Lesbian, gay, bisexual, and transgender individuals may be at a higher risk of developing an eating disorder than straight and cisgender individuals, with transgender people at the highest risk, according to a new study. This was the first study to examine eating disordered behavior among a significant proportion of transgender people compared to cisgender people.

Researchers surveyed more than 22,000 students from 223 U.S. universities between 2008 and 2011 about their mental health, substance use, sexual behavior, and nutrition history. They found that cisgender heterosexual men were at the lowest risk of eating disorders, while transgender people were at the highest risk.

“We found that broadly speaking, cisgender [not transgender] heterosexual men had the lowest rates [of eating disorders], followed by cisgender sexual minority women, cisgender heterosexual women, cisgender unsure and sexual minority men and women, and that trans people had the highest rates,” said the study’s lead author, Alexis E. Duncan from Washington University in St. Louis.

Overall, about 1.5% of the students reported being diagnosed with an eating disorder during the previous year, while nearly 3% had self-induced vomited or used laxatives to control weight. More than 3% had used diet pills in the previous month. These behaviors were most common among transgender students and least common among cisgender heterosexual male students, the researchers found.

Past studies of eating disordered behaviors have generally focused on heterosexual women, who are considered the most at risk. But in this study, transgender students were more than four times as likely as cisgender heterosexual women to report an eating disorder diagnosis. Trans students were also twice as likely to have used diet pills, self-induced vomiting, or laxatives to control weight.

Cisgender lesbian or bisexual women were less likely than cisgender straight women to report an eating disorder diagnosis. Meanwhile, Cisgender women and men who were unsure of their sexuality, along with cisgender gay or bisexual men, were more likely to report an eating disorder diagnosis.

A past study conducted by Monica Algars of Abo Akademi University in Turku, Finland, found a connection between eating disorders and gender dysphoria and body dissatisfaction among transgender people. Attempts to suppress features of their birth gender may manifest as a desire to control weight, Algars explained. Stress due to stigma and discrimination may also contribute to the problem.

“On a more positive note, many transgender people report that gender reassignment treatment can alleviate body dissatisfaction and eating (disorders),” said Algars.