Chapter Twenty: The Anti-Fat Bias of Eating Disorder Diagnoses
I have multiple chronic illnesses, so I spend a lot of time in doctor’s offices. Whenever I have to see a new doctor, giving my medical history takes quite a while. And there are always a lot of questions, especially since most doctors aren’t familiar with one of my two primary diagnoses.
My least favorite question of all of them is “What’s your eating disorder diagnosis?”
My chart shows that I have a history with eating disorders, because I do. But it doesn’t specify my diagnosis. Why? The short answer is anti-fat bias. The long answer is still anti-fat bias, but with more details.
When I first went into treatment for my eating disorders, I didn’t fit the diagnostic criteria for any of the established diagnoses. I wasn’t thin enough to meet the criteria for anorexia. Yes, weight is still a diagnostic criterion for anorexia. I didn’t display the classic purging behaviors for a bulimia diagnosis — vomiting or laxative use. At the time, orthorexia — an eating disorder characterized by an obsession with “health,” “clean eating,” and excessive exercise — was not yet a clinical diagnosis. It’s still not included as a diagnosis in the DSM-V.
I fell into the nebulous category of “Other Specified Feeding or Eating Disorder.” I fit most of the criteria for atypical anorexia. I fit many of the criteria for exercise type atypical bulimia. If orthorexia had been in the clinical lexicon then, I would have fit all the criteria for orthorexia. But given the diagnostic criteria at the time of my treatment, I didn’t get a clear diagnosis.
The outpatient treatment center I went to didn’t really bother with specific diagnoses anyway. The clinicians approached treatment holistically, treating the mind, body, and spirit. Though the clinicians worked with their patients to stop harmful eating disorder behaviors, the focus was much more on the underlying issues than the cessation of behaviors.
Unlike many eating disorder patients, I didn’t get a meal plan, I wasn’t told to stop exercising, and we didn’t really work on ending my specific behaviors. I kept track of when I was restricting, purging, and engaging in compensatory exercise, but the behaviors were not the focus of the treatment. Healing the traumas that had fostered the behaviors was our goal. Training me to sit with my feelings and truly feel them was the focus.
So, my treatment team never felt the need to define exactly which eating disorders I had. They just knew I had eating disorders and worked from there.
And this treatment approach worked for me. My eating disorder behaviors fell away as I learned to truly feel my feelings and as I confronted my trauma. It’s been years since I’ve intentionally engaged in restriction, purging, compensatory exercise, or obsession about health, weight, and food. This doesn’t mean that the thoughts and feelings don’t pop up sometimes. They absolutely do. But it means that I don’t go through every day struggling not to use eating disorder behaviors. For me, it means that I’ve fully recovered.
So, my lack of diagnosis hasn’t been an issue for me or the doctors that have been with me since treatment. However, it does seem to be an issue for all the other doctors who see me, especially new specialists.
Whenever I see a new doctor for the first time and their nurse or medical assistant has to do my long, complicated intake, we always have to have the uncomfortable conversation about my eating disorder diagnoses. I tell them that I didn’t meet the diagnostic criteria for a specific eating disorder so my official diagnosis is “Other Specified Feeding or Eating Disorder.” If they’re just looking to fill out a field on a form then, thankfully, the conversation usually ends there.
But when I get a zealous nurse or medical assistant who’s really committed to getting a thorough patient history, the conversation continues, sometimes at length. I appreciate the fact that these clinicians want to be so thorough, especially since my medical history is complicated. But I’m oh so tired of having to give the same explanations simply because the DSM-V’s biased criteria doesn’t include me.
I have to launch into the explanation that my main symptoms included severe caloric restriction, compensatory exercise, an intense fear of gaining weight, and an obsession with health and food choices. Then I have to explain exactly why I didn’t fit the diagnostic criteria for anorexia and bulimia.
And every single time I have to make this explanation, I’m reminded that the diagnostic criteria for eating disorders are straight up biased and anti-fat.
I engaged in all of the behaviors associated with anorexia — severe caloric restriction, intense fear of gaining weight, and body dysmorphia. However, I didn’t have the physical symptoms required for the diagnosis. I still got my period (because I had endometriosis!) and I was still within a “normal” BMI range. So, I couldn’t be anorexic even though all my behaviors were the same.
