Thin Privilege & Why Some College-Based Eating Disorder Treatments May Be Dangerous

Recently, I posted this story on my Instagram:

“If your college counseling center serves students with eating disorders at a severity level that they would refer out if it were any other mental illness, that’s thin privilege and it’s perpetuating systems that contribute to the development of eating disorders and the marginalization of those in large bodies. “

The response to this post was, to the credit of the beautiful community of followers on my Instagram account, overwhelmingly positive, but I got quite a few responses asking with curiosity about thin privilege – a privilege we don’t talk about often. Based on that feedback, I thought this might be a good topic to address more widely.

What is Thin Privilege and Why is Eating Disorder Treatment in Colleges Problematic?

It’s a great question: Because it seems like a good idea, right? Establishing clinics that are able to deliver diagnosis-specific treatment within a context (college campuses) where those diagnoses (disordered eating) are particularly prevalent sounds great… The problem is that access to care is a privilege and we need to talk about how the privileges offered to thin bodies contribute to a system that rewards disordered eating (and, in the process, negatively affects individuals in large bodies).

Because of the prevalence of eating disorders among college-age individuals, some college counseling centers are beginning to offer extended services to students with eating disorders – addressing eating disorders at a level of severity that the clinic is not equipped to handle in other mental health diagnoses.

When a college counseling center responds to a significantly depressed individual by refusing care due to severity and instead referring that individual to a list of referrals or resources, that’s a barrier to care. Instead of easily accessible on-campus care, many individuals (who may be experiencing the difficulty problem solving and self-motivating that’s typical with many mental health disorders) are asked to contact an off-campus service, and to arrange scheduling, payment, and transportation. If unable to overcome all the barriers to this off-campus care, these students are likely to experience worsening symptoms, leave school, or do poorly in classes.

This becomes a problem when the same college counseling clinics cater to individuals with restrictive eating disorders (statistically likely to be persons already with some privilege based on age, race, or class) at a severity level that would be referred out if the diagnosis was non-ED-related. Often, these services may include low-barrier support, resources on site, wraparound services including both a therapist and a dietician, groups, or access to more appointments than student with other diagnoses receive. These students, then, are able to access resources more easily, and thus are more likely to remain in school, achieve well in the classroom, and experience success long term.

The Issue:

Though well-intentioned, and even logical, ED treatment programs in colleges don’t account for the fact that eating disorders develop in the context of a system, and good care means not just treating an individual, but actively addressing how we as individuals and mental health clinics are implicit in the system that contributed to the development of disordered eating symptoms.

"Good care means not just treating an individual, but actively addressing how we as individuals and mental health clinics are implicit in the systems that contributed to the development of the symptoms."

That system goes by multiple names: Diet Culture, Thin Privilege, Fatphobia. They all mean the same thing: privileging of thin bodies while marginalizing bodies that are large. Despite slightly increasing inclusion of outliers, the “good” body in the West continues to grow increasingly thinner and/or surgically modified. And bodies outside of this ideal experience stigmatization – in fact, discrimination based on body size has more than doubled since 1996. Often large people develop disordered eating in response to stigma, but aren’t able to get treatment either because: 1. weight-bias diagnostic criteria, and because 2. even in the mental health field, we tend to applaud disordered eating behaviors by those in large bodies.

When we offer easier access to mental health care for thin bodies with restrictive eating disorders than we do for other bodies and other mental health issues, we are perpetuating a system that stigmatizes large bodies while rewarding the thin.

When we offer easier access to mental health care for thin bodies with restrictive eating disorders than we do for other bodies and other mental health issues, we are perpetuating a system that stigmatizes large bodies while rewarding the thin. While the ED treatment may reduce symptoms in the short term, it’s possible that both 1. these treatments may not be as long-term effective as treatments that engage systemic issues and 2. may, in the process, do harm to already vulnerable populations.

