found that bisexual women were more than twice as likely as lesbian women to report a past or present eating disorder diagnosis, while “out” bisexual women were more likely than heterosexual women to report an eating disorder (Koh & Ross, 2006). As such, bisexual women may be at greater risk of disordered eating, potentially accounted for in part by experiences of isolation and stigmatization after coming out. Considering the evidence that sexual minority girls and women may be at higher, or at least equivalent, risk of disordered eating compared to heterosexual women, it is imperative to better understand mechanisms and correlates of maladaptive eating attitudes, behaviors, and diagnoses among SMW.
FACTORS EXPLAINING DIFFERENCES IN DISORDERED EATING BY SEXUAL ORIENTATION Although some researchers have proposed a wide variety of psychosocial (e.g., social support) and individual (e.g., stress) factors that may explain differences in disordered eating by sexual orientation, such factors have been understudied in the empirical literature and remain largely speculative. A few previously studied potential factors with empirical support include sexual attraction, gender-related traits, and feminist beliefs. For instance, results from previous studies suggest that efforts to sexually attract men (Siever, 1994) and intrasexual competition (Li, Smith, Griskevicius, Cason, & Bryan, 2010) may explain greater body dissatisfaction, emphasis on thinness, and poorer eating-related attitudes among heterosexual women and gay men compared to lesbian women and heterosexual men. Additionally, gender-related traits such as masculinity and femininity may be associated with disordered eating, as evidence indicates that femininity predicts eating pathology in men and women irrespective of sexual orientation (Lakkis, Ricciardelli, & Williams, 1999; Meyer, Blissett, & Oldfield, 2001), while masculinity seems to be associated with relatively healthy eating-related attitudes and behaviors (Meyer et al., 2001). Further research in this area suggests that androgyny (i.e., high levels of femininity & masculinity) among women is associated with fewer disordered eating behaviors (Hepp, Spindler, & Milos, 2005). Other evidence suggests that feminist beliefs may protect against disordered eating among lesbian women (Guille & Chrisler, 1999); indeed, according to a recent meta-analysis, feminist beliefs may serve to protect women of all sexual orientations from body image problems (Murnen & Smolak, 2009). Given the range of potential mechanisms in the association between disordered eating and sexual orientation, additional research is needed. Preliminary findings suggest the potential importance of women’s awareness and internalization of sociocultural norms, specifically those regarding weight and sexual orientation, and warrant further research exploring these psychosocial and individual factors.
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Awareness and Internalization of Sociocultural Norms Research demonstrates that awareness and internalization of sociocultural norms regarding appearance, specifically valuing thinness, are associated with disordered eating in women (Kiang & Harter, 2006). Research also suggests that lesbian women may be less likely to internalize these values of appearance, dieting, and thinness (Bowen, Balsam, Diergaarde, Russo, & Escamilla, 2006). The tendency to adhere to sociocultural norms and hold negative attitudes about obesity may explain in part disparities in disordered eating in women by sexual orientation. Further, internalized heterosexism (i.e., negative thoughts and feelings about one’s sexual minority orientation) has been found to be related in gay men to disordered eating, appearance satisfaction, and self-esteem (Reilly & Rudd, 2006; Williamson & Spence, 2001). Thus, we might speculate that internalized negative attitudes regarding one’s sexual orientation may also explain in part disordered eating in SMW. Previous research has examined attitudes regarding weight among study participants of different genders and weights. Findings demonstrate that overweight men and women experience weight-based prejudice, as compared to average-weight men and women (Brochu & Morrison, 2007). In general, men tend to show more negative attitudes than women toward overweight individuals (Brochu & Morrison, 2007), but both men and women express anti-fat attitudes (Grover, Keel, & Mitchell, 2003). However, while men tend to implicitly (i.e., automatically) identify as “light” regardless of their actual weight status, the implicit weight identity of women is associated with their actual weight, explicit (i.e., self-reported) weight appraisal, and implicit self-esteem—a difference that may explain in part increased rates of eating disorders among women compared to men (Grover et al., 2003). Thus, women seem to more accurately perceive their body weight, possibly increasing their risk of disordered eating. Among many individuals who engage in restricting and purging behaviors, obesity is a feared condition (Jáuregui Lobera, Polo, González, & Millán, 2008). Patients diagnosed with the restricting subtype of anorexia show strong automatic and self-reported negative evaluations of body weights in the overweight range (Cserjési et al., 2010). A study of undergraduate women found implicit negative attitudes toward obesity among restrained and unrestrained eaters, but stronger explicit negative attitudes among restrained eaters (Vartanian, Herman, & Polivy, 2005). In another study of young women (sexual orientations unreported), thin-ideal implicit attitudes did not sufficiently predict body dissatisfaction, as being overweight was viewed negatively across all participants (Ahern & Hetherington, 2006). A more recent study of undergraduate women showed that implicit attitudes were able to predict drive for thinness, with this association moderated by attitude importance (Ahern, Bennett, & Hetherington, 2008). Thus, evidence suggests that attitudes regarding overweight individuals may be assessed to help to
