Due to the impacts of factors understood under the umbrella of gender, ethnic, cultural, and intersectional diversity to the diagnosis and successful treatment of eating disorders by clinicians, and the formation of effective policy through indirect social work, it is important for policy-makers, scholars, and clinicians to have a working understanding of how diversity impacts the nature of eating disorders. Culturally-specific foodways and understandings of mental illness make cultural diversity a problematizing factor for the diagnosis and the formation of policy toward eating disorders. Methodologically, the impact of diversity has been limited in the study of eating disorders. As late as 2008, studies of “the efficacy of psychosocial treatments for eating disorders in children and adolescents” tended to be limited by the lack of ethnic diversity among subjects and the exclusion of boys, and the “limited ethnic diversity” of the populations of college undergraduates from which scholars of eating disorders have drawn their samples. (Keel and Haedt, 2008, 56; Luce, Crowther, and Pole, 2008, 275)
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Clinicians in the United States have a lower probability of recognizing eating disorders in ethnic minorities than non-minorities, even when one controls for symptom severity. (Gordon, Castro, Sitnikov, Castro, and Denoma, 2010, 135) Diversity also relates to the perception of the barrier to care, with some ethnic minorities disproportionately dissuaded from seeking help by perceived stigma. Diversity has been and may continue to be of increasing interest in studies of eating disorders since 2000 due to globalization, the lack of research on diverse populations, and the need to approach culture as a component element of health. (Markey, 2004, 141; Striegel-Moore and Bulik, 2007, 186)
Gender by the late 2000s had been found to be a consistent marker for anorexia and bulimia, but not for binge eating. (Striegel-Moore and Bulik, 2007, 185) Therefore taking into account gender diversity is likely less a concern for policy-makers, clinicians, and scholars dealing with anorexia and bulimia, but remains a concern for those dealing with binge eating. Thus, virtually all studies of eating disorders focus on women because women are the overwhelming and dominant majority individuals with anorexia or bulimia. Consideration of additional and less-prevalent gender identities than male and female was not made for this review. Male binge eaters have been considered in this review only insofar as they overlap with other diversity criteria.
As late as 2007, some researchers argued that the “prevalence of eating disorders among culturally diverse populations (was) incompletely characterized.” (Becker, 2007, S111) Culture forms a particular problem for the diagnosis and treatment of eating disorders in particular out of mental health conditions in general due to its role in shaping diverse foodways through which a healthy individual might mediate their relationship with eating as well as its role in how individuals might articulate psychological distress and seek treatment for it. In addition, not every culture might recognize a set of symptoms in the same manner as Western medicine as indicating a particular disorder, or see the disorder as culturally relevant.
A priori, one can distinguish between approaching illness from universal principles and then attempting to identify culturally-coded articulations of symptoms to their closest universal equivalents, or by looking at local culturally-defined understandings of illness themselves and then attempting to associate these with a universally diagnosed condition. While this can lead to the observational phenomenon of the “culture bound syndrome,” since there is no “universal norm for body image, body experience, diet, and use of purgatives, meaningful designation of particular attitudes and (behaviours) as pathological must evaluate them relative to local cultural practices.” (Becker, 2007, S112) Many scholars, policy makers, and clinicians in the 2000s did not expect anorexia and bulimia by DSM-IV definition to occur in cultures which did not subscribe to social norms dictating that women ought to be thin and linking beauty with femininity. However, sufficient epidemiological statistics continued to lack for policy-makers to draw effective conclusions about eating disorders and culture. (Striegel-Moore and Bulik, 2007, 186)
Culture itself tends to be difficult to measure, since it forms to a significant extent the lens through which scholars themselves study social phenomena. As early as 19th century, anorexia-like symptoms were described in terms of the specific social environment of the patient, as they were approached as an environmentally responsive non-specific neurosis. By the 1970s, they were approached as a specific neurosis resulting from the ego and family dynamics of the patient. (Markey, 2004, 140) This original approach may have had some validity, given a study matching binge eaters – granted, patients suffering from what could be said to be the opposite symptom as anorexia and half the symptoms of bulimia – matched to women without significant symptoms and women with non-eating disorder psychiatric syndromes by age, ethnicity and education found through the application of a Risk Factor Interview and Parental Bonding Instrument that binge eaters had “higher exposure to childhood obesity, family overeating or binge eating, family discord, and high(er) parental demands” than the women in the comparison group, and combined with the women with other psychiatric symptoms, scored higher than the group without symptoms for “negative affect, parental mood and substance disorders, perfectionism, separation from parents, and maternal problems with parenting.” (Striegel-Moore, Fairburn, Wilfley, Pike, Dohm, and Kraemer, 2005, 907)
