Inequities in eating disorder diagnoses in college students: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA)

Abstract

Eating disorders contribute significantly to negative health outcomes across a broad range of domains. Despite their often-debilitating effects, they remain understudied, especially with respect to the experiences of people who are marginalized by multiple structural systems of power and oppression. The intersectionality framework highlights the mutually constitutive nature of those systems and the ways by which they uniquely shape lived experiences within and between populations. We used data from the American College Health Association National College Health Assessment III (ACHA-NCHA III), a repeated cross-sectional survey of college students, to estimate the prevalence of eating disorder diagnoses across intersections of gender identity, sexual orientation, race/ethnicity, and parental education via a Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA). Two models were fit, one assessing only stratum-specific variations and another including race/ethnicity, gender identity, sexual orientation, and parental education as main effects. The prevalence of eating disorder diagnoses in the sample was 5.13 %, with stratum-specific prevalence estimates ranging from 0.44 % for Black, straight, cisgender men whose parents have a bachelor's degree to 19.20 % for transfeminine and nonbinary, bisexual/pansexual, Indigenous people whose parents have more than a bachelor's degree. There was a large main effect of gender identity, with strata inclusive of transfeminine and nonbinary individuals having 6.55 times greater odds (95 % CI: 5.70-7.51) of eating disorder diagnoses compared to cisgender men. Intersectional interactions between gender identity, sexual orientation, race/ethnicity, and parental education contributed to 2.66 % excess prevalence among White, bisexual/pansexual, cisgender women whose parents had less than a bachelor's degree, and 2.93 % lower prevalence among White, gay/lesbian, transfeminine and nonbinary people whose parents had less than a bachelor's degree. These findings emphasize the concerning inequities in eating disorder diagnoses among college students, and call attention to the multiple, interlocking systems of power and oppression that shape them.

Keywords: Diagnosis; Eating disorders; Gender identity; MAIHDA; Race/ethnicity; Sexual orientation; Socioeconomic status.