Background: Eating disorders (EDs) are often stereotyped as a “women’s health issue,” due in part to the striking gendered inequities in risk. However, this stereotype has contributed to the prioritization of gender as the dominant analytic category through which to study the epidemiology of EDs, as well as research practices that erroneously treat the observed inequities as universal, fixed, or even self-evident. There are thus important knowledge gaps regarding the social patterning and structural drivers of EDs that may be undermining equitable resource allocation and intervention. Drawing on intersectionality and other critical feminist theories, this dissertation sought to address these gaps in three specific aims: (1) to examine how gender identity intersects with gender expression, sexual orientation, and weight status to shape the social patterning of EDs; (2) to evaluate the extent to which structural sexism (i.e., systematic gender inequality in power and resources) contributes to gendered inequities in EDs; and (3) to assess whether the relationship between structural sexism and EDs differs within gender identity groups by gender expression, sexual orientation, and/or weight status. Methods: Participants came from the Growing Up Today Study (GUTS), a U.S. national cohort of ~27,000 young people that began in 1996 and is ongoing. For Aim 1, a novel multilevel modeling method for quantitative intersectionality research was used to estimate the prevalence of ED diagnoses and associated symptomology (i.e., binge-purge behaviors) for 32 intersectional strata, or subgroups defined by all possible combinations of two gender identity categories, two gender expression categories, four sexual orientation categories, and two weight status categories. For Aims 2 and 3, a composite index of U.S. state-level structural sexism was linked to the geocoded GUTS data and sequential conditional mean models were used to evaluate the overall, gender identity-specific, and intersectional stratum-specific relationships between time spent living in a structurally sexist state and subsequent risk of ED symptomology. Results: Aim 1 revealed a complex social patterning of ED prevalence characterized by meaningful levels of heterogeneity both between and within gender identity categories. Importantly, intersectional strata including multiply marginalized girls and women (i.e., those who were gender nonconforming, sexual minority, and/or living in a larger body) reported the highest prevalence of both ED diagnoses and associated symptomology. In Aim 2, it was found that each additional year of living in a state characterized by a high degree of structural sexism (e.g., large wage gaps, few legal protections) increased ED symptomology risk by up to 9%; further, girls and women who had lived in a structurally sexist state for four or more years evidenced excess risk relative to boys and men, partially explaining the observed inequities. Aim 3 integrated findings from Aims 1 and 2 by demonstrating how long-term exposure to state-level structural sexism was particularly deleterious for multiply marginalized girls and women. Conclusions: Findings from this dissertation challenge prevailing stereotypes about EDs by demonstrating their inherently intersectional and contextual nature. This work also contributes theoretical and methodological advancements for social epidemiologic research on gender and EDs, and intersectional health inequities more broadly.

PURPOSE: We examined the combined influences of race/ethnicity and neighborhood socioeconomic status (SES) on long-term survival among patients with multiple myeloma (MM). METHODS: Data from the 2000-2015 NCI Surveillance, Epidemiology, and End Results Program (SEER-18) were used. Census tract-level SES index was assessed in tertiles (low, medium, high SES). Competing-risk modeling was used to estimate sub-hazard ratios (SHR) and 95% confidence intervals (CIs) for SES tertile adjusted for sex and age at diagnosis and stratified by race/ethnicity. RESULTS: Overall, living in a low SES neighborhood was associated with worse MM survival. However, we observed some variation in the association by racial/ethnic group. Living in a low versus a high SES neighborhood was associated with a 35% (95% CI = 1.16-1.57) increase in MM-specific mortality risk among Asian/Pacific Islander cases, a 17% (95% CI = 1.12-1.22) increase among White cases, a 14% (95% CI = 1.04-1.23) increase among Black cases, and a 7% (95% CI = 0.96-1.19) increase among Hispanic cases. CONCLUSION: These results suggest that the influence of both SES and race/ethnicity should be considered when considering interventions to remedy disparities in MM survival.

