week 6

It is well established in the literature that gender minority individuals experience elevated levels of minority stress, placing them at increased risk for adverse mental health outcomes such as disordered eating. Gender minorities are also at a disproportionate risk for negative social determinants of health such as food insecurity. Emerging research suggests an association between food insecurity and disordered eating in the cisgender population, but the relationship in the gender-diverse population has not yet been explored. Therefore, the overarching goal of the proposed research project is to examine how food insecurity influences disordered eating symptomology among gender-diverse adults living in the Southeastern United States. The proposed study will use online survey methods. After providing informed consent, subjects will complete the EDE-QS, the USDA-6 Short Form, the MSPSS, and the GMSR scale. A mediator/moderator analysis will also be performed to examine the impact of minority stress and social support on the relationship between food insecurity and disordered eating. The results of this correlational research study, “Food Insecurity and Eating Disorder Symptomology Among Gender Diverse Individuals Living in the Southeast,” will provide a better understanding of the relationship between food insecurity and eating disorder symptomology among gender diverse individuals living in the Southeast and how that relationship may be impacted by minority stress and social support.

Project Narrative

By examining the association of food insecurity, eating disorders, and social support through a minority stress lens, the current project may help elucidate the factors contributing to weight stigma in oppressed minority populations. This project will also provide pilot information to inform the need for targeted eating disorder interventions in the gender-diverse population. If the project aims are achieved, results may highlight inadequacies in support systems, emphasizing a need for more sexual and gender minority-inclusive public assistance programs.

Specific Aims

Current literature suggests that gender minorities experience elevated levels of minority stress, placing them at greater risk for adverse mental health outcomes such as disordered eating behavior than their cisgender counterparts (Diemer et al., 2018; Henderson et al., 2019; James et al., 2016; Kamody et al., 2020; Lefevor et al., 2019; Puckett et al., 2019; Russomano et al., 2019; VanKim et al., 2019). Gender minorities are also disproportionately impacted by several risk factors associated with food insecurity, homelessness, un/underemployment, and low socioeconomic status (Henderson et al., 2019; Russomanno et al., 2019). Evidence suggests that food insecurity is associated with disordered eating behavior, particularly among racial/ethnic minorities and low socioeconomic households (Becker et al., 2017; Becker et al., 2019). Emerging research suggests that food insecurity in the cisgender adult population is associated cross-sectionally with binge eating, bulimia nervosa, compensatory behaviors, and general eating disorder pathology (Hazzard et al., 2020). While minority stress may have a compounding effect, the relationship between food insecurity and disordered eating behavior in the gender-diverse population is unclear. Therefore, the overarching goal of the research project is to examine how food insecurity influences disordered eating symptomology among gender-diverse individuals. The results of this correlational research study will provide a better understanding of the relationship between food insecurity and eating disorder symptomology among gender diverse individuals living in the Southeast and how that relationship may be impacted by minority stress and social support.

The specific aims and hypotheses of the research grant are as follows:

1. Determine the strength of the relationship between food insecurity and eating disorder symptomology among gender-diverse individuals living in the Southeast.

Hypothesis: Food insecurity will be positively correlated with eating disorder symptomology among gender-diverse individuals living in the Southeast.

2. Determine how minority stress impacts the relationship between food insecurity and eating disorder symptomology among gender-diverse individuals living in the Southeast.

Hypothesis: Minority stress will mediate the relationship between food insecurity and eating disorder symptomology among gender-diverse individuals living in the Southeast.

3. Determine how social support impacts the relationship between food insecurity and eating disorder symptomology among gender-diverse individuals living in the Southeast.

Hypothesis: Social support will moderate the relationship between food insecurity and eating disorder symptomology among gender-diverse individuals living in the Southeast.

Research Strategy

Significance

It is well established in the literature that transgender individuals experience repeated episodes of stigma and discrimination due to their gender identity (Henderson et al., 2019; James et al., 2016; Lefevor et al., 2019; Schvey et al., 2020). These recurrences are part of what is known as minority stress, which is the culmination of distal stress processes such as discrimination and violence, and proximal stress processes such as internalized homophobia, concealment, and rejection (Meyer, 2003). Minority stress also includes general stressors, minority identity, environmental circumstances, and coping/social support (Meyer, 2003). The transgender population was not initially included in Meyer’s model of minority stress (Meyer, 2003). Hendricks & Testa (2012) expanded the idea of minority stress to include the transgender population, encompassing ideas such as trans-specific stressors and perception of minority stress, internalized transphobia, and resilience. The concept of minority stress is now widely utilized in transgender research.

