By Jana Keith-Jennings, LMSW
The majority of eating disorder treatments and research has been focused primarily on thin, straight, white, middle- or upper-class, able-bodied women with anorexia nervosa. While this focus has generated important findings, it has failed to address the bigger picture: the truth that eating disorders can affect anyone, regardless of age, race, ethnicity, gender, sexual identity, or socioeconomic background.
More intersectional and demographic-specific research is needed to better understand eating disorders (EDs), particularly in populations such as BIPOC, queer, trans, neurodivergent, fat*, older, and differently-abled. Exploring specific presentations in these populations along with rates of incidence and age of onset might yield data that differentiates or distinguishes these populations in ways that current modes of treatment fail to consider in their approaches.
*Note: The word “fat” is being used intentionally in the de-stigmatized, reclaimed sense.
Limitations of leading evidence-based eating disorder treatments for eating disorders
While current evidence-based treatments for eating disorders can be highly effective, they are not a good fit for everyone. Often, this is because they fail to integrate a nuanced understanding of the varied ways EDs present and the diversity of the people impacted.
Let’s explore some of the ways that current evidence-based eating disorder treatments are narrow in scope and thus require sensitive and skilled delivery to effectively meet the realities of a broader range of individuals presenting for care.
Most contemporary health models rely heavily on the body mass index (BMI) as a key indicator of health, despite the fact that the BMI was never intended to be used as a measure of health but as a descriptor of averages (e.g., height and weight) across populations. Furthermore, the BMI is based entirely on data collected from white European populations and does nothing to adjust ranges based on racial and genetic differences that might dramatically impact the BMI results across different populations. For example, the shift in identified ranges for obesity in the 1990s, which resulted in a much larger percentage of the American population being identified as obese virtually overnight, has continued to fuel a long-standing moral panic that has framed obesity as an “epidemic” of national proportions. This fat-phobic view continues to inform harmful, reductionist, anti-fat notions of health, pathology, and morality across medical and social institutions. It has also obscured a more nuanced conversation about health and body size, particularly when it comes to generalized knowledge of eating disorders.
While some parameters around weight are needed for clinical diagnosis of eating disorders, the BMI alone is an inaccurate tool for measuring health or defining physical recovery from an ED. Research and countless patient anecdotes tell us that medical professionals are so dependent on BMI as a diagnostic tool that they tend to under diagnose eating disorders across body sizes. They also fail to recognize the significant impact of weight suppression on larger bodies (as in atypical anorexia). People with average or higher BMIs are often invalidated or even dissuaded from seeking an ED diagnosis or treatment based on BMI alone. Meanwhile, bodies with dangerously low BMIs are also under diagnosed or overlooked as candidates for EDs, given the pro-thin, anti-fat bias that the “obesity epidemic” has unleashed.
In a longitudinal study across 10 years conducted by Harvard University, researchers measured trends in both implicit and explicit bias. Anti-fat bias is the one studied bias that has continually risen over the last 10 years in both forms (whereas gender, sexuality, and racial bias have gone down or neutralized). This bias serves as a form of unprotected oppression that allows employers, companies, and private citizens to freely act upon their own prejudices without social or legal intervention. It cannot remain unexamined in terms of its influence on individual “fear of fatness” and desire for thinness.
The fact that body size discrimination poses a very tangible threat to fat individuals—from public shaming to access to resources, issues of accessibility, employment, and infringement of basic civil rights—is not something that is fully acknowledged within current evidence-based ED treatments. Certainly, the lived daily impact of anti-fat bias on larger-bodied people plays a distinctly different role in their formation of body shape and weight concerns than it does for thin-bodied people. Treating these experiences as the same denies the basic lived reality and threat to personhood that people with fat bodies and eating disorders experience on a daily basis, which thin people with eating disorders may fear just as intensely but will never experience firsthand.
