Eating Disorders Through A Social Justice Lens: An Overview

Eating disorders, the treatment thereof, and the diet culture that fuels them are social justice issues. This page is intended as a resource to share basic information around this hugely important (yet all too often overlooked) topic.

Introduction

Here are a couple important things to keep in mind as you read:

Uncertainty is necessary for growth. Many of us are trained to try and tie up loose ends, but this work does not lend itself to finding certainty. We must work together to create space for the uncertainty, because it is valuable and valid.

Intersectionality is foundational to this work. In the words of Kimberlé Williams Crenshaw, who is credited with coining the term, intersectionality refers to “the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage. Intersectionality cannot be discussed outside of the context of systems of power and inequality.”

Overview on Eating Disorders

Eating disorders occur across all socioeconomic statuses, racial and ethnic groups, ages, gender identities, sexual orientations, abilities, sizes, etc. They are associated with anxiety, depression, OCD, substance abuse, and trauma.

DSM-V Eating Disorders:

• Pica

• Rumination Disorder

• Avoidant/Restrictive Food Intake Disorder

• Anorexia Nervosa – Restricting and Binge & Purge Subtypes + Atypical Anorexia Nervosa

• Bulimia Nervosa

• Binge Eating Disorder

• Other Specified Feeding or Eating Disorder – Purging Disorder, Low Frequency Binge Eating Disorder, Night Eating

• Unspecified Feeding or Eating Disorder

Anorexia Nervosa

• Approximately 80% of patients don’t “look the part”

• Carries the highest mortality rate of any psychiatric condition: about 15%, half of which occurs as a result of suicide

• Carries a risk of suicide that is 30x higher than the general population

Bulimia Nervosa

• A disorder that is easily hidden

• Diagnosis often requires direct questions

Binge Eating Disorder

• Often diagnosed with overeating – food restriction treatment approach in many medical settings which is not helpful

Who gets an eating disorder?

Societal, research, and medical/clinical institutions perpetuate the myth of the Cisgender, Neurotypical, Able-Bodied, White, Thin, Straight, Affluent Teenage Girl.

This reflects a limited imagination – socially, clinically, and in research settings – for people with eating disorders who are:

• Living with disabilities

• Queer

• Trans

• Non-binary

• Men

• Racialized

• Fat

• Poor

• Older

• …or any configuration thereof, as well as additional areas of marginalization

Assumptions

Assumptions circulate around who is at risk for and who is immune to eating disorders. Prevention strategies, treatment, and research are geared accordingly which actively harm marginalized communities struggling with eating disorders.

Stats

• Black teenagers are 50% more likely than white teenagers to exhibit bulimic behaviors, such as bingeing and purging. 

• A 2014 study found that rates of disordered eating have increased across all demographic sectors, but at a faster rate in male, lower socioeconomic and older folks

• Transgender college students were significantly more likely than members of any other group of college students to report an eating disorder diagnosis in the past year- 2015 study.

• Teenage girls from low income families are 153% more likely to struggle with bulimia than girls from wealthy families.

• Only 20% of those with eating disorders fit the “emaciated body” stereotype. https://www.nationaleatingdisorders.org/marginalized-voices

• AN & BED prevalence similar across racial groups, BN higher among Latinos and African Americans than Whites 

• Lifetime prevalence of any binge eating (ABE) was greater among each ethnic group in comparison to Whites (Marques ,Alegria ,Becker,Chen ,Fang ,Chosak ,Diniz, 2011; Becker, 2003)

• Eating disorders prevalence data suggests more similarities than differences in race/ethnic groups (Marques, Alegria, Becker, Chen, Fang et al., 2011)

• Some studies show lower prevalence for African Americans – research argue this is due to diagnostic biases (Ham, Iorio, & Sovinsky, 2012).

Dx and Race

• Study of 91 clinicians reviewing case profiles

• All cases were exactly the same eating disorder profile, the only differing characteristic was race

  • Case of White woman- 44% diagnosed her with an ed

  • Case of Latinx woman- 40% diagnosed her with an ed

  • Case of Black woman- 16% diagnosed her with an ed

(Impact of Client Race on Clinician Detection of Eating Disorders (2006) Gordon, Brattole, Wingate, Joiner)

Treatment Utilization

• Lifetime prevalence of mental health service utilization was lower among ethnic groups than for Whites with a lifetime history of any eating disorder.(Sala, et.al., 2013; Marques ,Alegria, Becker, Chen, Fang, Chosak, Diniz, 2011; Becker, 2003)

• Differences in clinical presentation not captured by traditional instruments that were developed primarily for white populations (Sala, et.al., 2013; Alegria et al., 2007)

• Different help seeking patterns (Sala, et.al., 2013; Becker et al., 2003) 

• Individual and the clinician might not recognize the eating disorder (Sala, et.al., 2013; Cachelin et al., 2001)

Transgender folks and eating disorders

• College Study –  Trans students reported significantly higher past year eating disorder diagnosis rates, past month use of diet pills, vomiting, and laxative use when compared to all other groups (Diemer, 2015). 

• Algars (2012) found that after surgical transition, both trans men and women reported that the disordered eating symptoms subsided. 

• 2016 study examined the treatment experiences of 84 transgender individuals with eating disorders- not one person reported a positive experience with treatment (Duffy, Henkel, & Earnshaw, 2016)

Disabilities and eating disorders

• Physical disabilities mistakenly seen as protective factor against eating disorders

• Young women with specific physical disabilities (Spina bifada and arthritis) higher rates of AN and BN  (Gross, Ireys, Kinsman, 2000)

• Study of women with scoliosis – restrictive eating related to effects of disability not weight (Smith, Latchford, Hall, Dickson, 2008)

• Limited studies on disabilities and eating disorders

Limitations of screening tools

• Focus on looks and appearance

• Heteronormative standards around body image

• Bodies are viewed as one dimensional

Eating Disorder Treatment Balance & Expansion 

• Psycho education – Medical risks, Psychological risks, therapy interfering aspects

• Willingness to hold space for process and readiness AND ambivalence

• Reframe “resistance” to protection

• Treatment agreements – harm reduction

What would treatment through a social justice lens look like?

• Addressing and understanding power differentials between staff and clients, both in their professional roles and in their identities

• Operating with the knowledge that marginalized people often have many previous negative experiences with healthcare systems

• Understanding that motivation to change can be a barrier, as readiness for recovery can work against marginalized folks with eating disorders

• Providing space for patients to show up safely and authentically, in all their identities

Body Justice: What Does it Mean to You?

Body Image (BI) Process

• How do we conceptually hold the process of shifting BI with our folks? It is a radical shift and may be too much for people to hold.

• How do we hold and honor the stories that come up with exploring BI? These often center around trauma, violence, pain, and injustice.

• How do we honor the internalized fatphobia/isms that serve as coping mechanisms?

• How do we acknowledge the world we live in with various forms of oppression and body targeting?

• How do we hold space for bodies in transition, bodies that are changing, and bodies with differing levels of ability?

Ask what folks hope for in weight loss

• This is generally love, respect, value, inclusion, etc

• Acknowledge how our systems of oppression attacks these essential human needs

• Acknowledge how capitalism manipulates us by knowing these essential human needs

• Belonging vs. fitting in

Resistance in shifting BI

• If your resistance could talk…what would it say?

Consultation with Body Trust – Hilary Kinavey, MS, LPC, and Dana Sturtevant, MS, RD (2019)