Pop culture tells us one thing about eating disorders: It’s a ‘white girl’ disease.
From The Bachelor to Natalie Portman’s Nina in Black Swan to Lily Collins’ Ellen in To the Bone, eating disorders seem to only affect affluent white girls on screen. And, as Kim Kardashian showed earlier this week in a series of Instagram videos that received an instant backlash, being called "anorexic" is problematically deemed a compliment.
But eating disorders don't only affect white females, and the glorification of eating disorders is dangerous. Black girls and women suffer from eating disorders too, but advocates argue that teachers, doctors, faith leaders, and even therapists don’t always catch an eating disorder when a woman of color walks through the door.
That's what happened to Stephanie Covington Armstrong, author of Not All Black Girls Know How to Eat. "Everyone assumed all of the stereotypes: Black girls are more comfortable with our bodies. We like being heavier. We don't develop eating disorders," she told The Daily Beast. "So I could hide in plain sight."
Covington Armstrong's memoir follows her struggle with yo-yo dieting, orthorexia (an obsession with healthy food), starving, and bingeing. "It's like an addict sampling drugs: you do just a little here, a little there, and then eventually they're doing you," she said.
But it took her a long time to seek help.
"Basically, it was getting to the bottom, and realizing, I'm going to die if I continue to believe I can handle this on my own," she said. "But when you come from a culture that's not pro-mental health support, you don't go to a therapist. You don't talk about your problems publicly. There was nowhere to go with an eating disorder," she remembered.
She didn't know where to start. "We're told to go to church. Keep it in the community," she said. "I've met many women who said, I prayed on it. [...] Handling it spiritually, you know, isn't enough help."
Then, she found an advertisement for an eating disorders treatment program in the paper. "I went to one of those guinea pig programs advertised on the back of the Village Voice. It said, 'You have an eating disorder, we can help you,'" she remembered. "I went, and I was like a freak."
Some advocates say that clinical measures aren't doing a good job of capturing the experiences of women of color. And according to the National Eating Disorders Association (NEDA), a “research and reporting bias” has made it difficult to track the true prevalence of eating disorders in communities of color. That means what we know about eating disorders—risk factors, prevalence, and even symptoms—largely depends on a body of work that's studied a specific population.
"This early assumption that eating disorders primarily affect young, affluent white women was based on research that was conducted on young, affluent white women," Claire Mysko, CEO of NEDA, told The Daily Beast.
Much of what researchers use to explain and understand eating disorders relies on something "called objectification theory," developed using white female participants.
Objectification theory is the idea that eating disorders develop when we learn to see ourselves like an observer, turning our bodies into things that should be monitored and judged, continuously. Treating your body as something to be looked at is, in clinical terms, called self-objectification. Self-objectification, in turn, manifests as self-surveillance—habitually monitoring your appearance—which then leads to weight and shape concerns, body shame, and disordered eating.
In this model, body shame is crucial: It's the in-between variable that explains how disordered eating happens—and, importantly, how it can potentially be stopped.
In a recent study published in the peer-reviewed journal Body Image, however, a team led by first author Lauren Schaefer surveyed women from multiple backgrounds and set their experiences side by side: 880 women at a southern university, of whom 71.7 percent were white, 15.1 percent were Hispanic, and 13.2 percent were black.
The cross-sectional analysis found that the validated objectification theory isn't actually one-size-fits-all, and it's not generalizable to all populations. In short, it doesn't describe or reflect the experiences of all women.
"Among black women, self-surveillance was not significantly correlated with body shame or disordered eating," the authors wrote.
The study found that white and Hispanic women experience disordered eating differently. For Hispanic women, self-surveillance was only weakly associated with body shame and disordered eating. For white women, self-surveillance, body shame, and disordered eating were moderately to largely associated.
This wasn’t the case for black women. Though the study found that all three groups felt a moderate level of body shame, black women's attitudes and reported experiences had a unique effect on their disordered eating. According to the study, black women's disordered eating wasn't a function of self-objectification and body shame, like it was for Latinas and white women. Instead, black women's disordered eating was a function of body shame only. Self-objectification didn't play a part at all.