I engaged in all of the behaviors associated with bulimia — eating an abnormally large amount of food in a short period of time and then engaging in a behavior to compensate for the food intake. However, I used exercise as my compensatory behavior instead of vomiting or laxatives. And I didn’t exercise enough for it to be considered “excessive.” So, I couldn’t be bulimic even though all my behaviors were the same.
The diagnostic criteria for anorexia and bulimia, still the only two official diagnoses that address restriction and compensatory behaviors, simply aren’t sufficient for diagnosing all the people who have eating disorders. The diagnostic criteria make it clear that eating disorder treatment, as guided by the DSM-V, is only interested in helping people who fit a very narrow definition. Traditional eating disorder treatment is only aimed at those who fit the classic picture of an eating disorder — a super thin, usually white, cis woman.
The diagnostic criteria for anorexia and bulimia purposely exclude people who don’t fit into the typical understanding of eating disorders. The diagnostic criteria for anorexia are also explicitly anti-fat. The diagnostic criteria for bulimia are not explicitly anti-fat because there are no weight requirements for diagnosis. However, they are implicitly anti-fat because they perpetuate the idea that a person with an eating disorder looks a certain way and engages in specific, definable behaviors.
These narrow diagnostic criteria are also anti-fat because they discourage doctors, therapists, social workers, and educators from screening for eating disorders when a person doesn’t fit the typical idea of an eating disorder patient. If a person is fat but engaging in dangerous caloric restriction, has a fear of gaining weight, and body dysmorphia, they’re not seen as possibly having anorexia. They’re seen as dieters, which is encouraged as a healthy behavior because of their weight. If a person is overweight but engaging in compensatory exercise instead of vomiting or using laxatives, they are again seen as engaging in healthy behaviors, not as a potential eating disorder patient.
The diagnostic criteria for eating disorders are definitely a problem, but they’re a symptom of a much larger problem of weight stigma in the medical community.
When a person is fat, they’re expected to lose weight at literally any cost. Doctors prescribe behaviors that would fit the diagnostic criteria for an eating disorder if a thin person were the one engaging in those behaviors. When a fat person’s thought process and behaviors cross the line from dieting to an eating disorder — a very thin line that gets crossed all the time — people still praise them for engaging in “healthy behaviors.” Why? Not because the behaviors are actually healthy, but because we as a society have completely different rules for fat people.
Thin people are allowed to have eating disorders because they’re already thin, which is the socially acceptable state of being. Fat people aren’t allowed to have eating disorders until they get thin enough.
The diagnostic criteria for eating disorders are completely weight-biased when they should be weight neutral. Like any other mental illness, and eating disorders are mental illnesses though there is a heavy physical component, the diagnostic criteria should focus on thinking and behavior, not bodies. Anyone who engages in restriction should be diagnosed with anorexia. Anyone who engages in compensatory behavior should be diagnosed with bulimia. Anyone who is so obsessed with healthy choices and health behaviors that it interferes with their life should be diagnosed with orthorexia. Anyone who changes their behavior because of an intense fear of becoming fat and an inability to properly assess their body size should be diagnosed with the eating disorder that fits their other behaviors. Period. Full stop. No arguments.
And the “Other Specified Feeding or Eating Disorder” diagnosis is insufficient. The whole reason that diagnoses are a thing is so that every clinician a patient encounters can be aware of their diagnoses and have a basic understanding of the medical implications of those diagnoses. When clinicians encounter a “Other Specified Feeding or Eating Disorder” diagnosis, they have literally no idea what that means. It doesn’t give them any useful information about a patient’s medical history or their behaviors. It doesn’t give them the information they need to make informed decisions about treatment, which is directly harmful to their patients.
When a clinician sees a diagnosis of anorexia, they know exactly what behaviors that diagnosis encompasses. The same for when they see a bulimia diagnosis, though they’ll likely need to clarify the compensatory behavior. These clear diagnoses and the understandings that accompany them empower clinicians to make informed treatment decisions that can only benefit their patients. “Other Specified Feeding or Eating Disorder” does not.
So, it’s way past time to revise the diagnostic criteria for eating disorders. It’s way past time to update these diagnoses so that they apply to everyone who has an eating disorder, not just people who look like they have an eating disorder.