Evidence That the DSM‐5‐TR Eating Disorder Criteria Perform Differently Across Cisgender and Transgender or Gender Diverse Individuals Using the Eating Disorder Diagnostic Scale

• Published in: The International journal of eating disorders
• Main Authors: Sharma, Anjali R., Bottera, Angeline R., Joo, Sean, Chen, Yiyang, Like, Emily E., Forbush, Kelsie T.
• Format: Journal Article
• Language: English
• Published: United States 23.09.2025
• Subjects: assessment; gender; item bias; diagnosis; health equity; gender diverse; eating disorder symptoms; transgender
• ISSN: 0276-3478; 1098-108X; 1098-108X
• DOI: 10.1002/eat.24554

Transgender and gender diverse (TGD) individuals demonstrate elevated risk for eating disorders (EDs) and ED symptoms compared to cisgender individuals. Rates of ED symptoms in TGD populations may be inaccurately estimated due to item bias or interpretation differences on assessments of ED diagnostic criteria. Differential item functioning (DIF) can indicate if individuals respond differently to assessment items at the same latent level of ED psychopathology. We aimed to assess for DIF in the ED diagnostic criteria, represented by items on the Eating Disorder Diagnostic Scale (EDDS), among cisgender men/women and TGD individuals. We expected small-to-moderate DIF between cisgender men/women. We hypothesized that items assessing body image, shape, and fear of fatness would demonstrate significant DIF with moderate-to-large effect sizes in TGD individuals relative to cisgender men/women. College students identifying as cisgender men (n = 1240), cisgender women (n = 3750), and TGD individuals (n = 271) completed the EDDS. DIF was tested using likelihood ratio tests. The magnitude of the effect was estimated to identify moderate-to-large effects. Results indicated large, significant response bias to items assessing weight concerns, psychosocial impairment, compensatory behavior frequency, and select binge-eating symptoms. Specifically, cisgender men and TGD individuals were significantly less likely to endorse these ED symptoms than cisgender women at the same latent level of ED psychopathology. This study was the first to investigate DIF in an assessment of ED diagnostic criteria in TGD individuals. Our findings identified a need for unbiased assessments of ED diagnostic criteria to more accurately assess ED symptoms across gender groups.