Written by Polly Moser, Stanford 22'
Edited by Fiona Benson, Yale 22', Meghan Gupta, Yale 21', and Mary Tate, Yale 21'
For many, an image of the archetypal eating disorder patient is easy to bring to mind; she is female, White, young, and painfully thin. This image dominates all forms of media regarding eating disorders, from educational materials to television shows. These depictions reinforce the idea that only people of certain races, genders, ages, and socioeconomic statuses can suffer from eating disorders. In reality, eating disorders are far less discriminatory in choosing victims.
Though medical journals have officially recognized eating disorders as a kind of mental illness since 1980, little attention has been paid to the prevalence of eating disorders among minority groups, and in particular among Black women. For decades, researchers studying eating disorders failed to include Black women in their samples at all. To this day, many physicians still consider eating disorders to be an illness primarily unique to White, middle-to-upper-class women (Connolly, 2011). Recent studies have proven this assumption to be categorically false. One 2016 study of over 1400 Black high school girls found that 17%, nearly 1 in 5 girls, exhibited at least one disordered eating behavior (Cha & Masho, 2016). In some cases, Black women may be at an even higher risk of engaging in certain disordered eating behaviors than their White peers. A ten-year survey of over 2300 girls in schools in California, Ohio, and D.C. revealed that Black teenagers were 50% more likely than White teenagers to exhibit bulimic behaviors like binging and purging (Goeree et al., 2011). In raw numbers, 44.6 million Americans identify as Black and 52% of these individuals identify as women (Hoeffel et al., 2011). Of those 22.4 million Black American women, approximately 3% suffer from some form of an eating disorder (Connolly, 2011). This means that over 600-thousand women are struggling with these problems every day.
However, despite these statistics and a growing body of research on the impact of eating disorders in Black communities, many of the theories, frameworks, and diagnostic tools used to identify and treat eating disorders are based on research conducted almost exclusively with White women (Connolly, 2011).
In this paper, I explore the ways in which weight-based and racial biases in the medical field may put Black women at a greater risk for undiagnosed and untreated eating disorders. Drawing from more recent literature on the interaction of perceived discrimination, stress, and disordered eating behaviors, I further argue that these biases in healthcare may foster the development of eating disorders among Black women in the first place.
The Problem of Underdiagnosis
Though many factors contribute to the rampant underdiagnosis of Black women’s eating disorders, doctors should be aware of the ways in which their own weight-based and racial biases may prevent Black women from being diagnosed and treated. Overall, physicians’ anti-fat attitudes and continued reliance on Body Mass Index (BMI) as a proxy for health and lingering race-based stereotypes of what an eating disorder “looks like” has led to a persistent lack of recognition of eating disorders among Black women.
Weight Bias and Underdiagnosis
The first barrier to diagnosis for Black women comes in the form of physicians’ over-reliance on BMI and bodyweight to measure health. BMI, in and of itself, is a faulty metric for assessing how healthy an individual is. Calculated using an individual’s height and weight, the BMI scale was developed in the 19th century by a Belgian mathematician (Hobson, 2016). The scale was intended solely for population studies and from the start was explicitly deemed inappropriate for individual evaluation. Some health researchers and eating disorder recovery advocates have repeatedly criticized BMI for failing to accurately assess whether or not an individual carries a dangerous amount of excess fat; BMI regularly misclassifies individuals as “healthy” or “unhealthy.” In one study of over four hundred thousand Americans, 47% of participants marked as “overweight” by BMI and 29% of participants marked as “obese” were found to be perfectly healthy based on five other metrics (blood pressure, cholesterol, etc.) while 31% of participants with a “normal” BMI were found to be unhealthy by two or more of those same metrics (Hobson, 2016). Therefore, doctors are incorrect to presume that a “normal” body weight is a prerequisite to health.
Importantly, the CDC has noted that body weight can account for only about “a quarter of the differences that are seen in people’s health outcomes” (Riobueno-Naylor, 2018). Furthermore, because BMI was originally derived solely from the measurements of French and Scottish individuals, for individuals of non-Western European ancestry, like Black women, BMI may be particularly inaccurate. The World Health Organization has acknowledged in recent years that “there is a need to develop ‘different BMI cut-off points for different ethnic groups due to the increasing evidence that the associations between BMI, percentage of body fat, and body fat distribution differ across populations’” (Riubeno-Naylor, 2018). Nonetheless, due to its simplicity, the same BMI standards continue to be applied to all Americans. Today, many doctors still consider BMI, and weight in general, to be a reasonable proxy for health.
