Eating disorders (EDs) are prevalent and deleterious, particularly among sexual minority individuals. Some recent research suggests sexual minority men and women are at greater risk for the development of EDs, with higher rates of ED symptoms compared to heterosexual individuals . Moreover, a nationally representative epidemiological survey of men and women found that sexual minority individuals have rates of current ED diagnoses that are 2–5 times higher than heterosexual individuals, and odds of a lifetime ED diagnosis that are roughly double to triple what is found compared to heterosexual individuals . Despite the higher risk and greater prevalence of EDs among sexual minority individuals, relatively little is known about the factors that may contribute to the presentation of weight and eating concerns within sexual minority communities.
Some have theorized that factors in the social environment may relate to the higher likelihood for EDs among sexual minority individuals. For instance, some attitudes and norms within sexual minority subgroups may present ED risk factors [3, 4]. Research indicates that norms within gay communities may promote greater idealization of athletic and lean builds, putting men within the gay community at greater risk compared to heterosexual men [5, 6]. This corresponds with some data that suggest that sexual minority men may be particularly vulnerable compared to heterosexual men to ED symptoms . Research that has acknowledged the potential for risk due to sexual minority community norms has also suggested that the LGBTQIA+ (Lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other gender and sexual identities) community may be a protective factor against ED symptoms [3, 4]. For instance, compared to heterosexual women, women from lesbian communities have been found to accept a broader ranges of body types , suggesting the potential for protection against dietary restriction. Greater sense of belonging within the lesbian community has been shown to be protective against negative effects of body dissatisfaction for lesbian women . Taken together, this research suggests there may be gender differences that affect whether sexual minority community norms serve as risk or protective factors in EDs. However, the existing research on the role of sociocultural factors in EDs for sexual minority individuals is limited. Much of the existing research in this area has focused on comparisons of disordered eating behaviors between sexual minority and heterosexual individuals. Additional work is needed to understand differences within sexual minority communities, and the ways in which social environmental factors may heighten or mitigate risk.
One theory that has sought to better understand the effects of different factors in the social environment on human functioning is Bronfenbrenner’s  ecological systems theory. This developmental model describes four environments that are nested within one another, namely the microsystem, mesosystem, exosystem, and macrosystem. The microsystem is the most proximal setting for an individual and includes the close relationships and roles (e.g., romantic partner) with which an individual has direct contact. The mesosystem includes the interactive connections between factors within the microsystem. The exosystem exists a step beyond an individual’s typical sphere, but could still affect the individual in more indirect ways. The macrosystem includes the norms, ideologies, patterns, and cultural conventions of a society. Bronfenbrenner has described that macrosystems can be implicitly adopted by the people who are part of a society. More specifically, when defining the parts of his Ecological Systems Theory he wrote “most macrosystems are informal and implicit–carried, often unwittingly in the minds of the society’s members as ideology..”(p. 515) . Elements of this theory have been included in previous models of eating behaviors, in which it is noted that sociocultural and interpersonal factors are major influences on eating . These influences fit within the macrosystem (i.e., overarching norms and factors that shape our cultural existence), and microsystem (i.e., the proximal factors which have a role in our individual existence), respectively. The mesosystem and exosystem pose less direct pathways toward influencing the individual, and as such have not yet been established as strong factors in connection to ED symptoms. As an example, the relationship between one’s partner and family (a mesosystem factor) may be less influential on beliefs about weight and shape than either of these microsystem sources independently. Similarly, a romantic partner’s workplace (an exosystem factor) is likely less influential than their partner (a microsystem factor). Therefore, we chose to focus on the macrosystem factor of sociocultural attitudes about weight and shape and the microsystem factor of romantic relationships in our study based on previous work that has established their importance.
