Eating disorders are one of the most lethal psychiatric disorders (Arcelus et al., 2011), second only to opioid misuse disorders (Chesney et al., 2014), and have noxious and chronic effects on biopsychosocial well-being. They are often comorbid with anxiety, mood, and substance-related disorders (Ulfvebrand et al., 2015), profoundly impair social functioning (Cardi et al., 2018), and contribute to robust physical limitations (Treasure et al., 2020), with people diagnosed with an eating disorder having mortality rates nearly 5 times higher than their age-matched counterparts (van Hoeken & Hoek, 2020). Collectively, eating disorders account for approximately $65B in annual economic costs in the U.S. alone (Streatfeild et al., 2021). Individuals with eating disorders also exhibit high rates of recurrence (Sala et al., 2023), underscoring the need to refine existing treatments and/or develop more effective treatments. One critical flaw in the existing treatment science is that many first-line interventions for eating disorders fail to incorporate multiculturalism and patient diversity (Burke et al., 2020).
Contemporary eating disorders research is homogenous in representation, primarily reflecting the identities and lived experiences of skinny, White, affluent girls (i.e., “SWAG”, Sonneville & Lipson, 2018), as well as those from Western cultural contexts (e.g., “WEIRD” samples, Henrich et al., 2010; He et al., 2022). Such narrow representation has lasting, negative effects on those who do not possess these identities, lived experiences, or cultural backgrounds and is especially concerning since people from minoritized identities often exhibit added risk for the development and maintenance of eating and body image disturbances and eating disorders (Burke et al., 2020). Researchers, clinicians, and advocates must work to reconcile the reality that our understanding of eating disorders reflects a small, non-representative subset of the global population, which can in turn lead to inconsistencies in the efficacy of treatment approaches across individuals. To this end, my research program: 1) uplifts minoritized voices in basic and treatment science, advancing our understanding of sexual minority, gender minority, and intraminority stress as models that help explain disparate rates of eating disorders in the LGBTQ+ community; 2) identifies high-risk subgroups for the development and maintenance of eating disorders in the LGBTQ+ community; and 3) reflects data from people outside of “SWAG” and “WEIRD” samples to advance a global understanding of eating disorders.
Uplifting Minoritized Voices: Advancing our Understanding of Sexual Minority, Gender Minority, and Intraminority Stress in the LGBTQ+ Community
My research considers multicultural nuances and individual diversity in explaining differences in the presentation of eating and body image disturbances and eating disorders among sexual and gender minorities. Sexual and gender minorities, or people who identify as Lesbian, Gay, Bisexual, Transgender, Queer, or other sexual and gender minority experience (LGBTQ+), consistently report high rates of eating and body image disturbances and eating disorders (Nagata et al., 2020). Models of sexual minority, gender minority, and intraminority stress (Meyer, 2003; Testa et al., 2015; Pachankis et al., 2020), which consider the role of stressors outside (heterosexist/cisgenderist discrimination [sexual/gender minority stress]) and within (stigma from other LGBTQ+ members [intraminority stress]) the LGBTQ+ community, are possible explanations for eating and body image disturbances and eating disorders in the LGBTQ+ community (Barnhart et al., 2022a; Barnhart et al., 2023a; Hong, Tang, Barnhart, et al., 2023; Soulliard et al., 2023). For instance, in sexual minority men and women from China, I have shown that in sexual minority men, but not women, lower levels of concealing one’s sexual orientation (i.e., greater openness of sexual orientation, a sexual minority stress variable) was associated with higher thinness- and muscularity-oriented eating and body image disturbances (Barnhart, et al., 2022a). This paradoxical finding, which diverges from Western cultural contexts (Convertino et al., 2021), was contextualized within a Chinese culture where sexual minority populations may experience overt and explicit stigma and harassment due to their sexual orientation.
My current research expands existing evidence on sexual minority, gender minority, and intraminority stress by speaking to the temporal nature of existing models in relation to eating and body image disturbances and eating disorders in the LGBTQ+ community. For example, my dissertation project uses a longitudinal design to test the temporal associations between sociocultural (e.g., appearance pressures from social contexts), sexual minority stress, and intraminority stress models and thinness- and muscularity-oriented eating and body image disturbances in a diverse, community sample of sexual minority men from the United States. This project, which will be completed by Summer 2024, builds on exclusively cross-sectional research to speak to the impact of stigma from outside and within the community on the development and/or maintenance of eating and body image disturbances in diverse sexual minority men. Considering diverse identities and lived experiences is key to assessing potential high-risk subgroups for eating and body image disturbances in sexual minority men.
