Disparities within Eating Disorder Treatment

This was written by Alice, one of our student interns. The opinions expressed herein do not reflect those of Civitas other than respect for the value of open dialogue.

TW: Discussion of eating disorders

When someone mentions an eating disorder, most people picture a thin, white, athletic, middle- or upper-middle class girl. This misconception is harmful to everyone, especially those who have struggled with disordered eating/eating disorders and don’t fit this profile. Not only this, but those with eating disorders who cannot afford therapy or a dietician are often left without treatment, and oftentimes without a diagnosis. It’s time to change the conversation around eating disorders and ensure anyone struggling has adequate access to the health care they need.

There are several misconceptions about eating disorders, so I believe it is important to clear them up before discussing the economic side of the issue. The first major misconception is that people with eating disorders are underweight. This is not true. Less than 6% of people with eating disorders are medically diagnosed as being “underweight.” While people typically think of anorexia when an eating disorder (ED) is mentioned, the most common ED in the US is binge eating disorder, which is characterized by, “episodes of eating large amounts of food, often quickly and to the point of discomfort.” Anorexia nervosa, which affects an estimated 2% of American women and .3% of American men, is characterized by extreme restriction of calories, low body weight, intense fear of weight gain, a distorted body image, and oftentimes has a compulsive exercise element. The final main type of ED is bulimia, which affects an estimated 1.5% of American women and .5% of American men, and is characterized by, “a cycle of bingeing and engaging in behaviors to compensate for a binge,” such as purging or over exercising. While these are the most common, there are several other variations, such as other specified feeding or eating disorder (OSFED), or atypical anorexia.

The criteria for EDs can be problematic, given that they can be based on BMI, which is a faulty and unreliable measure of one’s overall health. In addition to this, there is clear discrimination in who gets diagnosed with EDs. For example, “BIPOC are significantly less likely than white people to have been asked by a doctor about eating disorder symptoms, and BIPOC with eating disorders are half as likely to be diagnosed or to receive treatment.  Black people specifically are less likely to be diagnosed with anorexia than white people but may experience the condition for a longer period of time.” Weight discrimination also has a big impact on ED diagnosis, “People in larger bodies are half as likely as those at a ‘normal weight’ or ‘underweight’ to be diagnosed with an eating disorder.” All of which is to say: getting a diagnosis is a privilege. The difficult thing about EDs and mental health diagnoses in general is that they are subjective. One psychologist may have a different diagnosis than another, who might have a completely different diagnosis than the others. While I believe you should identify with the psychologist’s diagnosis that feels right to you, this isn’t enough for insurance companies. As a result, the subjectivity of eating disorders is extremely problematic for health insurance coverage.

Having been in recovery from an eating disorder for almost a year now, there are several instances in which I look back and recognize my privilege. First of all, I had parents who were understanding and open to mental health care. Not only that, but when my therapist stopped taking our insurance, they were able to pay out of pocket, something a lot of families could not have done. I was able to receive a diagnosis and therapy, something that I might not have if I was part of a racial minority. Since I was underweight at the time of the diagnosis, I did not face any questions about the validity of my eating disorder, whereas some individuals are forced to actively advocate for their diagnosis based on outdated weight criteria.    

So why is a diagnosis so important? Oftentimes insurance companies will not provide treatment options without it. Not only that, but they can deny individuals with EDs treatment based on their weight. Civitas speaker Jane Kleeb, the Chair of the Democratic Party in Nebraska, talked about a girl having to leave an anorexia treatment center because she gained one pound, meaning her insurance would no longer cover the treatment. Another justification for the denial of treatment is that there are no medical (as in physical) complications. These two reasons in particular add to an already harmful narrative that persists within those with eating disorders — that they are not sick enough. For example, I have often thought that since I was never hospitalized does that mean I don’t have an ED? Or because I only lost x amount of weight, does that invalidate my ED? Among my peers who have eating disorders, these are common thoughts, and they are made worse by the idea that you are somehow not “sick enough” to receive insured treatment. It’s important to note that eating disorders are a mental health disorder, often with varying levels of physical symptoms. In addition to this harmful narrative, the health insurance system makes it so only middle and upper-middle class people have access to validating and adequate treatment. This doesn’t stop with EDs, to be clear. Your socioeconomic status is one of the biggest determining factors as to whether you will get treatment for both physical and mental health issues. It is particularly difficult with mental health issues; however, because, as I mentioned before, diagnoses tend to be subjective in a way that a lot of physical health issues are not.

The combination of weight stigma, racism, and our flawed health care system in America make having an eating disorder even more difficult, especially when you don’t fit the stereotypical profile for someone who has an ED. It is up to all of us to change the conversation around eating disorders and mental health issues in general, and get rid of stereotypes that continue to invalidate groups of people. And, of course, to work to fix our health care system by voting for legislation that expands coverage and ensures everyone gets adequate treatment.