It is possible that messages from the macrosystem may be transmitted directly to individuals as well as filtered through the microsystem to relate to eating behavior among sexual minority individuals. Within the microsystem, in adulthood, romantic partners are likely the key figures through which sociocultural attitudes regarding weight and shape are transmitted. In contrast to research involving youth, in which parents are a key source for attitudes about weight , some previous research has not found a relationship between parental messages and body dissatisfaction in adults . The influence of parents may be even weaker for sexual minority adults, considering that some individuals consider close others in the LGBTQIA+ community to be a support system (e.g., “chosen family”) that may be as, or more, important than a family of origin . However, there is work to support to the importance of romantic partners in conveying sociocultural messages about weight and appearance in adulthood, and in sexual minority individuals in particular. Specifically, previous work indicates that gay men prioritize perceived attractiveness and thinness in romantic partners , but the same pressure is not known to exist for friendships. Similarly, romantic partners develop a level of closeness that may not replicate in other relationships and as such serve as important influences on beliefs and attitudes. That is, since individuals tend to develop a shared sense of identity in the context of romantic relationships , the attitudes held by one partner may become part of the shared couple identity over time. This places romantic partners’ attitudes and behaviors regarding eating and weight in a unique position of importance within microsystem factors. Similarly, individuals value the opinions and attitudes of romantic partners above other community members. For instance, the behavior and perceived approval of romantic partners has been shown to predict health behaviors (i.e., smoking) beyond that of friends . Individuals may be influenced, positively or negatively, based on the degree to which their partners adhere to and communicate sociocultural messages regarding body size. Therefore, it is possible that the salience of macrolevel sociocultural messages regarding weight and shape could be amplified by partners who have deeply internalized these messages and reinforce them within the romantic relationship, or diminished by partners who have developed an effective defense against these messages and challenge their tenants to discount their importance within the romantic relationship.
Published literature has yet to apply an ecological systems framework to ED symptoms in sexual minorities; however, previous research indicates these models are a useful approach to examine the physical and mental health experiences of sexual minority individuals more generally [18,19,20]. Similar approaches such as the tripartite model, which emphasizes the role of social factors in relation to ED risk, have been supported among sexual minority samples [21,22,23]. Therefore, it appears that to better understand ED risk and protective factors for sexual minority individuals, more attention is needed toward sociocultural and relationship factors.
Internalization of sociocultural attitudes
Some research supports the notion that internalization of sociocultural attitudes may be a particularly relevant factor in the development of EDs for sexual minority individuals. Much of the literature on this topic has examined this question separately for men and women.
For men, the relationships between media and body dissatisfaction and between media and lower self-esteem have been shown to be stronger for gay men compared to heterosexual men . Some have theorized that social media use may relate to greater internalization of sociocultural attitudes that promote negative body image through processes such as social comparison, self-objectification, and self-surveillance, and that this in turn heightens ED risk for sexual minority men . These ideas are supported by evidence indicating that social media use is linked to muscularity dissatisfaction and ED symptoms among sexual minority men . Similarly, greater exposure to idealized muscular images through fitness magazines has been linked to body dissatisfaction, greater physique-related anxiety, and greater drives for both muscularity and thinness for gay men . In addition to the exposure effects of images, some research has found that sexual minority men are more influenced than heterosexual men by images in advertisements focusing on physical appearance; this heightened sensitivity to internalization of social messages may explain the relationship between sexual orientation and ED symptoms for men . These findings further indicate that gay men are more influenced by social messages through media than heterosexual men; greater influence by these messages then may mediate the effect of sexual orientation on ED symptoms .
For women, the negative effects of internalization of messages in the social environment pertaining to weight and eating have been well-documented [30, 31]; however, less is known about this among sexual minority women. Evidence synthesized in a systematic review indicates that many of the sociocultural risk factors related to negative body image and ED symptoms among heterosexual women extend to sexual minority women as well . This research suggests that the internalization of sociocultural attitudes for sexual minority women may be similar to what has already been found for women in general. Some evidence consistent with these findings supports that internalization of beauty ideals predicts negative body image among sexual minority women . More recent research also indicates that media-based appearance-related pressures and internalization of thin and muscular ideals are similar for lesbian, bisexual and heterosexual women, and are linked to comparable levels of ED symptoms across sexual orientation groups . However, some research has found contrasting results. For instance, some have found that lesbian women have lower internalization of sociocultural beauty standards  and lower body dissatisfaction  compared to heterosexual women despite having similar or higher levels of ED symptoms. Others have found that lesbian women have lower appearance-related pressures from peers than heterosexual and bisexual women . As such, greater attention needs to be paid to the ways in which internalization of sociocultural attitudes relate to ED symptoms in sexual minority women.
