Treatment Bias in the Eating Disorder Community: Race, Gender and Age

Eating disorders have been associated with young white women in a high socioeconomic bracket since the inception of these illnesses in the 1970’s and 1980’s. As the incidence of eating disorders has grown significantly in recent decades, research has proven that the power of the diet culture, obsession with thinness and inexorable pull towards weight loss by any means has not discriminated by race, age or gender.

But eating disorder treatment remains very much focused on the original population who first became sick. Therapy, treatment philosophies and residential programs are all geared to young white women of means. The eating disorder treatment world does not make room for other people suffering with these illnesses. African Americans are much less likely to receive eating disorder referrals from their doctor. Men struggle to find any treatment open to them. Older patients are marginalized by a clinical culture that stigmatizes them as untreatable.

Much of this stigma stems from the cultural lie about eating disorders: a person cannot be sick unless they look very underweight. This misunderstanding of eating disorders remains the central diagnostic criterion to doctors, clinicians, families and lay people. Time and again, people say someone cannot be really sick unless they look emaciated.

Meanwhile, all eating disorders, including anorexia, can be serious and severe when people have many different shapes and sizes. Weight and shape are not a good indicator of severe illness. A full assessment of the patient is the only way to understand how sick they are.

Basing someone’s illness on body shape immediately discriminates. On the whole, marginalized people in the eating disorder world are the ones who are unlikely to fit the socially acceptable code for an eating disorder. Only young white women are likely to become emaciated enough to receive attention and a referral.

Facing diet culture and fat phobia also means seeing the inherent racism and bias associated with how clinicians diagnose people with eating disorders. We clinicians need to understand that our own internal racist, sexist and ageist beliefs cannot cloud our clinical judgment. Size, age and gender are not ways to understand someone’s eating disorder. Only a full examination and use of unbiased clinical judgment will allow for fair and equal treatment for all people who need it.

Please find a few resources below to explain more about the bias in eating disorder diagnosis and treatment:





Recovery in these Challenging Times

In the midst of the pandemic, the protests and the violence, everyone is reeling as they try to figure out how to manage. Most people are overwhelmed with their own emotions while also making sense of how to respond to the randomness of nature, the destruction wrought by humanity and the injustice and inequality around us.

How can someone caught in their own recovery from an eating disorder stay present for what is happening in the world and not lose sight of their own personal health?

It’s too easy to say this is not the time to fight for recovery. Instead just focus on surviving now and deal with the eating disorder later.

The problem is that eating disorders don’t stay stagnant while someone deals with the state of our world. It digs in deeper, becomes more powerful and sinks that person further into illness.

The only other choice is to both face the reality in front of all of us and stay present in recovery. Doing both things means staying true to who you are. Each of us needs to manage our own personal lives and find our own way to look at the current events unfolding around us.

It is crucial not to let these events distract from the goal of eating disorder recovery. Food logs, meal plans and journals to log emotions and personal responses remain as important as ever. These cornerstones of recovery serve as the way to stay connected with yourself and not pretend the eating disorder is the true core of one’s identity.

Continuing to attend all appointments for recovery provides opportunities to clarify thoughts and feelings and decrease the likelihood of leaning on eating disorder behaviors to cope.

Last, the more one uses the eating disorder to manage, the less true one’s voice becomes in the world right now. Thoughts and feelings need to stem from each of our own true and genuine selves and need to reflect the most honest place we can find in ourselves to see our world when it faces such an important crisis. The eating disorder will only cloud the truth behind the inanity of obsessing about food and weight.

Now is the time to focus on connecting with ourselves, our community and the people around us, not with a destructive illness.


Overcoming Judgment and Bias from Eating Disorder Clinicians

When people struggling with eating disorders seek help, they often feel like they are not really seen. Clinicians react so strongly to the disorder itself, they forget to see the actual person.
The focus on body, weight or health overrides the true person who sits in front of the practitioner. This is a human being seeking help for their own personal struggle. First and foremost, they deserve to be treated as an individual who was brave enough to show up for an appointment.

The problem is that eating disorders engender very strong reactions from clinicians or doctors.

Anorexia draws fear from almost all practitioners that this person may get very sick or even die. So almost every response translates into the fact that it’s time to go to a residential program or hospital.

Bulimia similarly brings out fear but also disgust. It can be hard for clinicians not to judge people with this illness and struggle to take the important step to see how and why this person is suffering so much.

Binging or compulsive overeating immediately leads to the inherent fatphobia in our society. Rather than work to understand the reason for the eating behaviors, treatment focuses on weight and potential health risks when many of these risks are fabricated by the medical establishment and diet industry.

Some of these concerns are real. Consistent starvation will lead to significant medical risks. Bulimia has medical risks as well. Binging causes enormous distress.

However, any doctor or clinician needs to temper those immediate concerns. The person who seeks help is searching for answers as well. They are aware that the psychological and physical manifestations of the eating disorder affect their lives. That’s why they came for support in the first place.

Any eating disorder clinician needs to see a patient as a person first. They need to understand the root for the behaviors and thoughts and establish a relationship with this actual person. That means putting away the biases around body, weight and food behaviors in order to establish a therapeutic relationship built on trust.

Any improvement in eating or health is important, but in the end these changes are meaningless unless they come from a foundation of emotional understanding and change. The eating disorder clinical world can embrace compassion over judgment, kindness over bias in order to help people start a path to health and recovery.


Disordered Thinking in Anorexia: the Most Concerning Symptom

A complicated aspect of anorexia is the underlying belief early in the illness that one is not truly sick.
Disordered thinking is a psychiatric term that means one’s brain cannot follow facts logically and cannot process information correctly. In other illnesses, examples of disordered thinking are paranoid thoughts, an inability to make sense and delusions (a fixed false belief) about the world.