This emphasis on BMI is particularly problematic when combined with doctors’ implicit weight-based biases. Weight stigma is commonplace in healthcare settings. In “The Stigma of Obesity: A Review and Update,” published in 2009, authors Rebecca Puhl and Chelsea Heuer examine the existing literature on physicians’ attitudes towards overweight and obese patients. Both experimental work and self-report studies reveal that physicians view higher BMI patients as “less healthy, worse at taking care of themselves, and less self-disciplined” (Puhl & Heuer, 2009). Doctors are also very likely to adopt a victim-blaming perspective on obesity, believing their patients to be almost entirely responsible for their “too high” weight. As a result of these perceptions, doctors spend less time with obese patients, are less likely to recommend diagnostic tests, and are less able to effectively communicate health advice (Puhl & Heuer, 2009). In a survey of overweight and obese women, doctors were indicated to be the second most common source of weight stigma. In fact, more than two-thirds of participants in a study report experiences of weight discrimination from a doctor at least once (Puhl & Brownwell, 2006). By today’s medical standards, more than four out of five Black American women are considered overweight or obese, a rate higher than that of any other race by gender group (Campo & Mastin, 2007). One diverse study comparing rates of weight discrimination based on race and gender across multiple settings found that Black women were the demographic group most likely to report experiencing weight discrimination while “getting medical care” (Dutton et al., 2014). Thus, for Black women, the problem of weight discrimination is particularly salient.
Restrictive Eating Disorders
Because Black women are 70% more likely to be classified as obese than White women (Darby et al., 2009), restrictive eating disorders, such as anorexia, with BMI-based criteria for official diagnosis often go unnoticed. However, just because an individual has a higher than average BMI does not mean they cannot suffer from anorexia. For individuals that develop eating disorders at a higher body weight, restriction-related weight loss is regularly overlooked or even praised. Even after losing a significant amount of body weight through disordered eating behaviors, obese or overweight patients may still be classified as such. Studies of patients with “atypical anorexia” (where all criteria for anorexia are met but the individual’s weight is within or above the normal range) show that these individuals usually have a greater percent weight loss and a longer duration of illness (Kennedy et al. 2017).
Regardless of how low an individual’s BMI is, restrictive eating disorders have consistent health consequences. In a study of low-weight versus above-BMI-threshold anorexia in women, no differences were found between groups in terms of psychological symptoms (depression, anxiety) or physical symptoms (loss of bone density, heart problems, loss of period) (Anderson, 2017). This finding is important because Black women are particularly vulnerable to above-BMI-threshold anorexia. While the official prevalence rate of anorexia among Black women hovers around 0.19%, when only the criterion of a “sufficiently low BMI” is removed this rate quintuples to 1.08% (Taylor et al. 2013).
Furthermore, Paula Brochu of the Center for Psychological Studies at Nova Southeastern University illuminates the link between obesity, weight stigma, and restrictive eating disorders. In her 2018 article “Weight Stigma is a Modifiable Risk Factor,” Brochu reveals that higher BMI individuals are actually “more likely to engage in restrictive eating-disordered behaviors than all other weight groups” (Brochu, 2018). Yet, having a BMI that classifies one as obese or overweight often significantly impedes diagnosis and treatment. Brochu emphasized that in a study she ran with mental health professionals-in-training, when hypothetical patients were described as “overweight” participants were less likely to correctly diagnose them with anorexia, less likely to recommend treatment sessions, and more likely to use weight-stereotypical language (Brochu, 2018).
On the flip side, doctors often attribute non-restrictive eating disorders like binge-eating disorder (BED) to a “lack of self-control” in overweight women and largely ignore them. Current estimates of the lifetime prevalence of BED among Black women hovers at around 2.5%, a rate significantly higher than that of the prevalence of anorexia (0.19%) or bulimia (1.3%) in this demographic group (Connolly, 2011). In some studies, BED has even been found to be more prevalent among Black women than other races by gender groups (Taylor et al., 2013). Furthermore, though it is unclear exactly how these factors influence each other, there is a link between obesity, race, and BED. In a comprehensive study of Black and White women who met criteria for BED, 83% of Black women and 56% of White women were considered obese based on BMI standards as compared to only 35% of Black women and 15% of White women without BED (Pike et al., 2001). Therefore, BED may actually be a risk factor in the development of obesity; the relatively high prevalence of obesity among Black women may, in part, be linked to the widespread nature and consistent underdiagnosis of BED in Black communities.
In addition to contributing to rapid weight gain, BED increases an individual’s risk of developing metabolic disorders, sleep problems, gastrointestinal difficulties, and cardiac issues (Guerdjikova et al., 2019). Unfortunately, weight-biased doctors regularly attribute these complications to “excess weight” and dismiss the possibility of underlying disordered eating behaviors. One survey of 270 American physicians revealed that more than 40% of the participants had never assessed a patient for BED (Guerdjikova et al., 2019). As a result, less than 10% of individuals with BED had received treatment in the past year (Guerdjikova et al., 2019). These numbers are even lower for Black women; a wide-reaching study by Pike and colleagues in 2001 found that when compared to their White peers, Black women were much less likely to have received treatment for BED (Pike et al., 2001). Overall, there is a remarkably high rate of comorbidity between obesity and eating disorders that is consistently being overlooked. Current population studies estimate that nearly 1 in 5 individuals classified as obese engage in either restrictive or non-restrictive eating disorder behaviors and this number has been consistently increasing (Darby et al., 2009).