When we provide care, support, and body-positive messages to thin bodies but refer out or even encourage disordered eating behaviors in large bodies, that’s stigma. Experiences of stigmatization for large bodies activate a trauma response. In a traumatic state, complex thinking (involved in good self-care) goes offline and research indicates that we move to more primitive coping skills (for many people: drinking, binge eating, self-harm, etc) which often contribute to weight gain.

Intolerance of body diversity can neurologically cause weight gain. Black background with white text in white boxes, pointing back and forth to each other with white arrows. Experiences of weight stigma lead to traumatic disregulation (prefrontal cortex offline, so the ability to complex problem-solve and make goal-based decisions is unavailable). Once in traumatic disregulation, we can attempt soothe-seeking, which often leads to binge eating (our brains in this state use the most basic self-soothing, which reflects traumatic deregulation); or we choose to avoid the stigma, which leads to reduced exposure to context of stigma (like gyms, medical offices, relationships, etc.). Both of these options eventually lead to weight gain, which continues the cycle back to experiences of weight stigma. — Often stigma cuts people off from accessing health care, enjoying activities, or being able to trust their family- all of which are health risk factors and can contribute to weight gain over time.

I believe addressing our internalized and systemic bias about bodies is a life and death issue for bodies that are thin, large, or any of the normal variations in body shape and size.

A Note on “Health”

Before you disagree on the basis of concern for the “health” of “obese” individuals, consider four points:

Research has strongly linked experiences of weight stigmatization with reduced life expectancy, even after adjusting for potential health compromises due to weight.
The belief that significant weight loss can be maintained over time has been disproven by dozens of peer-reviewed academic studies. Advertising reinforces this belief, not research.
Body size is one of many health factors, and having a large body and being healthy are not mutually exclusive. See meta-research analysis here: Weight Science: Evaluating the Evidence for a Paradigm Shift
NO ONE OWES YOU HEALTH. To demand that an individual conforms to your idea of health is a privileged perspective. People are large for countless and complex reasons, including medical conditions, trauma responses, genetics, and poverty.

How Can Colleges Address the Increase of Eating Disorders Appropriately?

Eating disorders continue to be a major mental health issue among college-age individuals, so how can we provide care without perpetuating harmful systems where thin bodies are given access to resources that large bodies aren’t?

Work to make sure no diagnosis is privileged within your organization. If you choose to provide extended services to students with eating disorders, invest in programs to support, assist, and follow-up with students who are referred out. Potentially you can offer referrals and provide support on campus via groups.
Make your clinic (and your campus) a safe space- for all bodies. Many large people have known only marginalization and exclusion from spaces that claim to be body positive, so this will require work. An “all bodies are welcome” statement on your promotional materials is a good first step, if you can follow it up with offering students the experience of inclusion.
Adopt a Health at Every Size framework for ED treatment and treat/screen all individuals for disordered eating, not just those in bodies that appear thin.
Edit your Language – Many of us, clinicians included, have adopted the cultural language that links food, exercise, and bodies with morality-based language. There are no “bad,” “evil,” or “sinful” foods. Practice noticing and kindly correcting yourself out-loud to retrain your brain and set an example for those around you.
Be mindful of your own bias – Health care providers – mental health workers included – often have a bias against fat bodies. Invite a Health at Every Size provider to do a training at your organization and ask your staff to engage their own bias and beliefs about people with large bodies.

Sources:

ARTICLE: Weighed down by stigma: How weight-based social identity threat contributes to weight gain and poor health by Jeffrey M. Hunger, Brenda Major, Alison Blodorn, and Carol T. Miller. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5720363/

ARTICLE: Weight science: evaluating the evidence for a paradigm shift by Linda Bacon https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041737/

ARTICLE The Experience of Being Obese and the Many Consequences of Stigma by Jane Ogden and Cecelia Clementi. http://dx.doi.org/10.1155/2010/429098

ARTICLE: Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006 by Tatiana Andreyeva, Rebecca M. Puhl, Kelly D. Brownell http://dx.doi.org/10.1038/oby.2008.35