Elevated levels of minority stress resulting from systemic discrimination may place the transgender population at greater risk for adverse mental health outcomes such as eating disorders (Lefevor et al., 2019; VanKim et al., 2019). The prevalence of eating disorders among transgender individuals appears to be higher than cisgender individuals (Diemer et al., 2018; Lefevor et al., 2019; Parker & Harriger, 2020; Puckett et al., 2019). Kamody et al. (2020) reported a lifetime prevalence rate of 1.7% for anorexia nervosa, 1.3% for bulimia nervosa, and 2.2% for binge-eating disorder among sexual minority individuals compared to heterosexual, cisgender individuals. The self-reported lifetime prevalence of eating disorders in transgender individuals was highest among trans men at 10.5%, with a 4.2% rate of anorexia nervosa and a 3.2% rate of bulimia nervosa. (Kamody et al., 2020). Trans women reported a lifetime prevalence of 8.1%, with a 4.1% rate of anorexia nervosa and a 2.9% rate of bulimia nervosa (Kamody et al., 2020). It has been reported that, despite the added risk of minority stress, social support is associated with less adverse mental health outcomes (Puckett et al., 2019)

Much of the current literature is limited to the binary transgender population. Less is known about individuals who identify outside the cisnormative spectrum, who may also be at risk for increased disordered eating behavior (Lefevor et al., 2019). Diemer et al. (2018) reported that MTF (male to female) individuals have higher levels of eating disorders than FBGNC (female assigned at birth gender nonconforming) individuals, with MTF individuals having .14 times the odds of reporting an eating disorder diagnosis than FBGNC. Similarly, FTM (female to male) individuals have .46 times the odds of an eating disorder diagnosis than their FBGNC counterparts. While both transgender and gender nonconforming individuals appear to be at elevated risk, trans males may be the most susceptible to an eating disorder diagnosis, with binge eating being the most pervasive disorder (Arikawa et al., 2020). Apart from gender identity, gender expression may also impact disordered eating behavior, with gender-conforming males reporting the lowest diet quality overall (VanKim et al., 2019). Differences in transfeminine versus transmasculine identification may be especially relevant in body dissatisfaction (Testa et al., 2017).

Systemic discrimination may also negatively impact social determinants of health, as data from the 2015 U.S. Transgender Survey (James et al., 2016) revealed that the transgender population is at greater risk for homelessness, unemployment/underemployment, low socioeconomic status, and food insecurity. Food insecurity is defined as insufficient food or access to food for all individuals in a household (Russomanno & Jabson, 2020). As food insecurity is related to socioeconomic, housing, and employment status, transgender and gender nonconforming individuals may be at a much greater risk for adverse health outcomes as compared to their cisgender counterparts (Russomanno et al., 2019). The transgender population experiences higher levels of food stress than their cisgender counterparts (Arikawa et al., 2020; Henderson et al., 2019; Russomano et al., 2019), resulting in poorer physical and mental health (Russomano et al., 2019). Transgender individuals frequently report episodes of discrimination and difficulty accessing support services as barriers to food security (Russomanno et al., 2019), and gender diverse individuals detail discriminatory legislative policies and social stigma as hindrances to successfully accessing emergency public assistance (Russomano & Jabson, 2020). Research suggests that food insecurity is associated with eating disorder symptomology in the cisgender population, with the greatest impact on racial/ethnic minorities and low socioeconomic households (Becker et al., 2017; Becker et al., 2019). Additional research suggests that food insecurity appears to be associated cross-sectionally with compensatory behaviors, binge eating, bulimia nervosa, and overall eating disorder behavior in the cisgender population (Hazzard et al., 2020). However, the relationship between food insecurity and eating disorders in the transgender population is not yet clear.

Innovation

Research focused on the transgender and gender nonbinary population is a burgeoning area, and the emphasis on how food insecurity impacts eating disordered behavior is in its early stages. The results of this correlational research study will provide a better understanding of the relationship between food insecurity and eating disorder symptomology among gender diverse individuals living in the Southeast and how that relationship may be impacted by minority stress and social support. While data on social support in the transgender community is limited, research suggests that, like the cisgender population, social support may be associated with less adverse physical and mental health outcomes and greater resilience. Social support in the transgender community may take many forms, including family of origin, the community at large, or friends who may be viewed as chosen family (Puckett et al., 2019). Additional research is warranted to determine the relationship between transgender individuals facing food insecurity and disordered eating behaviors and whether social support may be a protective factor.

This project could advance the sexual and gender minority literature in several ways. First, by examining the association of food insecurity, eating disorders, and social support through a minority stress lens, this research may help elucidate the factors that contribute to weight stigma in oppressed minority populations, as objectification and discrimination have previously been linked with disordered eating behavior in the transgender population (Brewster et al., 2019). This research could also provide pilot information to inform the need for targeted eating disorder interventions in the gender-diverse population. Lastly, it may also highlight inadequacies in support systems, emphasizing a need for more sexual and gender minority-inclusive public assistance programs.