To explain this, the researchers cite a study published in 1995:
"This finding may be interpreted in light of research indicating that black women tend to have more flexible and multifaceted definitions of attractiveness, as well [as] greater acceptance of larger body sizes. Given this more inclusive definition of appearance ideals among black women, observing one’s body may be less likely to produce negative cognitive, emotional, and behavioral responses in this group of women, as a wider variety of appearances would be deemed acceptable.”
Because research has suggested that white women and Latinas "often report more narrow appearance ideals, reflecting a greater emphasis on thinness and low body weight," Shaefer argued, their self-monitoring may be more likely to lead to body shame—and the effort to close the gap (self-discrepancy) between appearance and ideal can lead to disordered eating. The paper lists other risk factors dependent on racial/ethnic background: internalizing the thin-ideal, being dissatisfied with one’s body and appearance, and comparing one's body and appearance to others.
Yet the authors' interpretation of the findings—that self-objectification doesn’t impact how disordered eating thoughts/habits develop for most black women—isn’t universally accepted. Some advocates and treatment providers challenge the idea that black women are uniquely self-confident and proud of their bodies, which in turn protects them from feeling body shame, calling the reasoning "culturally-specific.”
"It isn't that there are certain communities that are immune to these pressures. I think that's very flawed," Mysko said. "It might look different depending on the appearance ideal across cultures, but you're still measuring yourself against something that is unattainable. It's not necessarily this thin ideal, but there still are rigid ideas of how you can achieve this appearance ideal, which can lead to very unhealthy weight control behaviors, disordered eating, or full-blown eating disorders."
More broadly, Covington Armstrong noted, the health care system doesn’t typically treat patients of color as well as white patients (literally), which leads to poorer health outcomes. This dynamic might discourage patients of color from opening up and seeking treatment, especially for issues that carry a stigma. It's made worse when some communities of color are reluctant to go to the doctor.
"There's a history of distrust between black people and medical professionals. It's hard, culturally, for black people to feel the same level of safety and permission," Covington Armstrong said.
The National Healthcare Disparities Report, which tracks over 250 measures of quality and disparities in several areas (e.g. effective treatment, access to care) based on race/ethnicity, income, and insurance status, found that "most disparities have not changed significantly for any racial and ethnic groups,” according to the most recent report published in 2016. According to a report by the Office of Minority Health, people of color experience more mental health issues than white people do. Studies suggest that racial discrimination itself causes a number of health issues.
"There's a very big 'suffer in silence' component," Covington Armstrong said. "We don't talk about our mental health issues in public. So it's harder to do studies about black women. It's harder to get black women to come forward," she said.
Covington Armstrong recalled one session in Compton, Calif. where she sat down with a group of black, Latina, and Asian women. "I started talking about my eating disorder, and by the end of it, four of them admitted that they were practicing bulimics. And they were all under the poverty line," she said.
Yet treatment options for eating disorders are slowly becoming more diverse. NEDA has featured Covington Armstrong on its diversity task force, for example.
"We need to make sure that the approach we're taking meets the needs of those communities that we know are at risk or actively struggling with disordered eating," Mysko said.
Along with other initiatives, NEDA reaches out to communities of color and healthcare providers: primary-care doctors, behavioral health centers, and eating disorders treatment programs. Its Body Project, which was recently pilot tested in five NYC-area schools, uses a 'train-the-trainer' model over four sessions to explore cultural influences on body image.
"It's about how we can encourage young women to talk back and really be empowered to have body confidence," Mysko said. "We often hear from people who call the helpline who will say, I waited a long time to reach out for help because I didn't think I was that sick. They see pictures of extremes. And I think that is also true of the language around eating disorders: the terminology of anorexia, bulimia, binge-eating disorder. You know, it might not be relatable."
Covington Armstrong said education is key, because disordered eating can be easy to miss.
"It's getting better. [...] There's still so much fear around seeking help," she said. "When I go into the inner cities to talk, it is much more prevalent, just people don't talk about it. They don't want to upset their parents. Their parents are struggling."
We think we know what an eating disorder looks like, but it manifests differently in women of color, she said. "A lot of black women don't realize that laxative teas, well, that's a version of bulimia. You know, taking laxatives teas every day [...] That's eating disorder behavior," she said.