Relationship factors are also an important consideration when examining ED symptoms in sexual minority individuals. The literature is mixed however regarding the nature of the association between romantic relationship factors and ED symptoms. Several studies have indicated relationships may include potentially harmful effects for ED symptoms in sexual minority individuals. For instance, pressures from significant others to have an “ideal” body are strongly associated with ED symptoms for sexual minority men and women . Additionally, having a partner who is of lower BMI can confer risk for ED symptoms for sexual minority men and women . Within the context of romantic relationships, gay men’s preferences in partners have been found to be influenced by attractiveness and explained by internalization of the thin ideal and dissatisfaction related to weight and shape . This finding suggests a high degree of importance is placed on attractiveness and physique in men’s same-gender relationships. Notably though, this was not found among lesbian women in the same study . Gay men have been shown to be more likely to influence and monitor their partners’ eating habits compared to heterosexual men and compared to lesbian and heterosexual women . Taken together, previous research suggests the importance of investigating gender differences in studies of relationship factors and ED symptoms among sexual minority individuals.
In addition to the studies that have pointed to a potentially negative role of romantic relationships, other work suggests being in a committed relationship may protect against risk for ED symptoms for sexual minority individuals. For instance, evidence suggests that gay men overestimate the degree to which other gay men are attracted to thin and muscular physiques; this leads to heightened body dissatisfaction for those who are single, but not for those in committed romantic relationships . Similarly, for sexual minority men, being single has been linked to greater restrictive ED symptoms  and greater drive for thinness both cross-sectionally , and longitudinally over a 10-year period . Gay men in stable relationships have been found to have lower ED symptoms compared to those who were not; however, no difference in ED symptoms has been found based on relationship status for lesbian women . Although less is known about the effect of being in a relationship on ED-related risk factors for lesbian women, related research shows that being unpartnered is related to greater depression, anxiety, and alcohol use for this group [8, 44]. This suggest that being in a relationship confers mental health benefits for lesbian women that may extend to EDs.
However, relationship status alone is not the only factor for consideration, as not all relationships are equally protective. Lower relationship satisfaction has been correlated cross-sectionally with greater bulimic ED symptoms in sexual minority men . Similarly, for sexual minority men, lower baseline satisfaction in their relationships was predictive of a trajectory toward a greater drive for thinness over a 10-year period . Although no published research has examined the effect of relationship quality on ED symptoms among lesbian women, related work demonstrates that relationship satisfaction is a significant contributor to depression risk , and it is possible this may hold for EDs as well. This finding suggests that factors found within satisfying committed relationships, such as stability, support, and compassion, may underlie the benefits that being partnered may carry. That is, the quality of the relationship, rather than simply one’s relationship status, may be instrumental in understanding the relationships in association to ED symptoms.
To our knowledge, no previous research exists to examine whether a positive relationship can protect against the damaging effects of internalizing negative societal messages about shape and weight. It is possible that the broader attitudes that are held by Western cultures that emphasize a lean build may carry less importance when one’s body is loved and appreciated by a partner in a satisfying and committed relationship. Similarly, the support and validation of worth that one receives from a partner may protect against negative sociocultural messages on eating behavior.
In sum, sociocultural and relationship factors warrant additional consideration as social environmental factors in relation to ED symptoms among sexual minority individuals. Few studies have considered the ways in which both overarching sociocultural influences and close romantic relationships affect ED symptoms in sexual minority individuals despite the elevated prevalence of ED concerns in this group. There is a demonstrated need to better understand risk and protective factors for ED symptoms among sexual minority individuals. In particular, very little work exists examining sociocultural and relationship factors within the context of same-gender couples, or across sexual minority men and women. There is a precedent in the literature of examining ED symptoms separately for sexual minority men and women and drawing inferences about risk; however, it is important to determine whether gender differences exist by comparing men and women directly.
The current study plans to fill these gaps by examining the relation of internalization of sociocultural attitudes and relationship quality to ED symptoms among sexual minority individuals in relationships with same-gender partners. The ability to examine these questions in a sample composed of couples allows us to control for relationship status and focus more on the quality of the relationship. This will allow us to determine whether the associations that may be observed are consistent across same-gender relationships, or whether differences between men and women may be present.
Our aims are as follows:
We aim to evaluate gender differences in the internalization of sociocultural attitudes, relationship quality, and ED symptoms.
We aim to examine the association of internalization of sociocultural attitudes and relationship quality to ED symptoms.
We aim to evaluate the interaction of internalization of sociocultural attitudes and relationship quality on ED symptoms. Specifically, we seek to learn whether the effect of a high-quality romantic relationship can buffer against the internalization of sociocultural attitudes pertaining to weight and shape, thus protecting against ED symptoms.
We plan to explore the conditional association of gender by examining:
The interaction of internalization of sociocultural attitudes and gender on ED symptoms.
The interaction of relationship quality and gender on ED symptoms.