Wednesday, December 13, 2006

Anonymous Hunger: Examining the need to identify eating disorders beyond white, middle to upper class, female afflictions – Kathryn Pollenz

Eating disorder diagnoses, interventions, and treatments target white, middle to upper class adolescent and college-aged females. Public health interventions have failed to comprehensively treat these disorders because they have focused their efforts on a population narrowly identified by race, age, sex, and socio-economic status. Eating disorders, characterized by “abnormal eating behaviors and beliefs about eating, weight, and shape” (, 2006), are experienced across diverse populations. The National Association of Anorexia Nervosa and Associate Disorders (ANAD) estimates that 1 million men in the United States have eating disorders and 10 percent of people who develop eating disorders begin at age 10 or younger (Beckman, 2004). Men, children, seniors and minorities are afflicted with eating disorders. By accepting and identifying these illnesses as white, middle to upper class female disorders, public health is denying access to treatment and recovery to those suffering outside of this exclusive demographic.

Individuals need to identify themselves as “at-risk” or “ill” in order to seek and receive treatment. Social science principles reveal that perception and acceptance of illness is socially influenced, and in the case of eating disorders, socially restrictive and biased against many populations. Treating an eating disorder requires both recognition and acceptance that one has an eating disorder, and belief that one is capable of overcoming and treating the disorder. Individuals suffering from these disorders, outside of the white, female, middle to upper class demographic, are less resourced, less educated and less supported in treatment. They lack a recognizable model to understand and address their disorder. Populations not stereotypically considered at risk for an eating disorder are less capable of 1) identifying their disorder, 2) realizing their ability to overcome it and 3) accessing support for treatment. The current public health approach targeting eating disorders undermines individuals outside of the white, middle to upper class female demographic. Social labeling theory, diffusion theory, and the cognitive summary model explain how non-stereotypical individuals suffering from these disorders are disadvantaged in seeking and receiving treatment and achieving recovery.

Identifying the Disorder
Social labeling theory explains that “who is to be called ill is determined by the individual’s social position and society’s norms rather than by universal and objectively defined signs and symptoms” (Waxler; L.Eisenberg and A. Kleinman (eds.), 1980). Illness identification is not based on biomedical assessment alone. Perception of illness, both from the perspective of the medical community and from the perspective of the individual is a socially influenced concept.
“Whether an individual labels himself as sick occurs within and is affected by the norms of the society around him. Cultural norms, the presence or absence of particular systems and the social position of individuals within their social group are all variables significant in the initial decision about whether an individual is ill or not.” (Waxler, 1980).

Selective labeling perpetuates the stereotype of the eating disordered individual. White females receive the majority of diagnoses and treatment, and therefore provide the majority of evidence for research and empirical data related to these diseases. This data therefore can be conceived as a product of social processing (Waxler, 1980). Males, on account of being excluded from the female paradigm for being at risk for eating disorders, can feel alone and incapable of confronting their illness. Like many emotional and psychological illnesses, eating disorders can be perceived as shameful. For men burdened with the misconception that they cannot suffer from an eating disorder, an illness that is considered to be a “female’s problem,” the shame they face is often worse (Something Fishy: Website on Eating Disorders, 2006). This shame prevents men from seeking treatment which perpetuates the stigma that eating disorders only affect females.

Eating disorders may also be underreported in ethnically and culturally diverse girls because of a lack of population-based studies that include representatives from these groups. The perception that non-white females are at a decreased risk may also contribute to lack of detection (Office of Women’s Health, 2004). The idea that eating disorders affect exclusively white women influences diagnosis and treatment of minority individuals with eating disorders. In her article, “Disordered eating in women of color, Dr. Maria Root suggests that mental health professional have accepted the idea that appreciation for larger body sizes, less emphasis on physical attractiveness, and stable familial and social structures in minority cultures have supported the stereotype of eating disorders being a “white girls disease” and suggest an invulnerability to the development of eating disorders in women of color (Daniels, 2006). Up until the last 20 years, the only information reaching anyone about eating disorders was through doctor’s offices, typically treating the white, middle to upper class community. It’s possible that due to lack of awareness, many women of color were either suffering in silence or didn’t realize how severe their problem could be (Something Fishy: Website on Eating Disorders). Availability and quality of diagnosis and treatment for eating disorders is dependent on the social characteristics of professionals and patients and the social contexts in which they meet. Currently, the accepted health context is exclusionary and in dire need of a “higher index of suspicion” for the expanding demographics of the affected population (Beckman, 2004).

Realizing the Ability to Overcome
Diffusion theory correlates the spread of information to the process of social change, and explains that people are most likely to accept new ideas or engage in behavior change when the ideas are presented by members of their social networks (Choi, Yep, Kumekawa, 1998). Diffusion theory substantiates the need for individual’s to have an understandable, familiar model to understand their behavior. In a social and health environment where eating disorders are associated with white women, men and non-white minorities lack a relevant context in which to accept their disorders and seek treatment. The diagnostic tests used to identify eating disordered behavior were created exclusively for the stereotyped target population of white women. The Eating Attitudes Test (EAT) is a rating scale that is designed to identify patients with anorexia from weight-preoccupied but otherwise healthy, female, college students (Costin, 1999). The Eating Disorder Inventory (EDI), a self-report measure of symptoms, is the most popular and influential of the available assessment tools. “Both the EAT and the EDI were developed to assess the female population who most likely have or are susceptible to developing an eating disorder” (Costin, 1999). These assessments, perhaps not proven capable of accurately diagnosing diverse populations, are widely used in surveillance and research producing data for interventions and treatment.