By the 1980s, eating disorders were seen as something resulting from Western culture in general, and due to cultural pressure for thinness. The 1990s introduced the notion of eating disorders as female-gendered neuroses. (Nasser and Katzman, 2003, 140) Until around 2000, studies of eating disorders tended to focus on “Western middle to upper class, non-Hispanic white, female youths,” though arguments that “all ethnic groups living in the (United States) are susceptible to eating disordered” behaviour go back to 1991, and it was found in 1996 that Hispanic and non-Hispanic white girls tended to be at equal risk of developing eating disorders. (Markey, 2004, 140)
Third World conditions, for instance, remove many of the physical opportunities for individuals to develop eating disorders. HKSAR and Indian patients often have an anorexia-like condition which occurs without fatphobia. Binge-eating-like behaviour may emerge as a result of poverty-related hunger. Fijians culturally endorse bulimia-like behaviour at communal feasts and consider thinness a desirable economic attribute in an employee, and lack an indigenous understanding of an eating disorder. (Becker, 2007, S112) A 2012 study notes that higher degrees of stress in men tend to correlate with higher ratings of the attractiveness of heavier-set women. (Bazian, 2012) To the extent that the two main genders tend to be the overwhelming majority of any population despite the diversity of cultural coding, and culturally-coded fatphobia is seen as an integral part of Western-diagnosed eating disorders, the increased stress of life in the Third World along with its unique cultural coding combined with reduced physical opportunities to develop eating disorders in the Western sense and the possible cultural coding of some foodways strongly resembling eating disorders as diagnosed by Western medicine must be kept in mind.
Further, one would thus expect a priori that socioeconomically disadvantaged minorities would need to have their numbers for the manifestation of eating disorders such as anorexia and bulimia adjusted, on a policy level, to take into account stress which one would a priori expect to accrue due to potential social isolation in an impoverished area. Studies from around the turn of the millennium of eating disorders outside the United States thus tended to show mixed evidence – that eating disorders were “relatively rare” outside the West, or that the incidence of eating disorders exploded in Newly Industrialized Countries, the Third World, and the semi-Westernized developed world through examination of Spanish, South African, Mexican, Indian, Fijian, Mainland Chinese, Hong Kongian, Singaporean, Thai, and Japanese data. (Markey, 2004, 141) Globalization has been pointed out as a possible culprit for the explosion scenario through anecdotal examples, such as the attribution of Agbani Daredo’s 2001 Miss World victory to her being too thin for the average ideal of female beauty in indigenous Nigerian cultures. (Striegel-Moore and Bulik, 2007, 186)
Therefore, pre-2000s studies tended not to problematize specific cultural approaches to foodways and mental illness. This is particularly important because where ethnicity is the social construction of phenotype, and therefore functions more as an arbitrary categorization measuring a grab bag of social and phenotypical results, culture is a psychological construct, and therefore of obvious intrinsic importance to the construction of psychological illness. Since eating disorders represent the Venn overlap of mental health and foodways, both of which are in turn constructed through the lens of the culture of the society in which they can be observed, culture is thus doubly important to the diagnosis and treatment of and formation of policy around eating disorders.
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Ethnicity, while primarily a social rather than a psychological construct like gender and culture, remains an important component of diversity for the consideration of scholars, policy-makers, and clinicians. Prior to the 2000s, clinical practice and treatment trials tended not to find many ethnic minority subjects or patients. Samples continued to be biased to an overrepresentation of white women and girls into the decade. Ethnic minority women were disproportionately less likely to seek care for an eating disorder and to receive care when seeking care. A sample of 2054 Black women showed a lower incidence of all eating disorders and none with anorexia as opposed to 1.5% of white women, though this study was not corrected for socioeconomic status. Purging in this sample tended to be more common among whites, and binge eating among blacks. (Striegel-Moore and Bulik, 2007, 185) Another study also found that Blacks in the United States tended to have higher rates of binge-eating. (Becker 2007 S115) Blacks in the United States were found by Pratt and Patel to be of higher risk of developing eating disorders than Hispanics, Native Americans, or Asians, who were found to be roughly in line with whites in their risk factors for the development of an eating disorder. (Pratt and Patel, 2003)
However, a study of 162 women meeting DSM-IV criteria for binge eating disorder and two comparison groups of women without histories of clinically significant symptoms of eating disorders matched for age, education, and ethnicity and corrected with a Risk Factor Interview and Parental Bonding Instrument found ethnicity had little effect on binge eating. (Striegel-Moore, Fairburn, Wilfley, Pike, Dohm, and Kraemer, 2005, 907) Further, “other studies (had) found no racial/ethnic differences in the prevalence of recurrent binge eating” by the late 2000s, and the ethnic diversity of the American population tended to be poorly captured by epidemiological statistics for eating disorders, thus suggesting that whites might not be more prone to anorexia, bulimia, and conditions with similar symptoms; even if the evidence is mixed for Blacks and binge eating. (Striegel-Moore and Bulik, 2007, 185)
