Black, Indigenous and People of Colour, Larger Bodies and Eating Disorder Recovery 2
Cultural Discrimination
Dr. Connie Coniglio, my former boss and a clinical psychologist who specialized in adolescent eating disorders, once said to me about her time heading up inpatient facilities (paraphrasing): “We have to separate those with anorexia from those with bulimia because those with anorexia are really unpleasant to those with bulimia.” It’s a mean-girls gathering where “binges” are the shame-filled loss of control.
“Research has shown that in the minds of individuals diagnosed with EDs, AN is frequently described as a more desirable and acceptable diagnosis than BN (Mond & Arrighi, 2012) (e.g., “a bulimic is an anorexic who failed, and I had no intention of failing” (Eli, 2018, p. 164); “with eating disorders everybody kind of wants to be anorexic” (Frey, 2020, p. 143).”
The researchers in the above quoted excerpt also identify the patient’s internalized hierarchy and stigma of the diagnosis originate from those clinically-assigned arbitrary checklists. Anorexia and bulimia (BN) checklists have language that embed a dichotomy of success vs. failure. Those with a diagnosis of anorexia are given the attributes of high-achievers with tremendous self-control and an ability to delay gratification. Conversely, those with bulimia are given the attributes of emotional instability, coming from families with alcohol and weight issues and unable to delay gratification or maintain control.[2] Those definitions are cultural frameworks in how society moralizes the suppression of our physical requirements needed for survival. There is absolutely nothing biologically defensible in denying any body energy (food) and restoration (sleep).
Imagine for a moment if the cultural frameworks were utterly removed from the checklists of eating disorder typecasting. Biologically, anorexia is self-limiting and kills the person. Biologically, the onset of any kind of feeding, after anorexia has been initiated, is the potential reversal of the self-limiting impact of anorexia. That’s it.
The above quoted research was published just last year. Take a look at how cultural views of weight drive everything for eating disorder classification:
“Madison said her disordered eating behaviors stemmed from coping with stress rather than a desire to lose weight. However, after doctors told her (a) she would be diagnosed with AN if she lost weight, and (b) that her disorder was mild, because of her BMI, despite multiple hospitalizations, Madison reported her focus shifted to losing weight to prove to her providers that she was “sick enough.” Madison described “I was in denial that I had a problem when I was not underweight” noting that she did not believe she was in any danger because “I don’t look that bad. Like even the doctor said it’s just mild anorexia.” Madison mentioned that “even now I’m still going through a big loop of binging and purging or whatever, but I’m in the normal BMI range now so no one really cares.”
Eating disorders are not weight disorders but they are diagnosed and treated as such, causing so much needless suffering and physical damage to so many patients. Eating disorders can be bundled up into one condition: eating avoidance disorder.
Instead of anorexia, bulimia and binge eating disorder being distinct conditions, they are the same condition primarily plotted over time. The prevalence of binge eating disorder is double that of bulimia which is then almost double that of anorexia.
Those of average and above average weight only get diagnosed with bulimia or binge eating disorder usually after a period of restriction that never met the threshold for an anorexia diagnosis (due to weight, not actual restriction of intake). Often, they only seek diagnosis and treatment because they cannot maintain the restriction (which is a good thing because unwavering restriction has a hard stop: death) and the compensatory eating is very upsetting to them. People with eating disorders who end up underweight get dragged in for treatment before their bodies start fighting hard to stay alive.
The thing that distresses the person with an eating disorder is eating. In an inpatient setting we have the early detection group of underweight patients who are diagnosed with anorexia nervosa, and then we have the later arrival patients of average and above average weight who have already survived the restriction-only phase of the onset of the eating disorder and get labelled with bulimia or binge eating disorder, or maybe an SFED or ARFID label thrown in occasionally. That’s not to say that we cannot have those who have persistent anorexia over many years, but even they cycle through periods of restorative eating and destructive restriction.
This failure to recognize the arc and progression of the eating disorder condition is comparable to the misrepresentation of breast cancer screening as prevention. Screening doesn’t prevent cancer. However, it catches the presence of cancer (when it’s there) earlier than when no screening is done. It’s also why the five-year survival rate is higher for those who undergo regular screening in the recommended age range. That survival data point then gets twisted to represent “saving lives.” It merely represents starting the five-year counter much earlier because screening detects the cancer in its earlier state. Anorexia and bulimia are not two distinct conditions, anorexia simply represents starting the counter earlier in the progression of the eating disorder.
Early detection for breast cancer is still a very useful thing! It will result in likely more straightforward intervention and treatment and may avoid future recurrence for some. However, early detection does not prevent cancer and it’s unclear whether early detection truly saves lives. Mortality rates for breast cancer have had a nice steady decline overall from 2000-2020, however how much of that is due to the vast improvements in treatment vs. the regular screening programs is hard to disentangle.
Restriction is integral to all facets of an entrenched eating disorder but it’s never the focus of treatment for those of average and above average weight. Over two-thirds of the population with eating disorders, just by being average or above average weight, never receives the treatment they need: how to repeatedly approach and eat food without any re-establishment of restriction.
Next installment June 13.
Image in Synopsis: DeviantArt.com: Wolfepaw
Christian HP. “You’re Just Looking at One Piece of the Puzzle… My Weight”: A Phenomenological Examination of Diagnostic Crossover in Eating Disorders. American Journal of Qualitative Research. 2024 Jan 1;8(1):57-70.
ibid.
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