In addition to diagnostic tools, interventions and treatment models need to be reflective of specific target populations and not representative of a single demographic. Effective outreach and treatment needs to be culturally and socially specific. Practitioners need to demonstrate an understanding of their target audience in order to provide meaningful insight to develop effective strategies to change individual behavior and improve health (Siegel, 2004). Confronting eating disorders outside of the white, middle to upper class female community necessitates developing interventions reflective of the core values of diverse target audiences.
There is a shortage of therapy and treatment centers available specifically for men. Men may feel isolated among a group of women, in a program designed for women (Something Fishy: Website on Eating Disorders, 2006). Dr. Weltzin confirms that patients repeatedly report that they feel more hopeful about recovery when they meet other men who have an eating disorder. “Often, they have been the only males in treatment programs or support groups filled with female patients and specifically designed for females (Weltzin, 2002). Diffusion theory elucidates the need for recognizable, socially and cultural specific models for behavior change. Locally-relevant and accessible models for assessment, diagnosis and treatment are missing in public health’s current approach to eating disorders.

Accessing Support and Treatment
The cognitive summary model correlates patients’ and health professionals’ cognitions and behavior to patients’ outcomes. It states that the behavior of health professionals is determined by their cognitions and the behavior of patients is determined by their cognitions. Patients’ health outcomes are determined by patients’ behavior, patients’ cognitions, and the medical procedures and treatment received (Marks, 1996). The current practice for diagnosing and treating eating disorders is exclusionary and neglectful of many populations. Mental health professionals have unconsciously bought into the notion of eating disorders as a “white girls disease” and assessing and diagnosing women of color simply “doesn’t cross their minds” (Something Fishy: Website on Eating Disorders, 2006).

Aside from contradicting the white, female paradigm for eating disorders, minority cultures are dually challenged by the tendency of many ethnic and cultural groups to discredit seeking professional help for emotional problems. Because psychological treatment is not common practice, minority individuals are challenged in accessing care due to the shortage of culturally sensitive treatment centers (Office on Women’s Health, 2004). Health professionals’ cognitive processes, which influence treatment, are biased towards white, middle to upper class women. Men are less likely to be diagnosed with eating disorders than women. The statistical scarcity of disordered incidence in males leads to clinicians’ inability to recognize eating disorders in men. Also, theoretical biases exist in some diagnostic methods that preclude eating disorders from being diagnosed in males. The young, white, upper middle class female stereotype “may lead clinicians, especially those not accustomed to routinely treating disorders, to miss the diagnosis when it does occur, as it often does in older women, in minorities, or in males of any age.” (Anderson, 1990). This lack of awareness on the part of healthcare providers translates to impaired patient cognition resulting in patients’ disadvantaged ability to seek treatment and pursue wellness.

The exact nature of the most common eating problems, including the risk and protective factors vary from group to group but no population is exempt. Dysfunctional eating behaviors and attitudes occur across cultures (Office on Women’s Health, 2004). Public health’s current approach to eating disorders prohibits equal diagnosis, treatment and recovery across populations. The white, middle to upper class, female paradigm for these diseases undermines non-white minorities, men, children and seniors from seeking and achieving wellness. Perception of who is at risk, availability of treatment, cognition of health professionals, and types of diagnosis and treatment are all affected by social context. Social labeling theory explains that defining and labeling illness can be influenced by demographic variables like race, class, sex and age, and that this definition serves as the impetus for treatment. Diffusion theory implies that the ability to access and benefit from treatment depends on the availability of treatment, the social and cultural relevance of the assessment tools and treatments offered, and the capacity to identify with the practitioners delivering the treatment. The cognitive summary model demonstrates that the quality of treatment is influenced by health professionals’ understanding and the cognitions of patients, two variables influenced by society’s perception of who is at risk for illness. The current public health approach to eating disorders must reflect a more encompassing definition of the at-risk population in its assessment, diagnosis and treatment. Until this happens, demographics outside of the white, middle to upper class female community will foster lower self-efficacy in pursuit of treatment and continue to be disproportionately neglected by healthcare systems.

1. Anderson A. Diagnosis and treatment of males with eating disorders. Males with Eating Disorders, A. Anderson. New York: Brunner/Mazel Publishers, 1990; 133-162.
2. Eating disorder (Dictionary). 2006;
3. Beckman O. Rethinking eating disorders: treatment must account for diversity of affected population. Behavioral Healthcare Tomorrow 2004; 12-14.
4. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10(Supplement A): 19-30.
5. Costin C. The Eating Disorder Sourcebook. Los Angeles: Lowell House, 1999.
6. Daniels J. The diagnosis of eating disorders in women of color. Something Fishy: Website on Eating Disorders 2006;
7. Marks DF. Healthy psychology in context. Journal of Health Psychology 1996; 1:7-21.
8. At risk: all ethnic and cultural groups. Office on Women’s Health 2004;
9. Seigel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3-A), pp. 66-69. In: Siegel M, Donner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers, 2004.
10. Cultural roles. Something Fishy: Website on Eating Disorders 2006;
11. Issues for men with eating disorders. Something Fishy: Website on Eating Disorders 2006;
12. Waxler N. The social labeling perspective on illness and medical practice. The Relevance of Social Science for Medicine, L. Eisenberg and A. Kleinman (eds). Dordrecht, Holland: R. Reidel Publishing Company, 1980; 283-306.
13. Weltzin T. Unique inpatient program treating boys with eating disorders. The Brown University Child and Adolescent Behavior Letter 2002; 5-7.


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