It’s More than Just Stigma: Systemic Barriers to Eating Disorder Treatment

National Eating Disorders Awareness Week

You may have heard the phrase “eating disorders don’t discriminate.” This is certainly true. Anyone can suffer from any eating disorder regardless of gender, age, weight/size, ethnicity, orientation, socioeconomic status, etc. What is not often talked about is that for those who try to seek treatment for an eating disorder, there are systemic barriers that can prevent people who badly need treatment from accessing it.

It is estimated that the prevalence of eating disorders, especially among those with marginalized identities, is widely underreported, and even then only about 23 percent of people with diagnosed eating disorders receive treatment. This is partly because receiving insurance approval for eating disorder treatment is extremely hard, and people in larger bodies, or who have a BMI above what is considered “normal” are regularly denied coverage even if they present the same symptoms and medical complications as patients in smaller bodies.

In light of NEDA Awareness Week, I talked to Anna Lutz, a registered dietitian who has a private practice in Raleigh, NC, and specializes in weight-inclusive care for people with eating disorders. According to Lutz, there are systemic barriers that can make it harder for people with marginalized identities to access treatment, even when they are willing. Lutz explained that the media perpetuates a stereotype that only thin, affluent white women develop eating disorders, and this stereotype has become deeply ingrained in the healthcare system. 

“I think because of that stereotype, providers don’t ask the right questions — and biases get in the way of diagnosing the eating disorder, or even asking questions about eating behavior — and so people’s eating disorders go undiagnosed, and it’s really hard to seek treatment if you don’t know you have an eating disorder,” Lutz said. 

According to Lutz, in order to truly change the system and promote equitable access to care for all people, there needs to be broad, systemic change. However, there are small steps that individuals, including students, can take to help break down the stereotype that eating disorders only impact a certain group of people. 

“I think eating disorders thrive in secrecy and thrive in shame, so the more that we can talk about the truth about eating disorders so that we can reduce the shame, I think that is one avenue to open up access,” Lutz said. 

“If a friend is expressing behaviors that are concerning, express your concern for them. And you could say, ‘You know, what do you think about getting help? I’ll go with you.”

Lutz also emphasized the importance of talking about other factors that create barriers to accessing treatment, such as insurance costs and coverage, as well as the link between food insecurity and eating disorders. She also mentioned that for individuals with marginalized identities, it may be difficult to find a provider who can relate to your specific situation and experiences, since only about 2.6% of dietitians identify as Black, and most registered dietitians are white women. Because of this, women who are part of minority groups are less likely to seek and receive treatment than non-minority women.

Additionally, individuals who identify as LGBTQIA+ may have a harder time accessing treatment. Although rates of eating disorders and disordered eating behaviors tend to be higher in the LGBTQIA+ community, accessing treatment can be tough. Most eating disorder treatment centers are geared toward cisgender, heterosexual women, and oftentimes clinicians are not fully informed of the nuances of eating disorders in the LGBTQIA+ community. 

Another factor that could prevent individuals from seeking treatment is the misconception that people with eating disorders must be thin. In reality, eating disorders can impact people at any weight, and some people can actually gain weight as the result of an eating disorder. Yet, the belief that it is necessary to achieve a certain weight in order to be considered “sick enough” can prevent some people from seeking treatment.

Ariane Smith-Machin, a licensed sports psychologist who works within NC State Athletics, explained that students do not need to have all the “typical” symptoms of an eating disorder for it to be considered a problem. Smith-Machin explained that in addition to the clinically diagnosable eating disorders like Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder, there are also “subclinical” eating disorders, which means a person may have some symptoms but may not have the full criteria that define an eating disorder. 

Smith-Machin emphasized that even if students do not meet the criteria for an eating disorder, having any kind of disordered thoughts around food or body image is a sign that it may be beneficial to seek help. 

“Even if you just have one that’s going on for you, that’s actually a perfect time to come talk about it,” Smith-Machin said. “You don’t need to label anything, but if you feel like you have a lot of extra thoughts about body size and shape, or eating, or these expectations on yourself about your appearance, or feeling as though you’re comparing yourself to others more often that not, that is a perfect opportunity to just go talk to someone about it.”

Smith-Machin emphasized that the Counseling Center is available to all students who may have concerns about food or body image. For students who may be seeking help for the first time as well as for those who have sought help in the past, Lutz emphasized that it is important to start where you feel the most comfortable. 

“I always get asked the question ‘Should I see a doctor, should I see a dietitian, should I see a therapist?’ and I think the best answer to that is go see the person you feel the most comfortable making an appointment with and following through with the appointment,” Lutz said. 

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Skye Sarac is an undergraduate intern in the Women’s Center.