Depth Citations:

Research shows that “people of all ages, sexes, and from a number of different cultures stigmatize and subsequently discriminate against obese people.”^[1] These stereotypes are independent of the body size of the person doing the rating^[2] and independent of the large person’s competency.^[3] Weight based stigma is “pervasive and intensifying,”^[4] having more than doubled between 1995 and 2006.^[5] As an acceptable type of discrimination (legal in 49 of 50 US states), there are virtually no legal or social consequences for discriminating against a person based on the size of their body. Research also shows that, despite what some believe,^[6] stigma does not motivate weight reduction, in fact, weight based stigma has been shown to negatively impact mental health,^[7] increase binge eating,^[8] ^[9] decrease use of health care services,^[10] and increase the likelihood of weight gain over time.^[11] Stigmatization can be driven by a belief that weight can be controlled through willpower and behavior modification, but long-term studies repeatedly show that after a period of deprivation, virtually all bodies will return to their beginning weight or heavier,^[12] often with poorer overall health due to the damaging effects of weight cycling.^[13]

[1] Jane Ogden and Cecelia Clementi, “The Experience of Being Obese and the Many Consequences of Stigma,” Journal Of Obesity (2010): 2.

[2] Tiggeman and Rothblum, 1988, cited by Ogden and Cecelia Clementi, “The Experience of Being Obese and the Many Consequences of Stigma,” Journal Of Obesity (2010): 2.

[3] Larken & Pines, 1979, cited by Ogden and Cecelia Clementi, “The Experience of Being Obese and the Many Consequences of Stigma,” Journal Of Obesity (2010): 2.

[4] Andreyeva, Puhl, & Brownell, 2008; Vartanian, Pinkus, & Smyth, 2014 cited by Jeffery M. Hunger, et al., “Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes to Weight Gain and Poor Health,” Social & Personality Psychology Compass 9, no. 6 (2015): 255.

[5] https://www.ncbi.nlm.nih.gov/pubmed/18356847

[6] Bayer, 2008, cited by Jeffery M. Hunger, et al., “Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes to Weight Gain and Poor Health,” Social & Personality Psychology Compass 9, no. 6 (2015): 255.

[7] Bacon & Aphramor, 2011, cited by Jeffery M. Hunger, et al., “Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes to Weight Gain and Poor Health,” Social & Personality Psychology Compass 9, no. 6 (2015): 256.

[8] Almeida, Savoy, & Boxer, 2011, cited by Jeffery M. Hunger, et al., “Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes to Weight Gain and Poor Health,” Social & Personality Psychology Compass 9, no. 6 (2015): 255.

[9] Rebecca L. Pearl, Rebecca M. Puhl, and Kelly D. Brownell, “Positive media portrayals of obese persons: Impact on attitudes and image preferences,” Health Psychology 31, no. 6 (2012): 821

[10] Ibid.

[11] Hunger & Tomiyama, 2014, cited by Jeffery M. Hunger, et al., “Weighed Down by Stigma: How Weight-Based Social Identity Threat Contributes to Weight Gain and Poor Health,” Social & Personality Psychology Compass 9, no. 6 (2015): 255.

[12] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041737/

[13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3041737/

Image Description for Screen Readers:

Intolerance of body diversity can neurologically cause weight gain. Black background with white text in white boxes, pointing back and forth to each other with white arrows. Experiences of weight stigma lead to traumatic dysregulation (prefrontal cortex offline, so the ability to complex problem-solve and make goal-based decisions is unavailable). Once in traumatic disregulation, we can attempt soothe-seeking, which often leads to binge eating (our brains in this state use the most basic self-soothing, which reflects traumatic deregulation); or we choose to avoid the stigma, which leads to reduced exposure to context of stigma (like gyms, medical offices, relationships, etc.). Both of these options eventually lead to weight gain, which continues the cycle back to experiences of weight stigma.

Thin Privilege & Why Some College-Based Eating Disorder Treatments May Be Dangerous