Background Marginalized populations experience increased eating disorder (ED) risk and encounter significant barriers to treatment. Intersectionality provides a framework for understanding how systemic oppression contributes to inequities in EDs; however, intersectional approaches have yet to be applied to a clinical ED sample. The current study examined inequities in ED severity and treatment outcome across the intersections of race/ethnicity, sexual orientation, and socioeconomic status (SES).

Methods Adult women (N=3,016; M=27.2 years) with transdiagnostic EDs presenting to affiliated treatment sites across the United States completed the Eating Disorder Examination-Questionnaire (EDE-Q) at admission and discharge. Race/ethnicity and sexual orientation were self-reported; SES was measured using the area deprivation index of participants’ neighborhoods. Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) was used to estimate baseline EDE-Q global score; change in EDE-Q global score and binge eating, self-induced vomiting, laxative use, and driven exercise frequency from admission to discharge; and reason for discharge (routine or non-routine) across intersectional subgroups.

Results In this sample of women with access to treatment, MAIHDA models predicted higher baseline levels of overall ED pathology among sexual minorities (predicted M=4.10). There were few differences in ED symptom improvement across intersectional subgroups, with some small yet potentially meaningful inequities. Racially/ethnically minoritized subgroups were slightly less likely to complete treatment (predicted percent non-routine discharge=41.50%).

Conclusions Future research should build on these findings by analyzing other dimensions of inequity (e.g., gender, weight status, disability status) to further characterize and address intersecting systems of oppression that disparately influence ED outcomes.

Dr. Le Grange receives royalties from Guilford Press and Routledge. He is co-director of the Training Institute for Child and Adolescent Eating Disorders, LLC, and a member of the Clinical Advisory Board of Univa Health. Dr. Rienecke receives royalties from Routledge and consulting fees from the Training Institute for Child and Adolescent Eating Disorders, LLC.

This study was funded by the National Institute of Mental Health (DLG, grant number R34MH123596; SG, grant numbers K23MH126201, R21MH131787; EER, grant number K23MH131871; SS, grant number T32MH018261); the National Institute on Minority Health and Health Disparities (ALB, grant number 5F32MD017452); and the Brain and Behavior Research Foundation (SG, grant number 5F32MD017452).

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The current study was approved by the Salus Institutional Review Board. All participants and their legal guardians provided informed assent and consent.

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↵† Drs. Rienecke and Reilly share responsibility of senior authorship.

samar.shaqourucsf.edu; sasha.gorrellucsf.edu; simar.singh2ucsf.edu; kianna.zuckerucsf.edu; daniel.legrangeucsf.edu; erin.reilly3ucsf.edu; ariel.becciachildrens.harvard.edu; megan.riddleercpathlight.com; alan.duffyercpathlight.com; phil.mehlerercpathlight.com; renee.rieneckeercpathlight.com

All data produced in the present study are available upon reasonable request to the authors.