Identifying High-Risk Subgroups in the LGBTQ+ Community
Indeed, another avenue in my program of research focuses on identifying high-risk subgroups for eating and body image disturbances and eating disorders in the LGBTQ+ community. The LGBTQ+ community has historically been conceptualized as a monolithic group, with existing research efforts combining sexual and gender minority identities in the interest of increasing statistical power and ease of interpretation of findings. The downside to this practice is that it prevents an understanding of unique differences in mental health by sexual and gender identities, including potential high-risk subgroups in the LGBTQ+ community. Building on these interests, I spearheaded a cross-sectional research study using an intersectionality framework to better understand the role of minoritized identities and lived experiences in relation to differences in eating and body image disturbances in a sample of sexual and gender minority adults from the United States (Barnhart et al., under review). Utilizing person-centered analyses, colleagues and I identified classes of eating and body image disturbances (e.g., high pathology vs. low pathology) and various lived experiences (e.g., elevated weight status) that described a higher likelihood of membership to the high pathology class. Furthering this work, colleagues and I have examined the role of sexual self-labeling (e.g., ‘Top’, ‘Bottom’, ‘Versatile’) to describe high-risk subgroups for eating and body image disturbances in a sample of gay and bisexual men (Barnhart et al., revise and resubmit). Building on theories of gender in sexual minority men, I found higher levels of thinness-oriented eating and body image disturbances in ‘Bottoms’ and higher levels of muscularity-oriented eating and body image disturbances in ‘Tops’, with ‘Versatiles’ reporting lower levels of both thinness- and muscularity-oriented eating and body image disturbances relative to their counterparts.
This preliminary research underscores significant heterogeneity in sexual and gender minorities in the experience of eating and body image disturbances which has key theoretical and practice implications. On the side of theory, explanations for eating and body image disturbances in the LGBTQ+ community should be responsive to such nuances to describe these symptoms more accurately. On the side of practice, this research informs potential treatment approaches that target the specific needs and attributes of these subgroups compared to the current “one size fits all approach”. Both implications take needed steps in the direction of reducing health disparities in eating and body image disturbances and eating disorders in the LGBTQ+ community.
Advancing a Global Understanding of Eating Disorders
Finally, I advance a global understanding of eating disorders through research on the quantitative assessment, etiology, and correlates of eating and body image disturbances in non-Western populations (e.g., people from China). Central to gaining a global understanding of eating disorders, including representation of identities and lived experiences outside of “SWAG” and “WEIRD” populations, is scale adaptation of self-report measures in non-Western cultural contexts. In one demonstration of this, I helped adapt self-report scales for the assessment of drive for muscularity in women (Tang, Barnhart, et al., 2022), body talk in women and men (He, Lu, Barnhart, et al., 2023), and appearance schemas (e.g., investment in one’s body image) in women and men (Chen, Wang, Barnhart, et al., revise and resubmit) from China. Furthermore, I helped examine the psychometric properties of these adapted measures, as well as existing measures that have already been adapted to Chinese (Mandarin) such as muscularity-oriented disordered eating in women (He, Cui, Barnhart, et al., 2023a), functionality appreciation (i.e., a facet of positive body image) in women and men (He, Cui, Barnhart, et al., 2023b), and intuitive eating (i.e., an adaptive eating behavior) in women and men (Ji, Sun, Barnhart, et al., revise and resubmit). Furthering this line of research, I also helped create a new construct, muscularity bias internalization, a counterpart of weight bias internalization reflecting the degree of endorsement of muscularity-based stereotypes and negative, self-directed evaluations of one’s muscularity in Chinese men and women (He et al., 2022; He, Cui, Barnhart, et al., 2023c). Collectively, this research helps increase our confidence in the reliability and validity of these self-report measures in the Chinese context which takes an essential step in the accurate description of symptoms related to eating disorders from a non-Western cultural context.
In addition to quantitative assessment, I am also interested in better understanding the etiology and correlates of eating disorders outside of the Western cultural context. In support of these interests, using both cross-sectional and longitudinal research designs, I helped lead research efforts extending well-supported explanations of eating disorders to Chinese heterosexuals (Barnhart, et al., 2022b), sexual and gender minorities (Barnhart, et al., 2022a; Barnhart et al., 2023a), and adolescent (Barnhart et al., In Press; Barnhart, et al., 2023b), college (Liang, Barnhart, et al., 2023), general adult (He, Barnhart, et al., 2023), and older-aged (Barnhart, et al., 2023c) populations to provide theoretical backdrops for future research into treatments that are sensitive to diverse, non-Western populations across the lifespan. This work is essential to increasing our understanding of eating disorders and potential treatments globally.
References
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Wesley R. Barnhart, M.A. 