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The Quest to Make Eating Disorder Treatment More Inclusive

Kelsey Tyler

When Stephanie Covington Armstrong was in the deepest throes of bulimia, vomiting up to 10 times a day and “completely unable to function,” she saw a newspaper ad for an eating disorder study. “If you are struggling with bulimia, we can help,” it said. She decided the time was right to finally seek treatment.

“I went to this intake program at this fancy hospital, and they were looking at me like I was a purple, two-headed giraffe,” she says. Armstrong, who lives in Los Angeles, was the only Black person in the room. “Did I need to say, ‘I only throw up fried chicken and watermelon?’” While she continued with the program, she still wrestled with powerful urges to throw up. “I knew they weren’t going to help me. They were too fascinated with me as a Black woman, [rather] than as just another person with bulimia.”

Armstrong’s experience, which she documented in her book Not All Black Girls Know How to Eat, is echoed by many people of color who seek help for eating disorders; an even greater number never reach out for treatment, often because they don’t know there’s a reason to. 

Eating disorders are typically depicted as a white woman’s disease. A Google image search for “eating disorders” yields a sea of photos (and some illustrations) of light skin. Websites for eating disorder treatment centers are dominated by white faces and bodies, both in patient testimonials and stock photos. This stereotype also infiltrates research; most of the science on eating disorders is based on the study of white girls and women.

But the limited research that does include people of color supports growing evidence that eating disorder rates are similar across racial and ethnic groups. One study found that Black women were as likely to report binge-eating and vomiting as their white counterparts. Some studies have found that Black and Hispanic teenagers are more likely than white ones to have bulimia. Even so, people of color who voice concerns about eating or weight to their doctors are less likely to receive follow-up questions about eating disorder symptoms.

“Just because we don’t want to look like Farrah Fawcett doesn’t mean we don’t want to look like Beyonce.”

“There’s still the idea that you have to be an emaciated white woman to have an eating disorder,” says Dr. Lesley Williams, a physician and eating disorder specialist. On top of that, there’s a misconception that “women of color are immune to eating disorders because they come from communities that tend to be more accepting of body size diversity.”

“Just because we don’t want to look like Farrah Fawcett doesn’t mean we don’t want to look like Beyonce,” says Joy Arlene Renee Cox, a researcher, body justice advocate and author of Fat Girls in Black Bodies. In the 2019 autobiographical documentary Homecoming, Beyoncé talks candidly about resorting to extreme weight-loss tactics, including a diet so dangerously low in calories that nutrition experts subsequently warned people to stay away from it. “I’m hungry,” Beyonce admitted in the movie.

Beyoncé might have the power to single-handedly define beauty ideals, but that doesn’t mean she’s immune to the pressure of living up to them, Cox points out. In other words, even Beyoncé faces pressure to change her body to “look like Beyoncé.”  

“Beyoncé is beautiful. She’s a beautiful person, she makes beautiful music. But even Beyoncé doesn’t have that much liberty to just kind of be,” says Cox. “If Beyoncé wanted to gain 60 pounds and said, ‘This is me and I’m good with it,’ you would have a problem with the brand.”

Diet culture sets a potentially dangerous backdrop for people who are vulnerable to disordered eating. But Armstrong emphasizes that her own eating disorder was more of a coping tool than a means of achieving a specific body type.

“I think what people get wrong is that when Black women have an eating disorder, it has a lot less to do with trying to look like a white woman than people think,” she says. “That doesn’t even come into play. We don’t want to be skinny and white. We just want to loosen the valve of trauma pressure. I had all these deep wounds and pain, and I had no coping mechanism. Food and my body was something I could focus and obsess on and try to change. And if I could change that, then I would be safe.”

While in general, coping mechanisms and control are common themes underlying eating disorders, the mental health impacts of racism cannot be overstated, according to many eating disorder survivors and experts of color.

“Racism is a daily trauma,” says Armstrong, “the day-to-day of getting through the world as a Black woman. If you’re white with bulimia, it’s not that you don’t have high levels of trauma, but one of them isn’t racism.”

Eating disorders have the highest mortality rate of any mental illness.

Anecdotally, among her patients who are women of color and struggling with eating disorders, Williams says “ninety-nine percent of them had a history of some type of trauma,” including racial trauma.  Now she worries about new challenges and vulnerabilities related to the pandemic.

“You’re stuck in the house, you’re being retraumatized every time you turn on the television, having to emotionally navigate video footage not only of George Floyd’s murder,” but also reports of nationwide police brutality, coronavirus numbers and bleak economic forecasts, says Williams, “and the one thing you have access to is an environment where your eating disorder can flourish.”

Eating disorders have the highest mortality rate of any mental illness. Someone dies as a direct result of an eating disorder every 62 minutes

That’s why, from a public health perspective, it’s crucial to include people of color in studies, as well as account for geographic and socioeconomic diversity within those populations. “Money and resources are put where the need is, and if the need isn’t identified, then there won’t be money or resources invested,” Williams says. “You can’t look for eating disorders in only one swath of the patient population.”

Now in recovery, Armstrong works as an eating disorder educator and advocate. “I’ve talked to girls in South Central [Los Angeles] and other underserved communities, and they’re struggling with bulimia, compulsive eating, remnants of childhood trauma and sexual abuse,” she says. “Unless people are educated about what an eating disorder is, you won’t know you have an issue.”

Williams often sees patients who exhibit clear symptoms of eating disorders but don’t acknowledge it. “It’s having the frank conversation: Maybe the weight you’re trying to maintain is not what is natural for your body, because you’re having to do all these things. Maybe we can explore what a natural place for your body and a healthy relationship with food would look like.”

To Cox, these kinds of conversations are imperative for patients to begin healing. “What needs to happen is relationship-building,” she says. In order to do that, white researchers and healthcare providers must approach patients of color with a genuine desire to understand and help them. “There’s been a lot of black people being studied by this outsider looking in, and it’s not enough,” she says. “Aside from studying me, do you really want to know who I am as a person?”

For patients of color frustrated by feeling unseen, Cox recommends asking for a different practitioner. “Often in the Black collective, we feel we don’t have choices, but know that you have agency in choosing,” she says.

She advises people to find a community somewhere, even on social media. Organizations like Nalgona Positivity Pride offer resources and support, such as the monthly online discussion and peer support group Sage and Spoon. The National Eating Disorders Association has also compiled a list of mental health and wellness resources specifically focused on the experiences of those who are Black, Indigenous and people of color.

“It can be extremely isolating to be in a space where you feel you don’t have support,” Cox says. “But you’re not alone in feeling like that, and you’re not alone in experiencing what you’re experiencing, and it may require more on your part. Don’t stop knocking on doors. There is support, and people are speaking out on behalf of Black people. The hope is out there.”

*If you or someone you know is struggling with an eating disorder, you can call the National Eating Disorders Association Helpline at 1-800-931-2237, text “NEDA” to 741-741 or click to chat

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