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= Sexual orientation and eating disorders =

Sexual orientation influences eating disorders, which is mediated by several factors such as psychological factors and body dissatisfaction. Many studies showed that some specific sexual orientations are more vulnerable to eating disorders such as the homosexual men. Atypical gender role behavior during childhood, gender role behaviour in gay couples, body ideal implemented in society and reinforced in the gay community, stress due to stigmatization, or even observational learning, are several factors that are taken into account for this prevalence of eating disorders. Another aspect that increases the risk of developing an eating disorder is the dissatisfaction with ones body shape that is predominantly found in transgender and gender-nonconforming individuals.

While sexual orientation’s influence on eating disorders is found in both men and women, the association seems clearer in men than in women. In fact, no real relationship between sexual orientation and the amount of eating disorders has been found in women, but rather a greater prevalence of specific types of eating disorders in some particular kind of sexual orientations has been observed in some studies.

Finally, hormones, and more specifically ghrelin, can be another factor that influences the risk of eating disorders. As the level of ghrelin is higher in women and seems to be higher in feminine gay men as well, they both tend to be more vulnerable to eating disorders.

Sexual orientations and EDs in men
The estimated prevalence of homosexual men has declined, comparing data from 1948 to that from 2000. In 1948, Alfred Kinsey, one of the developers of the Kinsey scale, reported in his book “Sexual Behaviour the Human Male”, that 10% of the male population is gay. In later years, the 2000 U.S. Census Bureau concluded that homosexual couples add up to less than 1% of American households. The Family Research Report announced that around 2-3% of men are homosexual or bisexual.

In Western countries, homosexual men are seen as more vulnerable to eating disorders. An average of 42% of males with eating disorders have a gay orientation. There are many possible reasons as to why homosexual men engage in disordered eating and why exactly homosexuality is a risk factor for developing these disorders. Using the methods of Hudson et al’s National Comorbidity Study on the prevalence of eating disorders, diagnoses were conducted. For the gay and bisexual male subgroups, measures were taken such as on a scale from one (strongly agree) to seven (strongly disagree) about how worthy they felt in their social groups. The results of this particular study displayed that gay or bisexual men had a significantly higher percentage of them suffer with an eating disorder, in this case bulimia to be more specific.

It has been suggested that atypical gender role behaviour during childhood puts males at greater risk for adult body dissatisfaction. During a study, a within-group analysis showed that a high feminine subtype of gay males showed greater body dissatisfaction than the less feminine subtypes possessed. These results support that gender role behaviours can contribute to body dysmorphia in men.

The development of body dysmorphia in gay men can be linked back to social psychology, specifically social norms, social learning and enculturation. The way in which social norms may lead to the acquisition of an eating disorder is explained through the behaviour within the gay community. There are many pressures to fit a certain body ideal within the gay community, which could lead men that are part of it to desire for their body to physically change to fit this ideal. Enculturation can also be seen as a form of social learning. Specifically focusing on culture in this case, the acquisition of characteristics and norms of a culture or group will be triggered over time through a gay man coming in frequent contact with other gay men who suffer from eating disorders. Another way in which social learning may affect the development of an eating disorder, specifically for a gay man, is through vicarious learning. What vicarious learning essentially focuses on is learning a behaviour through observing and later on imitating a person performing a certain way of behaving. Vicarious learning is a form of observational learning which inevitably will result in a person replicating the observed behaviour. In gay men, this could be them observing how others within their community are either starving themselves or purging or engaging in any other form of disordered eating.

Following the idea and findings of Scott M. Strong’s study that concluded that more feminine gay men have greater feelings of body dissatisfaction, the idea of gay men acting more feminine can be explored. During a study, it was discovered that gay men's desired partner characteristics were hugely biased towards masculinity. This proves that gay men are attracted more to masculine partners, which in turn could mean that they would want to feminise themselves to seem more appealing.

Sexual orientations and EDs in women
In contrast to men, studies with women often do not show a difference between homosexual and heterosexual orientations and the prevalence of eating disorders, or have mixed results. A meta-analysis came to the same results but revealed that there is actually a difference between heterosexual and bisexual women. Eating disorders were much more prevalent in the latter group, which is a difference to results of investigations with men. One further reveal of this study is that in general the levels of eating disorders in women are not associated with their sexual orientation but rather there is a connection between different sexual orientations and the type of eating disorders the women show. Heterosexual women have different eating patterns than homosexual women, namely they show restrictive eating more often than binge-eating or purging behaviors. There is no difference in the overall prevalence of eating disorders in homosexual women but they show more often binge-eating.

