On the one hand, people with eating disorders seem to merit grave concern. Doctors and clinicians worry about the medical effects of any eating disorder, often exaggerate the consequences and easily cross the line to insist on a higher level of care as an ultimatum to stop treatment.
On the other hand, people who lose a large amount of weight are praised for the improvement in their health, how much better they look and are encouraged to be proud of their achievement.
Even more disturbing, people in larger bodies are seen as unhealthy from the start, slovenly, unable to care for themselves and a ticking time bomb of medical illness. Even when larger people heavily restrict their food, rarely do clinicians see any concern about their health.
The hypocrisy around these judgments of people based on size is pervasive, and nowhere is it more prevalent than in the medical field. Doctors who are burdened by an overbooked schedule and demands of endless electronic paperwork rely on losing weight and exercise and the de facto prescription for any illness. Because of the powerful weight bias in our culture, patients always take this suggestion seriously, no matter how unsubstantiated or even absurd.
For many people, eating disorder diagnoses appear to be more about the conflation of weight with morality and inherent personal value in our country than it is about health and well being. The diagnosis applies to certain people in certain situations and not in others. That is not the typical process of obtaining a medical diagnosis.
Young underweight women are much more likely to be diagnosed with eating disorders than anyone else, even with the exact same symptoms. They are also much more likely to be sent on a residential treatment merry go round for months, if not years.
The pressure for profit from the private equity companies, which own most residential facilities, also skews the goals. If profit is number one, then extending treatment for the most vulnerable (who have good insurance) is a reasonable priority. Overall health and recovery don’t factor into these decisions.
Eating disorder diagnoses need to incorporate social stigma, cultural norms and the ever-present media bias towards thinness into a broad understanding of what an eating disorder diagnosis actually confers in our society. Ignoring these trends means turning a blind eye to the fact that eating disorders represent a clinical symbol for our current assessment of the most attractive body.
The diagnostic criteria for Anorexia in the DSM may not change quickly, but clinicians make diagnoses based on cultural norms as much as on the general consensus of a boardroom of a bunch of psychiatrists.
If eating disorders are a bellwether of the state of the cultural messaging about our bodies, then there need to be treatment approaches which meet people where they are, recognize the forces that push them into the treatment world and help them find a way to being well.
Programs run by inexperienced clinicians and owned by financial companies combined with practitioners more wary of their own personal liability and hampered by their own hidden biases only lead to alienating the people who seek help.
The answer is to see eating disorders in all its facets and focus on individualizing treatment. We are not treating a cultural bias applied to humans. We are treating actual people caught in the maelstrom of weight bias.
The next post will address the people who get trapped in an endless treatment cycle and the deleterious effects on their lives.
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