The intersection of ethnicity and culture has been taken as a theoretical beginning to try to understand the diversity dynamics of eating disorders by some scholars. The argument that ethnic minorities are at even greater risk of developing an eating disorder than non-minorities due to higher dissatisfaction with their bodies or greater cultural stress go back to 1997. (Markey, 2004, 140) A study of 276 white, Black, and Latinx college girls showed that “among Black women, the discrepancy between perceived body shape and perceived ideal body shape for the United States was predictive of Eating Disorder Inventory Body Dissatisfaction…and Drive for Thinness…scores” as well as their discrepancy with the perceived ideal body shape for their ethnic group, while “the discrepancy between perceived body shape and perceived ideal for their ethnic group was predictive of EDI-BD and EDI-DFT scores” for Latinx women, but not for their discrepancy with the perceived ideal body shape for the United States. (Gordon, Castro, Sitnikov, and Holm-Denova, 2010, 135) Black women also tend to report a heavier personal body shape ideal than white or Latinx women. (Gordon, Castro, Sitnikov, Castro, and Denoma, 2010, 135) Mexican Americans in the 1990s tended to develop bulimia along with accepting mainstream body ideals, but not Blacks.
Defining acculturation as the process by which individuals change their attitudes and behaviours in a multicultural society or when exposed to a new culture, acculturative stress, but not acculturation, tended to be associated with EDI-BD scores for Black women and EDI-DFT scores among Latinas. This is despite the fact that more acculturated Latinxs tended to have more antifat attitudes. White college girls still tended to have higher EDI scores for body dissatisfaction, bulimia, and drive for thinness than Black or Latinx college girls, though Latinxs reported a greater discrepancy between their personal body ideal and their perceived body shape than any of the other two groups. (Gordon, Castro, Sitnikov, and Holm-Denova, 2010, 138) Striegel-Moore and Bulik argue that studies considering cultural transition of subpopulations and individuals making the transit to thin-ideal cultures face steep methodological limits and concur that they show mixed results. (Striegel-Moore and Bulik, 2007, 186)
Health consumers also perceive diversity-identified factors as social barriers to the treatment of eating disorders. A survey of 32 Americans with eating disorders in 2010 found 78% of participants identified at least one diversity-identified category as a problem for access to care, while 59% felt stigmatized or ashamed in a manner which hurt their care. Ethnic-minority-identified groups reported these more than 20% less than non-minorities. They also felt affordability or availability of care was a barrier approximately 10% less than non-minorities. However, they did not report significantly less of a barrier to treatment from social stereotypes than non-minorities. Minorities in this study also self-reported eating disorders 21.7% less than non-minorities. Native American and Latinx people with comparable symptoms to whites were less likely to be referred for care for eating disorders. This is partially due to the perceptual bias created by eating disorders whereby sufferers tend to go for help with weight loss or another problem, and the lingering stigma surrounding mental health. (Becker, Arrindell, Perloe, Fay and Moore, 2005, 643, 636, 634) Therefore, while the subsample of ethnic minorities in this study fell well short of statistical significance, and the subsamples of any one ethnic minority were smaller again, it does suggest that ethnic minorities are disproportionately affected by social stereotypes and stigma and to a lesser extent affordability and accessibility. While this study approaches the anecdotal in its significance, it should be an important reminder of the importance of considering cultural, ethnic, and gender diversity for clinicians at practice in the field of offering psychosocial treatments for eating disorders.
Therefore; gender, ethnic, and cultural diversity was by the 2000s an aspect of the study, treatment, and making of policy to combat eating disorders which was only beginning to emerge from the Americentric overrepresentation of young, white, Western women and girls which studies of eating disorders had begun to emphasize by the 1980s with the nature of its emphasis on cultural factors, to the measurable detriment of older, ethnic minority, culturally non-Western, male, developing world, trans, and other individuals outside the anorexic stereotype which must have seemed very intuitive to scholars, clinicians, and policy-makers during that decade of high non-Japanese developing world growth and post-Cold War optimism – and its attendant heroic chic Kate Moss standard of female beauty – which must have formed such a deep part of their own cultural lens. Modern clinicians, scholars, and policy-makers are thus by virtue of their own places in the shifting cultural milieu in a stronger position to treat, study, and craft policy for the treatment of anorexia, bulimia, binge eating, and less studied or prevalent eating disorders than their counterparts who created the anorexic stereotype.
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