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identify disordered eating behaviors, which are often marked by high levels of secrecy. Negative attitudes toward overweight individuals are highly prevalent in the U.S., with individuals of both genders (Grover et al., 2003) demonstrating such attitudes. Evidence suggests that individuals engaging in restricting and purging behaviors may reveal more extreme negative attitudes regarding obesity (Vartanian et al., 2005). No studies identified to date have compared women of different sexual orientations on their attitudes regarding weight. However, evidence suggests that women aiming to sexually attract women (vs. men) may hold less negative views of obesity (e.g., Boehmer & Bowen, 2009)—a finding which appears to be consistent with the assumption that SMW may be at decreased risk of restricting and purging behaviors, compared to heterosexual women. As such, it could be important to determine whether SMW truly hold less negative attitudes regarding obesity compared to heterosexual women and, if so, to explore the role these attitude differences may play in influencing eating behaviors by sexual orientation. Findings also point to the importance of considering the role of attitudes regarding sexual orientation in relation to disordered eating. First, internalized heterosexism has been linked with maladaptive eating attitudes among gay men (Williamson & Spence, 2001). Also among gay men, negative attitudes regarding one’s own minority sexual orientation have been associated with poorer appearance satisfaction and self-esteem, while negative attitudes regarding others’ gay orientations have been associated with bulimic behaviors (Reilly & Rudd, 2006). Further, in a recent meta-analysis, internalized heterosexism was linked to internalizing mental health problems among gay and lesbian individuals in multiple studies reviewed (Newcomb & Mustanski, 2010). In the literature identified to date, attitudes regarding sexual orientation have not been examined as a potential factor influencing the association between sexual orientation and disordered eating among women. Existing findings suggest that women’s attitudes toward lesbian and heterosexual women are equally positive (Steffens, 2005). Although women in general may evaluate lesbian women as positively as heterosexual women, we know little about how SMW evaluate their own sexual orientations and the orientations of other SMW.
CLINICAL IMPLICATIONS Although our empirical understanding of disordered eating among SMW remains equivocal, findings indicate that disordered eating is not experienced identically in women of all sexual orientations and, therefore, reveal an important issue requiring attention in clinical practice. Clinicians can be instrumental in eating disorder prevention, assessment, and treatment efforts for all women, irrespective of sexual orientation. Eating disorder prevention
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efforts may be targeted both for women generally and for SMW specifically. Given evidence of connections between sociocultural norms valuing thinness and disordered eating (e.g., Vartanian et al., 2005), educational programming and campaigns should continue to raise awareness of the dangers of glorifying unhealthy body types in the media. As demonstrated by a review of eating disorder interventions, a media literacy approach appears beneficial in preventing eating disorder symptoms among college students (Yager & O’Dea, 2008). Providers could assist in communicating these important messages in their practices, through providing information and educational materials to patients and their family members. Evidence of associations between internalized heterosexism and disordered eating (e.g., Williamson & Spence, 2001) suggest that, for SMW, prevention efforts may also necessitate ongoing policy work aimed to increase equal rights of sexual minority individuals in today’s society (e.g., Mathy & Lehmann, 2004). Given the unfortunately long-term nature of this goal, in the meantime, individual providers may assist in minimizing health disparities with advocacy efforts on a smaller scale. To begin, providers should strive to create culturally competent practices where SMW feel comfortable seeking healthcare (IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011), especially given evidence that SMW may not be receiving the services they need even in the context of health disparities (IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011). Assessment efforts appear to be critically important, especially in considering the historical assumption that restricting and purging behaviors are less prevalent among SMW compared to heterosexual women (e.g., Heffernan, 1994), thus presenting the potential risk of these behaviors being overlooked in this demographic group (e.g., Wilson et al., 2003). Observations of similar disordered eating behaviors among women of all sexual orientations presented here (e.g., Feldman & Meyer, 2007; Maloch et al., 2013; Moore & Keel, 2003; Share & Mintz, 2002) should serve to caution clinicians against overlooking or underestimating these dangerous, potentially life-threatening, behaviors (e.g., Keel, 2010) in SMW. Given the inherent secrecy and shame surrounding disordered eating behaviors, it may be especially difficult to identify them in clients who present with problems other than eating disorders, and clinicians operating under the unsupported assumption that SMW are less likely to engage in such behaviors may be at a further disadvantage. Thus, clinicians should remain aware that all women—regardless of orientation—appear to be at increased risk of disordered eating behaviors compared to men, and they should routinely conduct a thorough assessment of these behaviors. For a review of relevant assessment measures, see Túry, Güleç, and Kohls (2010); clinicians may consider choosing a complete measure or selection of items to incorporate a self-report of eating disorder symptoms into their typical intake procedures. Clinicians could also