The objective of this study was to investigate how gender identity, the overwhelmingly prioritized dimension of social identity/position in eating-related pathology research, intersects with gender expression, sexual orientation, and weight status to structure the social patterning of eating disorders and disordered eating behaviors among young people in the U.S. Data were drawn from the 2010/2011 Growing Up Today Study (GUTS; N = 11,090-13,307). We conducted an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) by nesting participants within social strata defined by intersecting gender identity, gender expression, sexual orientation, and weight status categories in a series of multilevel logistic models for four outcomes (past-year purging, overeating, and binge eating; lifetime eating disorder diagnosis). To illustrate the advantages of intersectional MAIHDA, we compared the results to those from unitary and conventional intersectional analyses. The intersectional MAIHDA revealed a complex social patterning of eating-related pathology characterized by heterogeneity and outcome-specificity. Several multiply marginalized strata (e.g., those including gender nonconforming, sexual minority, and/or larger-bodied girls/women) had disproportionately elevated prevalence, although all estimates were driven by additive effects. Notably, these patterns were obscured within the unitary and conventional intersectional analyses. Future epidemiologic research on eating-related pathology should continue to adopt an intersectional approach through the use of appropriate methodologies.

INTRODUCTION: On average, patients with axial spondyloarthritis (axSpA) suffer from symptoms up to 13 or more years before diagnosis, contributing to psychological distress and healthcare burden METHODS: We conducted six semi-structured focus groups with 26 axSpA patients (from 3 rheumatology practices located in the states of Massachusetts, Colorado, and Pensylvania, USA) exploring early disease and diagnostic experiences. Verbatim transcripts were coded using a start list with emerging thematic codes added. A qualitative thematic analysis was performed RESULTS: Many participants described meandering and frustrating diagnostic journeys. Participants reported that intermittent axSpA symptoms and idiopathic pain contributed to physician confusion and delay in patients seeking care. Participants were sometimes perceived as somaticizing, drug-seeking, or "crazy." Diagnostic delay led to frustration and mental suffering. Doctors "giving up" was considered profoundly negative. Stories of symptoms fell into five areas: (1) pain; (2) stiffness; (3) impact on sleep; (4) impact on daily activities; and (5) changes with weather. Self-advocacy and family advocacy were considered essential. Participants suggested wider use of HLA-B27 testing and development of a definitive diagnostic test CONCLUSION: Most participants described significant suffering prior to axSpA diagnosis which could have been avoided with earlier intervention. Further research on the early disease experiences of axSpA patients is needed.

BACKGROUND: Health care satisfaction is a key component of patient-centered care. Prior research on transgender populations has been based on convenience samples, and/or grouped all gender minorities into a single category. OBJECTIVE: The objective of this study was to quantify differences in health care satisfaction among transgender men, transgender women, gender nonconforming, and cisgender adults in a diverse multistate sample. RESEARCH DESIGN: Cross-sectional analysis of 2014-2018 Behavioral Risk Factor Surveillance System data from 20 states, using multivariable logistic models. SUBJECTS: We identified 167,468 transgender men, transgender women, gender-nonconforming people, cisgender women, and cisgender men and compared past year health care satisfaction across these groups. RESULTS: Transgender men and women had the highest prevalence of being "not at all satisfied" with the health care they received (14.6% and 8.6%, respectively), and gender-nonconforming people had the lowest prevalence of being "very satisfied" with their health care (55.7%). After adjustment for sociodemographic characteristics, transgender men were more likely to report being "not at all satisfied" with health care than cisgender men (odds ratio: 4.45, 95% confidence interval: 1.72-11.5) and cisgender women (odds ratio: 3.40, 95% confidence interval: 1.31-8.80). CONCLUSIONS: Findings indicate that transgender and gender-nonconforming adults report considerably less health care satisfaction relative to their cisgender peers. Interventions to address factors driving these differences are needed.