The Diagnosis of Eating Disorders in Women of Color

The Myth about Eating Disorders

A common myth about eating disorders is that eating disorders only affect white, middle-to-upper class females in there teen or college years. Until the 1980's, little information was available about eating disorders and the information that was distributed was often only to the health professionals serving primarily upper class, white, heterosexual families. And the research made available to these professions supported the myth of eating disorders as a "white girl's disease." It wasn't until 1983 and the death of Karen Carpenter that any information let only accurate facts about eating disorders began reaching the public. Yet again, Carpenter's race supported the myth of a "white girl's disease." Where her death brought recognition of the disease to the public and allowed many women to name what their suffering was about, it did so only for white girls and women (Medina, 1999; Dittrich, 1999).

It is highly possible that up until recently many women of color were suffering from eating disorders and disordered eating behaviors in silence and/or without knowing the severity of their disease or even that it was a disease. In a recent phone call with a Latina friend that is suffering from anorexia she said, "After Karen died and all the media coverage, I went to the doctor to tell him that I also had anorexia. I was severely underweight and my skin had a yellow undertone. After examining me he told me, 'You don't have anorexia, only white women can get that disease.' It was 10 years until I went to another doctor" (personal communication, February 1999). The idea of eating disorders as a "white girls disease" still influences many health care workers.

Unfortunately, eating disorders do not discriminate. Individuals of any race, class, sex, age, ability, sexual orientation, etc. can suffer from an eating disorder. What can and does differ is the individual's experience of the eating disorder, how health professionals treat them, and finally, what is involved in treating a woman of color with an eating disorder. Research that is inclusive of the women of color eating disorder experience is still quite lacking in comparison to eating disorder research that is conducted from the white ethnocentric viewpoint.

Some current researchers are calling for a re-evaluation of the eating disorder diagnostic criteria for the DSM-V based on their belief that the criteria as defined in the DSM-IV (1994) is "white" bias (Harris & Kuba, 1997; Lee, 1990; Lester & Petrie, 1995, 1998; Root, 1990). Root (1990) identifies stereotypes, racism, and ethnocentrism as reasons underlying this lack of attention of women of color with eating disorders. Further, Root (1990) suggests that mental health professionals have accepted the notion of certain blanket factors in minority cultures. An appreciation for larger body sizes, less emphasis on physical attractiveness and a stable familial and social structure have all been named as rationalizations that support the stereotype of a "white girls disease" and suggest an invulnerability to the development of eating disorders in women of color (Root, 1990). This idea that these factors protect all women of color from the development of eating disorders "fails to take into account the reality of within-group individual differences and the complexities associated with developing a self-image within an oppressive and racist society" (Lester & Petrie, 1998, p. 2; Root, 1990).

A Common Trait in the Development of Eating Disorders

Who gets eating disorders? The one thing that appears to be a required factor for the development of an eating disorder is low self-esteem. It also appears that a history of low self-esteem needs to have been present during the individual's formative and developmental years (Bruch, 1978; Claude-Pierre, 1997; Lester & Petrie, 1995, 1998; Malson, 1998). That is to say, that a woman who develops an eating disorder at the age of 35 years old, most likely dealt with low self-esteem issues at some time prior to the age of 18 years old whether or not this issue was resolved prior to the development of an eating disorder. This trait runs cross culture (Lester & Petrie, 1995, 1998; Lee, 1990). Individuals with eating disorders also seem to be more apt to personalize and internalize negative components of their environment (Bruch, 1978; Claude-Pierre, 1997). In a sense, low self-esteem combined with a high propensity towards personalization and internalization primes the individual for the future development of an eating disorder. Cultural influences self-esteem and aids in the maintenance of an eating disorder yet does not solely account for the development of an eating disorder.

Eating Disorders and Women of Color

The relationship between ethnocultural identity and eating disorders is complex and research in this area is just beginning. In the initial research in this area, it was believed that a strong perceived need for identification with the dominant culture correlated positively to the development of eating disorders in women of color. To put another way, the greater the acculturation the greater risk of the development of an eating disorder (Harris & Kuba, 1997; Lester & Petrie, 1995, 1998; Wilson & Walsh, 1991). Aside from the remaining ethnocentric quality in this theory, current research has found no correlation between general identification with dominant white culture and the development of eating disorders in women of color. Nor has it been found that a strong identification with one's own culture protects against the development of eating disorders (Harris & Kuba, 1997; Lester & Petrie, 1995, 1998; Root, 1990). Though it has been found that when a more specific and limited measure of societal identification is used, that of the internalization of the dominant cultures values of attractiveness and beauty, there is a positive correlation in the development of eating disorders with some groups of women of color (Lester & Petrie, 1995, 1998; Root, 1990; Stice, Schupak-Neuberg, Shaw, & Stein, 1994; Stice & Shaw, 1994).

African American Women and Eating Disorders

Although research is lacking in the study of separate groups of women of color, Lester & Petrie (1998) conducted a research study involving bulimic symptomatology among African American college females. Their results indicated that when "dissatisfaction with body size and shape was higher, the self-esteem lower, and when the body mass was greater, the number of reported bulimic symptoms was also greater" (p.7). Variables that were found to not be significant indicators to symptoms of bulimia in African American college women were depression, internalization of societal values of attractiveness, or the level of identification with White culture (Lester & Petrie, 1998). Whether or not this information could be generalized to African American women outside of college is at this time unknown.

Mexican American Women and Eating Disorders

Again, it is Lester & Petrie (1995) that conducted a specific study concerning this group of women of color. Again, this study was conducted with the focus on Mexican American females in a college setting and the information gathered may or may not be salient to Mexican American women outside of the college setting. Lester & Petrie's (1995) research revealed that unlike African American women in college, the adoption and internalization of White societal values concerning attractiveness were related positively to bulimic symptomatology in Mexican American college women. Similar to African American women, body mass was also positively correlated. Body satisfaction as well as age was found to be unrelated to bulimic symptomatology in this cultural group (Lester & Petrie, 1995).

Implications for the Counselor

One basic implication for counselors would be to simply be aware of the fact that women of color can and do experience eating disorders. A question a counselor might need to keep in mind would be: Do I think of the possibility of eating disorders in a women of color who comes into my office with the same quickness that I might if the individual had been a white girl? Root (1990) notes that many mental health professionals have unconsciously bought into the notion of eating disorders as a "white girls disease" and diagnosing a women of color with a eating disorder simply doesn't cross their minds. Considering the death rate of eating disordered individuals this mistake can be extremely costly.

Another suggestion made by Harris & Kuba (1997) was to note that the identity formation of women of color in the U.S. is a complex process and the counselor needs to have a working understanding of the developmental stages of this formation. Each developmental stage can take on quite different implications when combined with an eating disorder.

Lastly, due to the white bias within the diagnostic criteria in the DSM - IV (1994) clinicians need to be willing to use the category of "Eating Disorder NOS" as to justify insurance coverage for clients with atypical symptoms (Harris & Kuba, 1997).

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