Social context and social media
The current leading ED treatment models do not focus on the larger social context impacting the development of eating disorders of all kinds. Our societal preoccupation with weight, shape, and food control drives a collective preoccupation that can easily fuel the fires of a burgeoning eating disorder. It would be remiss not to consider the significant impact and influence of societal norms, especially when looking at how young people are socialized through social media today and the growing understanding we have about how much tech has been designed with psychological manipulation as its main function and goal.
One of the most significant historical changes in the social context in which EDs incubate is the role of social media in the daily lives of all of us. The barrage of images and messages disseminated around the clock impact individuals of all ages. There is already a well-established link between social media use and mental illness. A number of studies have demonstrated the connection between social media use/exposure with negative body image and the development of eating disorders. We know that some of the most potentially harmful social media content preferentially targets young people, which is particularly concerning since the mean age of onset of eating disorders is 18. The prevailing treatments need to be updated to incorporate interventions to address social media use and the psychological impact of social media exposure.
Differences in genetics and physical characteristics across racial groups, as well as cultural norms around eating, beauty, and body size, mean that race will invariably impact narratives and attitudes about eating and weight. To be effective, treatment should understand and address these nuanced human differences, among other things, to validate the lived experience of BIPOC individuals. Cultural language about eating, bodies, and embodiment varies across racial and ethnic experiences and must be considered in terms of treatment interventions as well.
Current evidence-based treatment models do not inherently integrate the impact of the lived daily experience of cultural and systemic oppression, and the nuances of race-based traumatic invalidation. Thus, providers delivering the treatments are called to bring in their own cultural competencies, thoughtfulness, and sensitivity to be sure that BIPOC patients feel seen, understood, and appropriately supported through treatment.
Trans and gender-diverse people
There is a small amount of research investigating the incidence of EDs in gender-divergent youth, specifically at the onset of puberty. Anecdotal data suggests that there may be a consistent trend of trans and gender-divergent youth reverting to eating disorder behavior as a way to stave off, slow, or cope with the secondary sex characteristic body changes brought on by puberty. Current treatments don’t directly address this potential “function” of weight control and food restriction.
The efficacy and medical considerations around the use of puberty blockers, HRT, and gender-confirmation surgery for individuals with EDs, and especially those with weight restoration goals, has yet to be fully researched. To date, there is little medical guidance around this, let alone consideration for it in evidence-based treatment models for eating disorders.
The experience of both body dysphoria and dysmorphia, and the confusion or conflation of the two in gender-divergent people, is another area of intersection with EDs that deserves a more nuanced understanding when considering diagnosis and treatment among this population. It takes skill and sensitivity for clinicians to decipher if a patient’s body image distress is related to body dysmorphia, gender dysphoria, or more general internalization of societal pressures in relation to body ideals and gender norms. Transgender folks will invariably relate to their bodies in complex and unique ways, and effective treatment needs to be responsive to these differences.
Mental health providers who offer services to transgender individuals can reference several models for care that provide recommendations and guidelines that extend well beyond “trans 101” competency. But at this time, providers need to “manually” integrate gold-standard ED treatment with models and guidelines for competent care of transgender individuals. Integration of standard treatment with updated guidelines would improve treatment delivery and access.
The impact of neurodivergence on executive function, as well as an individual’s perception of body signals and experience of hunger cues, are other areas yet to be researched. Factors related to neurodivergence could have a significant impact on the effectiveness of treatment interventions, especially when tasks like meal monitoring are a central part of treatment.
More than intention
There has been positive movement in the mental health community as evidenced by the proliferation of mission statements and resolutions in relation to the provision of culturally competent and affirming care. That said, we need more than good intentions. There is a dire need for quality research focused on relevant topics for each of these marginalized communities — and this research should acknowledge intersectional identities (e.g., trans or larger-bodied people of color). Further, research should center around adapting current evidence-based specialized treatments — like gold-standard CBT-E for eating disorders — so they can be more sensitive, effective, and appropriate for a wider range of individuals presenting for care.
This blog post is the third and final in a series that takes a deep dive into the impact of eating disorders. To check out the first and second posts, click the links below:
If you or a loved one is facing disordered eating of any kind, please don’t hesitate to schedule a complimentary call with one of Columbus Park’s experts.