In a study by Eli Doris, the influence of acculturation on the development of eating disorders is being reviewed. As a result they stressed that eleven studies pointed out cultural change as an important factor. However six studies showed little or no association between the psychopathological disorder and acculturation, but as the majority of the studies suggested that greater or lesser cultural change can be seen as a potential risk factor for eating disorders.

EDs in Transgender and Non-binary individuals
It is scientifically evident that the LGBTQ+ population shows higher risk of developing eating dirsorders compared to the cisgender group. Elevated stress due to stigmatisation is but one of the reasons.

In transgender and gender-nonconfoming individuals the dissatisfaction with ones body shape might be another reason adding to the stress which results in a higher chance to develop an eating disorder. Female to male (FTM) individuals might restrict to avoid developing female specific features such as breasts and hips, while male to female (MTF) individuals might develop disordered eating to appear slimmer and more feminine. There are also differences in the prevalence of eating disorders amongst MTF, FTM, gender-nonconforming individuals female assigned at birth (FBGNC) and gender-nonconforiming individuals male assigned at birth (MBGNC). In a secondary analysis of the Project VOICE, which was a cross-sectional study of stress and health in transgender adults, it was found that overall 7.4% of the sample self-reported that they had an eating disorder. Compared to the FBGNC participants there was no significant difference in the odds to report an eating disorder in the FTM or MBGNC group, whereas the MTF participants were only 0.14 times likely to report an ED. And even though some differences were not significant, the FBGNC participants still formed the highest group of participants that reported an ED. This might mean that nonbinary individuals who are assigned female at birth may have a higher motivation to change their gender specific outer apperance.

Another study that focused on eating disorder psychopathology (including anxiety, perfectionism, body dissatisfaction, self-esteem etc.), showed that Transgender people who undergo cross-sex hormone treatment (CHT) show similar levels of eating disorder psychopathology as the general population, compared to those who do not undergo CHT, who show higher levels. This suggests that CHT might be able to alleviate some of the eating disorder symptoms.

Hormonal theories
It is difficult to determine whether homosexuality itself is due to hormonal factors. However the idea that a certain category of man in the gay community would act more feminine might create a hormonal change. Women typically have higher ghrelin levels than men, but what if femme acting could affect these levels in homosexual men? And maybe this makes them, too, more hormonally at risk of developing an eating disorder. Ghrelin, also known as a hunger hormone affects appetite. It plays a role in the hypothalamus which is a part of the brain that also controls appetite. It can also affect regions of the brain that are involved in reward processing. People struggling with anorexia are known to have high ghrelin levels. To further investigate the hormonal theory, specifically focusing on ghrelin, one could look into the possibility of neurochemical factors affecting the development of eating disorders. In a study it has been found that metabolic alterations have been found in eating disorders. What this study discovered is that altered ghrelin levels have been indicated. Continuing with the idea of partner preferences in relation to hormonal theories, another theoretical explanation as to why gay men are more suseptible to developing an eating disorder could be due to their female like acting, which could trigger a higher release of ghrelin levels in their body that women naturally have. Because women naturally have more ghrelin, they are more likely to develop an eating disorder such as anorexia. Having said that, gay men, who have already been distinguished as more likely to have an eating disorder than straight men, have certain members in their community that purposefully act feminine due to them wanting to attract a partner like straight women would. This is why it is possible that paired with straight women, feminine gay men are also more hormonally likely to develop an eating disorder (Bailey 1997).

A study examining the rate of bulimia nervosa and binge eating in heterosexual, as well as homosexual women found out that lesbian women are more likely to have binge eating disorder than straight women. . Preexisting biological vulnerabilities, such as a Ghrelin dysfunction as well as social learning may play a role in the development of binge eating. . Transgender people not on cross-sex hormones reported higher levels of eating disorder psychopathology than people who were on cross-sex hormones, which underlines the crucial role of hormones. . The article 'Hormonal Treatment Strategies Tailored to Non- Binary Transgender Individuals', published in 2020 in the Journal of Clinical Medicine emphasizes the importance of hormonal treatment for non-binary individuals to better meet their needs and contribute to an improvement of one's life quality and a reduction of stress. . On the other hand, these treatments could potentially bear similar risks as it does for transgender individuals who reported higher levels of eating disorders when they did not receive hormonal treatment.