The previous two installments on the 3rd Weight Stigma Conference can be found here and here. As I touched on in the first two installments of this review: privilege, status and power are not experienced through merit, or innate validity; they are forces that must push against other (the disenfranchised, the marginalized, and the stigmatized) in order to be realized.
Jen Rinaldi (Faculty of Social Science & Humanities, University of Ontario Institute of Technology) and Andrea LaMarre (Department of Family Relations and Applied Nutrition, University of Guelph and contributor at Science of EDs) presented some initial findings of their work under the expository title: “Intersecting stigmas, intersecting solutions: Insights from “Through Thick and Thin,” a collaborative research project exploring queer women’s experiences of body image, and body management.”
I didn’t take notes. It wasn’t so much a decision not to take notes, as it was an instinct not to do so. I just wanted to absorb the material being offered.
Jen and Andrea took turns initially providing the background, scope and initial outcomes of the research project. Their intent, as they continue with the project, will be to use the results to create a training program for healthcare providers working with queer women, and to address the impact of weight stigma in healthcare settings with particular attention to how LGBT individuals experience such stigma.
There are many facets to their research project, however what they highlighted were three brief video voice/photo collages created by queer women. Each woman could self-identify as both queer and as a member of a minority group within Canada.
By way of explanation, both the words “queer” and “fat” are terms used in mainstream culture as derogatory and discriminatory insults. Within the communities who often face these terms as hurled insults, many have chosen to purposefully use and reclaim these words to imbue these terms with self-respect and self-affirmation. It’s a form of language or cultural akido—using the force of hatred coming at them and neutralizing it by merely directing that same force back to the instigator.
I have been struggling to write this post and it has undergone several iterations. I was profoundly moved by the videos, but have now resigned myself to the fact that there is absolutely no way to relay their content here in any way that would do them justice. Instead, this post will be about what those videos have inspired me to evaluate when it comes to treatment for eating disorders.
Please note that the content of these videos addresses topics of sexuality, sexual preference, body image and eating disorder issues and therefore the content may not be suitable for some viewers.
We viewed: Karleen, Margaret and Robin's stories during Jen and Andrea's presentation.
Recently I was chatting with someone, let’s call her “Kate”, who underwent inpatient treatment for an eating disorder as a young teen here in Canada. We were comparing notes on how Maudsley family-based treatment (FBT) has several limitations when it is implemented anywhere other than within a very mainstream middle-class, educated, western and white environment.
Within immigrant communities, children and adolescents tend to lead more pronounced double lives—one foot in their family’s culture-of-origin and the other firmly planted in the adopted culture of their new home. Kate grew up, as most of us do in our cities across Canada, in a fairly multicultural setting where she recalls many Muslim girls in her school would remove their hijabs (one of several styles of head coverings worn by Muslim women when out in public) before getting to school and would put them back on to return home.
Obviously all teens live double lives to some extent, as this is a natural part of individuation. However, for those where their parent’s culture differs significantly from the dominant culture that surrounds them, the divide between peer life and family life is intense.
No teen wants to involve his or her parents in the recovery process of an active eating disorder. But for a teen where her parents may come from a history of persecution, scarcity and/or war, then her reality of an eating disorder is confusing to her parents on a level that wealthy white parents never experience.
And it’s wrong to assume that immigrant or minority communities will automatically respond to their child’s eating disorder with confusion, frustration, or perhaps embarrassment: “What’s a calorie?”
I know a school health nurse who works in an elite girl’s school in the UK and her struggle is that students from Korea have parents who actively reinforce restrictive eating behaviors and denounce that their child has any problem because thinness will ensure success and marriageability.
And even though I am reflecting on these examples, please know that none of these presumes there is really a “one response-per-minority-group” reaction to a child who develops an eating disorder within those communities. The point of the matter is that the lone evidence-based treatment available to children and adolescents with eating disorders, FBT, has no way to address a pronounced divide between the proximal culture and a distinct familial culture.
I know another woman who experienced inpatient care as a teen where her parents were isolated from her care because the institution’s administrative leadership chose to discriminate against her parents based on the fact that they believed the presence of an eating disorder was supernatural in nature. Instead of engaging with the parents, they alienated them and as a result the parents ended up just removing their daughter from the hospital.
And then there are all the children and adolescents who must navigate their sexual identities and preferences where an eating disorder becomes enmeshed with the discrimination they face both from their peers and their own families as well. FBT is founded on the premise that a nuclear family can and should resolve the presence of an active eating disorder in one of its members, and clearly there are many reasons why family is not automatically or universally a building block towards remission.
Eating disorders are not a middle-class, white girl condition of privilege. But you wouldn’t know that when you see all the young white girls and women receiving FBT in both inpatient and outpatient settings across our western developed nations. When Kate was in treatment, no visible minorities were represented among the patient cohort at all, despite the city’s multicultural demographic.
Many middle-class, white, educated parents are zealous supporters of FBT and such support is understandable when we take into account that to this day absurd psychoanalytic constructs still reinforce mainstream attitudes that cold and distant mothers cause eating disorders in their children.
And when all adolescents will beg for their parents not to be told when it comes to any challenge or issue in their lives, it’s also understandable to brush aside those pleas knowing that most adolescents are still developing good judgment, and that their fledgling skills in this area are made worse by starvation’s impact on brain function.
However, not all nuclear families are equipped to apply FBT for their child’s treatment of an eating disorder. Merely the concept of there being a nuclear family in the first place reflects mainstream middle-class western culture. And even where a family might be ready, willing and able to apply FBT, the child herself may be struggling with self-identity development that means she cannot remain ensconced within the normative family-based setting and realize remission from an eating disorder at the same time. We also cannot overlook all those raised in abusive and traumatizing environments where involving the family in the child’s treatment will only reinforce the abuse.
While it may be medically necessary as well as societally expedient to place teens needing treatment for an eating disorder in a central inpatient setting, it removes them from any exposure to peers who don’t have eating disorder behaviors. For adolescents who have a very bifurcated existence between home and peer settings (i.e. those from immigrant families, those with self-identities that are not well-aligned to familial or societal values, or those from profoundly dysfunctional home environments) these family-and-patient-only settings remove them from any chance at connecting with a self-defined community of acceptance that could really influence their eating behaviors in a positive way.
FBT has captured a key element of reaching remission: human beings are optimized to eat in communal and accepting environments and constant exposure to these normative settings does allow for the threat identification system to be retrained to stop reacting to food as a threat over time. However for many children, teens and adults, a familial setting is not automatically interchangeable with a communal setting.
Perhaps, if communal-based therapy were developed, many adolescents who do not benefit from FBT, as well as all the independent adults for whom FBT is not designed in any case, remission rates might start to improve.