Racial Bias and Underdiagnosis
The insidious racism that characterizes American society has also infected the medical profession. Numerous studies have illustrated the ways that physicians’ explicit and implicit racial biases still greatly impact patient health outcomes. As previously stated, most early research on eating disorders tended to focus on the experiences of White women while ignoring the effects of disordered eating on communities of color. For decades, the “buffering hypothesis,” the argument that women of color are “protected” from eating disorders by their own cultures and due to its “roots in white body ideals,” was used to justify excluding non-White women from most research (Riobueno-Naylor, 2018). Because studies of body image among Black women revealed lower levels of body dissatisfaction and less thin-ideal internalization, many clinicians prematurely concluded that ethnicity formed a barrier to developing eating disorders (Riobueno-Naylor, 2018).
While numerous studies have confirmed that, in general, Black women are more accepting of a greater range of body types, doctors have consistently overlooked the effects of acculturation, wherein minority cultures adopt the values and cultural norms of the majority or mainstream culture (Talleyrand, 2006). Specifically, when restrictive eating disorders manifest in Black American women, it is often due to the “internalization of White cultural values” and the influence of “White sociocultural pressure to be thin” (Connolly, 2011). More and more new research has begun to shed light on the existence of eating disorders in Black communities, but both race-based generalizations and the assumption that Black women are largely immune to eating disorders persist and prevent accurate diagnosis.
These faulty assumptions have real world consequences. In one experiment where clinicians were presented with identical hypothetical case studies of disordered eating symptoms in White, Hispanic, and Black women, doctors were twice as likely to identify the woman’s eating behavior as problematic if the woman was described as White rather than Black (Gordon et al., 2006). Clinicians are also far more likely to ask questions about potentially disordered eating behaviors and then refer patients for further evaluation or treatment if that patient is White (Gilbert, 2006). Even when Black women do receive an official diagnosis, it is usually only after their symptoms have become more severe than is typical of eating disorders (Gilbert, 2006). Thus, the racial biases of physicians perpetuate the existence of eating disorders among Black women by preventing individuals from accessing treatment.
It is certainly true that part of the reason for these low rates of diagnosis and treatment is that Black women are also much less likely to seek out treatment for eating disorders. One study showed that even when doctors prescribed treatment for difficulties with binge-eating only 8% of participants followed-through on this recommendation and sought treatment (Riubeno-Naylor, 2018). However, this hesitancy to seek out treatment is often grounded in expectations of racism and stigma. While systemic barriers such as lack of financial resources, insurance coverage, or transportation do contribute to this problem, social concerns such as “fears of being labeled, shame, [and] fears of discrimination” present a significant roadblock for Black women needing treatment for eating disorders (Riubeno-Naylor, 2018). Thus, by creating the expectation of discrimination and stress, experiences of weight-based or racial stigma in healthcare settings may contribute undertreatment and underdiagnosis of Black women’s eating disorders.
The Triggering of Disordered Eating Behaviors
In addition to preventing the accurate diagnosis and treatment of eating disorders among Black women, physicians’ weight-based and racial biases may actually contribute to the development of eating disorders in the first place. Essentially, experiences of perceived weight stigma or racial stigma cause a stress response in stigmatized patients (in this case Black women) which can lead to the use of disordered eating behaviors as a coping mechanism.
First, experiences of weight discrimination or racial discrimination in healthcare settings can activate the process of identity threat and felt stigma (Phelan et al. 2015). Identity threat happens “when patients experience situations that make them feel devalued because of a social identity” such as their weight or race (Phelan et al. 2015). Felt stigma describes a patient’s “expectation of poor treatment based on past experiences of discrimination” (Phelan et al. 2015). A combination of this expectation with the in-the-moment feeling of devaluation leads to a dramatic stress response in Black women who face stigmatizing experiences surrounding their weight or race. To cope with this stress, patients may resort to disordered eating behaviors. Recent research by Yale psychologist Rebecca Puhl showed that experiences of weight stigma and weight-based criticism have been associated with the development of bulimic or anorexic behaviors regardless of BMI (Puhl and Suh, 2015). Weight-based stigma may also contribute to the development of BED. In a far-reaching study, 80% of participants reported eating more food, in binge-like quantities, as a result of weight stigma experiences (Puhl & Brownwell, 2006).