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capitalize on knowledge of the link between attitudes regarding obesity and restricting behaviors by implementing measures of attitudes into their assessment or screening protocols. While individuals engaging in restricting behaviors may not be willing or motivated to disclose disordered eating behaviors to providers, incorporating self-report measures to assess awareness and internalization of norms valuing thinness could allow clinicians to identify patients at potentially increased risk of these dangerous behaviors. In establishing culturally competent practices, providers should include items assessing for sexual orientation with their regular intake materials. Providers could also consider screening for internalized heterosexism (for several brief measures recommended for use in clinical practice, see Szymanski, Kashubeck-West, & Meyer, 2008) with their sexual minority patients to identify individuals at potentially increased risk of disordered eating behaviors, among other mental health concerns (Newcomb & Mustanski, 2010). In terms of eating disorder treatment efforts, providers might consider addressing internalized sociocultural norms when relevant. For example, cognitive-behavioral intervention efforts might address negative attitudes regarding obesity by targeting cognitive distortions. Future quantitative research will be necessary to test the effectiveness of different components (e.g., cognitive restructuring) of these intervention efforts incorporating techniques to minimize disordered eating behaviors by targeting maladaptive attitudes and beliefs about weight among women of all sexual orientations. Consideration should also be given to adapting cognitive-behavioral interventions to populations of SMW (e.g., Pantalone, Iwamasa, & Martell, 2009), who may also possess other marginalized identities. Culturally competent interventions are essential for addressing disordered eating behaviors— which appear to be associated with internalized heterosexism—among SMW, and trained clinicians are needed to carry out these interventions. This may require training technically and culturally competent therapists, who are skilled both at treating disordered eating and in working with non-heterosexual clients.
RECOMMENDATIONS FOR FUTURE RESEARCH Investigators in this area must address some potential limitations in studying disordered eating and differences by sexual orientation. First, researchers face the challenge of conceptualizing the construct of disordered eating (Túry et al., 2010). While some studies have examined eating disorder diagnoses (e.g., Feldman & Meyer, 2007), others consider specific attitudes (e.g., body dissatisfaction, drive for thinness) and behaviors (e.g., restricting, purging, binge eating) associated with disordered eating (e.g., Moore & Keel, 2003; Share & Mintz, 2002). Given this variety of predictor variables, comparisons across studies can be difficult (Túry et al., 2010). Second, in the
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research literature in general, a lack of consistency exists in measuring sexual orientation (e.g., IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011; Sell, 1997). Some significant challenges in conducting health disparity research include the barriers of relatively small populations of sexual minority individuals, and of participants’ willingness to identify a sexual minority orientation, due to issues of stigma and privacy, among other concerns (IOM Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011). Often small sample sizes force exclusion of “questioning” participants, or other participants who do not identify clearly as heterosexual or lesbian, from statistical analyses because they are underpowered to use the group as a reliable comparator on its own. In operationalizing sexual orientation, researchers might consider assessing multiple components of the construct (e.g., attractions, behaviors, identification), and base decisions about which components to utilize in analyses on relevance to the research questions and other constructs being examined. The present state of the literature in this area remains inconclusive, owing in part to challenges investigators face in comparing across studies. Future research could facilitate cross-study comparisons by offering clear and uniform operationalization of variables and examining differences across all sexual orientations.
CONCLUSION Additional research is warranted to better understand disparities—and mechanisms accounting for these disparities—in disordered eating in women of different sexual orientations. Large, longitudinal studies, incorporating comprehensive assessments of sexual orientation and disordered eating, would help us learn whether rates of disordered eating behaviors and eating disorder diagnoses significantly differ among women of different sexual orientations, by allowing for examination of ways in which the developmental processes of understanding one’s sexual identity and coming out may influence disordered eating among SMW. In the meantime, clinicians and other healthcare providers should remain cognizant of the historical assumption that SMW may be at decreased risk of disordered eating compared to heterosexual women is not supported by empirical evidence, and carefully screen for disordered eating in women patients of all sexual orientations.
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