Approach

A quantitative, correlational study design consisting of online survey methodology was chosen for the proposed research. It was decided that a quantitative design was the most appropriate design to examine the strength and direction of the relationship between the predictor (food insecurity) and criterion variable (eating disorder symptomology), allowing for a larger sample size while minimizing costs and researcher bias.

Measures and Procedures :

Data will be collected using a convenience sample of trans and gender nonbinary (TGNB) adults living in the Southeast states of South Carolina, North Carolina, and Georgia. Participants will be recruited via social media (open support groups, shared posts on Facebook and Instagram, targeted ads) and area non-profit organizations that serve the sexual and gender minority community. The study survey will be created using Qualtrics. Respondents who meet study criteria must acknowledge that they have read and understood the informed consent before being allowed to proceed. After informed consent is provided, individuals will be given access to the survey instruments. No identifying information will be collected, but respondents will be allowed to provide their email to receive study results. At the conclusion of the survey, respondents may choose to click a link to enter a drawing for a gift card for their participation in the study. Respondents will enter their email addresses to enter, but no identifying information will be linked to their data. Respondents will also be given a link to the National Eating Disorders Association (NEDA) website for further information on eating disorders and how to seek treatment. A link to Feeding America will also be provided where participants may enter their zip code to find a food pantry in their area.

The proposed study will be conducted using instruments that have been shown in previous research to be both reliable and valid. Food insecurity will be measured using the 6-item Short Form of the USDA Food Security Survey Module. This instrument, which Carlson et al. (1999) validated, is an abbreviated version of the original 18-item USDA Food Security Survey Module. The Short Form was chosen due to its brevity and a similar ability to the 18-item module to capture food insecure households accurately. Eating disorder symptomology will be assessed using the EDE-QS (Gideon et al., 2016), a short-form of the EDE-Q. This frequently used instrument has shown to be a reliable and valid instrument in prior eating disorders research and with the population of interest (Duffy et al., 2021). Minority stress will be examined using the Gender and Minority Stress and Resilience measure (GMSR), which has been validated in the population of interest (Testa et al., 1995). Social support will be assessed using the Multidimensional Scale of Perceived Social Support (Zimet et al., 1988). This frequently used instrument has proven to be a reliable and valid measure of social support in prior research.

Data Analyses:

Data will be entered into SPSS for analysis. A correlation coefficient will be used to examine the relationship between food insecurity and eating disorders. A mediator and moderator analysis will be conducted to investigate the impact of minority stress and social support on the relationship between food insecurity and eating disorders. All data will be securely stored on a password-protected computer for a period of 3 years.

Data Security:

The Institutional Review Board of Northcentral University will approve the proposed study. The researcher involved in data collection has received training through the CITI program on research ethics. Study subjects will consist of TGNB adults living in the Southeastern United States who are capable of providing informed consent. Subjects must acknowledge that they have read and understood the informed consent before being allowed to proceed with the survey. Due to the sensitive nature of some questions, subjects will be informed of their right to terminate the survey at any time. All data will be de-identified, and no additional identifying information will be collected to maintain the anonymity of participants. Only the researcher will have access to the data, which will be securely stored on a password-protected computer to maintain respondent confidentiality. At the conclusion of the study surveys, subjects will be provided the opportunity to click a link to enter their email address in a drawing for a gift card. Clear instructions will be given on how to enter, and it will be noted that not all participants will receive a gift card. The likelihood of coercion due to compensation is low, as there is minimal risk to the participants associated with the proposed study. Email addresses that are collected for the purposes of compensation and study results will not be linked to participant data to protect anonymity. As the TGNB community is a stigmatized population, all study instruments will be free of discriminatory language (Adams et al., 2017). Informed consent will also use gender-neutral language. The study sample will be accessed using open, publicly available groups on social media that do not require express permission to join or post (Facebook and Instagram). The researcher has agreements with area non-profits that serve sexual and gender minorities that will also be utilized for recruitment efforts (Alliance for Full Acceptance and Charleston Black Pride). The organizations will post all study recruitment materials on the researcher’s behalf to minimize conflict of interest.

Limitations:

It is acknowledged that the sampling methods of the proposed project may be a limitation. However, as the transgender and gender nonbinary population can be a hidden population, it was determined that non-probability sampling methods were suitable for the proposed research. It was also determined that non-probability sampling methods would increase the likelihood of obtaining a sample size that is sufficiently large enough to reduce systematic error.

Bibliography and References

Adams, N., Pearce, R., Veale, J., Radix, A., Castro, D., Sarkar, A., & Thom, K. C. (2017).