In parallel to this, experiences of racial stigma can also lead to disordered eating behaviors. In her dissertation for Boston College’s Counseling Psychology Doctoral Program, Margaret Connolly in her dissertation explains how racism contributes to eating disorders. Black American women, she argues, experience the “double jeopardy of racism and sexism” and “efforts to respond to these stressors can lead to eating disorders” (Connolly, 2011). Similarly, George Mason University professor Dr. Talleyrand found that racial stressors were directly related to a variety of disordered eating behaviors in Black women (Talleyrand, 2006). The potential for experiences of racial stress to snowball into disordered eating is significant considering over one-third of Black Americans report personally experiencing or knowing someone who has experienced racism in a medical setting (Lillie-Blanton et al., 2000).
Depending on the individual, restrictive and non-restrictive disordered eating behaviors may both be triggered by experiences of perceived racism. As previously mentioned, Black women who have internalized White cultural values of thinness are more likely to restrict their diet in response to stress than Black women who have not. However, particular attention should be paid to BED due to its higher prevalence in Black communities and significant under-recognition by the medical establishment.
Experiences of racial discrimination have been clearly linked to BED since the “adverse emotions” that regularly arise as result of perceived racism have also been shown to precede bingeing episodes (Connolly, 2011). Researchers have also suggested that for Black women, a demographic group significantly less likely to have access to mental health services, binge-like eating is a more easily accessible and “socially acceptable stress-reduction technique” (Taylor et al., 2013).
The story of Gloria Oladipo, a Black woman and a rising junior at Cornell University, reveals how discrimination and stereotypes can interact to trigger and perpetuate an eating disorder. Gloria, writing for Ravishly Magazine in 2019, describes how she had developed “extreme body hatred” by the time she reached fifth grade. She attributes this hatred significantly to the “scrutiny [she] received from doctors [who] routinely labeled [her] as overweight and obese, always encouraging [her] mom to monitor and restrict [her] diet” (Oladipo, 2019). As Gloria began to lose weight, she received both criticism and praise. She found that often these critiques and compliments were grounded in anti-black, anti-fat beliefs. Family and friends admired her for becoming “thinner and therefore more attractive,” but simultaneously accused her of restricting her diet in order to be more “White.” No one, neither her doctor nor her family, “recognized that [she] had an eating disorder.” Ultimately, she emphasizes that work must be done within the Black community to end stigma around receiving treatment for mental health problems. At the same time, health providers must “acknowledge their own biases” and work to combat “these myths that begin with the medical community” (Oladipo, 2019).
Eating disorders, admittedly, are multifactorial illnesses; an individual’s genetics, environment, and life experiences all shape if and in what form an eating disorder develops. Nonetheless, the impact that physicians’ weight-based and racial biases can have on the development and perpetuation of eating disorders among Black women should not be overlooked. First, experiences of weight discrimination or racial discrimination often trigger visceral stress responses in stigmatized individuals. Because Black women, in general, have more limited access to mental health services, they may be at great risk of using disordered eating behaviors in order to cope. Second, doctors’ implicit anti-fat, anti-Black biases prevent them from accurately diagnosing eating disorders among Black women. Inevitably, then, these women are less likely to receive treatment for their eating disorders, putting them at increased risk for numerous health consequences and even death.
Significant work must be done to reduce the risk of eating disorders among Black women while also ensuring better access to treatment. First, because official diagnosis of an eating disorder is often a prerequisite for an individual to receive treatment, new and relevant assessment measures should be formed so that eating disorders can be better detected in Black communities. More inclusive studies should be initiated, and these new measures should be rigorously tested on diverse samples. Then, to increase the likelihood of doctors recognizing disordered eating behaviors, medical students should be exposed to recent literature on the prevalence and symptomology of eating disorders among Black women. Addressing implicit bias is particularly challenging, but “cultural competency” training, wherein participants are taught to become more self-aware and better able to overcome cultural conditioning, has proven to help increase empathy and reduce racial bias (Friar, 2017).
Overall, if warning signs continue to be overlooked, if doctors continue to stigmatize patients based on their weight and race, if Black women continue to be excluded from eating disorder narratives, then it is inevitable that thousands of women will die and thousands more will suffer a severely reduced quality of life.
Individuals with anorexia have a mortality rate six times higher than the general population, and all manifestations of eating disorders are inextricably entangled with depression and suicide ideation. Without diagnosis or treatment, the odds of fully recovering from an eating disorder are low. And without recovering, the odds of living a life that could, in any sense, be considered full are even lower. Each of us must deconstruct in our minds the archetypal image of an eating disorder. We must learn to recognize the warning signs of disordered eating and carefully police our own weight-based and racial biases. Hold your doctors, friends, family, and colleagues accountable for their implicit bias. Use your voice and help to end the silent suffering of many.
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