Some eating disorder symptoms begin to appear somewhat disordered but never represent overall disordered thinking, such as body image distortion or wildly overestimating the calories of food.

However, severe anorexia does have one thought process that appears disordered. In some of the worst cases of anorexia, people don’t believe they are truly sick. Sometimes people who are clearly underweight can’t see it. Others who are eating very little food in a day believe their body doesn’t need more. In the worst case scenario, people with significant medical problems from their illness cannot believe they are truly sick. These people may be shown irrefutable evidence of their illness and simply do not believe it.

The disordered thought process in anorexia is important for another reason. These cases are the most severe and have a likely chance of chronic illness and early death.

Tackling and challenging this thought process is imperative. In less severe cases, the standard treatment is nourishment and restoration of health because some issues with brain function reverse with food. In the most severe cases, food doesn’t change the underlying thoughts and may reinforce them because any weight gain only solidifies the disordered thoughts.

For these patients, it’s critical to have therapy focus on questioning these thoughts. The goals are to present the case for why the anorexia is severe over and over again. The disordered thoughts give the patient relief since they justify the need to restrict. Instead therapy needs to make the person question these thoughts each day. The risk of the disordered thoughts is that they become an undeniable truth. If that is too solidified, the chance of recovery goes down significantly.

It’s necessary for the person to know that this battle between disordered, untrue thoughts and the unpleasant reality needs to be the crux of treatment. Without a clear sense of the truth, all therapy will seem meaningless and the anorexia will take over completely.


Starting Treatment for an Eating Disorder during the Pandemic

For many people, the pandemic can be a reason to delay starting treatment for an eating disorder. Virtual treatment is not a valid justification to allow an eating disorder to continue to dominate your life.
Eating disorders rule one’s life and make it so difficult to forge a path. The eating disorder thoughts and behaviors can take up more and more time each day. The lack of structure for many people during this time allows the eating disorder even more footing, especially if that person is not in treatment.

As I described in the last post, virtual therapy is very effective and may even have some benefits for people starting eating disorder treatment. The main positive aspect is around body image thoughts. Not being in a room with a new therapist is easier than feeling physically exposed by being face to face.

The time and lack of structure actually give recovery a lot more room to try to make a dent in the disorder. Logging food is more possible. Connecting in between sessions, writing about emotional reactions to food and changing meal plans all can happen now without distraction.

In addition, it’s easier to meet with a few people in order to find the right therapist, another critical part of determining the best path to move forward.

Last virtual therapy can allow for a true bond to form to fight the eating disorder just as much as in person therapy. Any step into recovery matters. In times like these, the illness can take over more or it can galvanize a person to put their all into changing their life.


The Pros for Virtual Therapy for an Eating Disorder

Virtual therapy by video or phone is the current new norm and has been a part of my practice for many years, although never the exclusive form of treatment until now.
Traditional psychotherapy always valued the therapist and patient in a private, safe room together. This framework has been considered essential to effective work.

There is truth to this therapeutic axiom, but eating disorder treatment has different needs that can be well suited to virtual therapy. Two specific and important components of eating disorder treatment come to mind.

First, a critical part of eating disorder therapy is distorted body image. Typically, therapists who treat people with eating disorders have pillows or blankets available for people to cover their body during the session. Seeing one’s body can be upsetting and distracting during the session, so covering up can actually make the session more productive.

Virtual therapy obviated the need for a pillow or blanket. Phone or video takes away the experience of being seen by the therapist and immediately focuses on the work at hand rather than a need to cover up in order to feel comfortable.

With the physical body image less central to the treatment in a virtual format, it can be easier to dive into important work more quickly. However, at the end of the session, deeper work leaves the patient feeling more exposed and vulnerable.

Many people in the therapist’s office might subconsciously begin to pull back from this work towards the end of a session since they know they will leave soon and have to face the world again.

In a virtual session, they are already in a safe space. So if the session ends at an emotional or vulnerable place, they will be somewhere that allows them time to regroup before restarting their day.

The virtual sessions take away two significant obstacles for effective treatment: the physical self and the act of going back into the world after the session.

Although the in person sessions provide a sense of safety together in the office, these two benefits from virtual sessions often lead to very effective treatment as well.


Quarantine and Eating Disorders, Part II

Although some people have been able to use this period as a time to take steps forward in recovery, others have struggled more with their eating disorder.
The constant stress and pressure of the pandemic have affected everyone, no matter their psychological state before. The barrage of news, the pause on life and the lack of contact have affected daily life for everyone. As this period has extended for weeks and weeks, it has taken its toll.

By and large, people have relied on tried and true coping mechanisms to manage the stress. For people with eating disorders, that has often meant a gradual escalation of symptoms.

Even if the intention is to maintain any gains or to stop the creep of worsening behaviors, many have found the eating disorder has started to infiltrate the extra time in their lives whether it means more food behaviors, worsening thoughts or increased exercise. We are all relying on what helps most during times of stress, and that is the same for people with eating disorders.

Few people have stayed in place with respect to their eating disorder. Most have either moved forward either seeing this time is a pseudo-program, as explained in the last post, or else drifted into worsening symptoms to cope with the stress.

The people who have seen this as a type of treatment entered the quarantine already primed to focus on recovery. That means having either just left a treatment program or just resolved to try to get well.

Those who are seeing an escalation of symptoms tend to have already been in a steady place with their eating disorder or struggling to find ways to get better.

Eating disorders always seem to be changing. Either the situation is improving or worsening most of the time. This pandemic appears to have escalated the pace of change for many people with eating disorders.

However, for those who want help, the support is available and just as effective remotely as in person. This is not a time to despair or wait. It’s as good a time as any to try to move forward with recovery.