Title: Eating Disorders in Gender and Sexual Minorities
Hegemonic masculinity, the dominant culture’s feminine and masculine ideals, homonegativity, and transnegativity collude to create a hostile environment toward those identifying as anything other than cisgender and heterosexual. This stigma makes its way through the minds of those identifying as LGBTQIA and manifests in some functional (advocacy, community building, pride, etc.) and some dysfunctional patterns, including manifesting as body image distress and EDs.
This presentation and interactive dialogue will focus on research, theory, and interventions for gender and sexual minorities with eating disorders.
Bio: Jonna Fries, Psy.D. is a psychologist with a clinical focus on diversity, trauma, and eating disorders. She is the Director of Counseling and Psychological Services at Cal State LA, adjunct faculty for The Chicago of Professional Psychology’s forensic psychology program, is an EMDR certified therapist, Approved Consultant, and Facilitator, an Integrative Body Psychotherapy Instructor, she co-facilitates iaedp’s bi-monthly consultation group, and has a private practice in the Mid-Wilshire area. Her co-edited book, Eating disorders in special populations: Medical, nutritional, and psychological treatments was published in 2018.
Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland) or street parking
In the spring of 2018 major league baseball player, Mike Marjama abruptly retired from the sport to focus on being an ambassador for the National Eating Disorders Association. He struggled with an eating disorder growing up and his move to working with NEDA was only to help save lives but to give men who are struggling a voice to hear that they aren’t alone. Mike Marjama is a reminder that eating disorders can affect anyone of any gender.
According to the National Eating Disorders Association, about one in three people with an eating disorder in the United States are male. That’s roughly about 10 million males. There is a long-standing myth that men do not have eating disorders. A common misconception is that eating disorders are a women’s issue. As a result, many men are ashamed or may not even recognize that they have an eating disorder.
Eating disorders are complex mental illnesses with both genetic and environmental contributing factors. It is also important to be aware that just because someone has poor self image does not necessarily mean they have an eating disorder and vice versa.
Although eating disorders are about much more than body image, it’s hard to ignore the societal impact of cultural ideals of beauty and gender. Women are not the only ones impacted by gender ideals. The ideal male body includes large muscles and little to no body fat. Next to the Cosmopolitan magazines are the men’s magazines with models showing off their six-pack abs. I recall a time shopping with my fiance when we came across the packages for men’s underwear. There, staring me in the face, was a man with a Spartan-like body, doing his best to sell this product. I could see how men could feel intimidated, just like when women are walking through a Victoria’s Secret store. Many males they are taught at a young age to be ‘tough” and “not to cry.” Expressing feelings is often frowned upon.
According to the National Eating Disorders Association, “25% of normal weight males perceive themselves to be underweight and 90% of teenage boys exercised with the goal of bulking up.” Male athletes can become hypersensitive to their bodies when sports such as running, gymnastics, or wrestling has them paying close attention to their weight. Many males are loathe to ask for help because it may make them appear weak or too feminine The fear might be “I am not man enough.” Unfortunately, health professionals may also not recognize eating disorders in males who are usually diagnosed later in their illness, which can lead to a worse outcome.
A few years ago there was a reaction to the athletic physique that had been so celebrated. The “dad bod” trend became a thing where it was okay for men to be more round in the middle. But even with this new trend it still puts out a message that there are only certain body types that are acceptable. What if you are round in the middle and round all over? Is that not okay? And isn’t any guy who is a father technically walking around in a Dad-Bod? It is great that there is more room for different bodies, but we need to expand our acceptance to all shapes and sizes. And not only accept different bodies, but also recognize that the body doesn’t define who someone is as a person.
How can you help a male that you know is struggling with an eating disorder and body image? Just as with females, we need to work on celebrating the men in our lives with what they do and not how they look. We need to let boys know it’s okay to show emotion. It’s okay if they do not look like Superman. Having bulky muscles or not having bulky muscles doesn’t define the strength of a person; especially their character. We need to accept people of all genders and all bodies in all their glorious diversity. It isn’t about your body that defines you, but who you are as a person. If only people could be more impressed with the contributions we put out there instead of the size of our stomachs. Hopefully, with more men like Mike Marjama coming forward, it will decrease the stigma surrounding this mental illness and more men will seek the appropriate help that they need.
Carolyn Hersh, LCSW and our other therapists are able to work with people of all genders at Eating Disorder Therapy LA.
I’ve recently returned from the Association for Size Diversity and Health (ASDAH) Conference and I’m reflecting on all I’ve learned. I’ve wanted to share and further explore Substantia Jones’ keynote, “Fat Visibility Through Photography: the Who, the How, and the Hell Yeah.”
Jones is a photographer, a “Fat Acceptance Photo-Activist,” and the proprietor of the Adipositivity Project. She started Adipositivity in 2007 to “promote the acceptance of benign human size variation and encourage discussion of body politics” by publishing images of women, men, and couples in larger bodies. Substantia is passionate about the fact that fat people don’t see a balanced representation of themselves in the media—as she says, “Humans need visibility. Positive and neutral visibility is being denied to fat people.”
So many of the media images we see of larger-bodied people portray them in negative and stereotyped ways: unkempt, unhappy, eating fast food, and often headless—as if they are ashamed to show their faces. At the same time, the range of body types provided by media images does not really represent most bodies. The media typically culls the thinnest or fittest sliver of the population, and then proceeds to photoshop the images of these bodies. According to the Body Project, “Only 5% of women have the body type (tall, genetically thin, broad-shouldered, narrow-hipped, long-legged and usually small-breasted) seen in almost all advertising. (When the models have large breasts, they’ve almost always had breast implants.)”
In September 2009, Glamour included a photo of Lizzie Miller, a model who is a size 12-14. The photo showed Lizzie nude and looking joyful while displaying a roll of belly fat. The response was overwhelming—American women were thrilled to see a woman who looked more like them and was happy to boot.
While this was groundbreaking, the average American woman is a size 16. So where are the images of the upper half of the weight spectrum? It should be noted that it is not only larger bodies that are marginalized; other bodies are often not portrayed in mainstream media. These include bodies that are darker-skinned, disabled, aging, and gender diverse.
It is important that people in larger bodies see images of people that look like them. It is also important for all people to broaden their aperture on what people should look like. This includes viewing images of fat people who are happy, sexy, desired, and beautiful and engaging in all the activities that make up a fulfilled life.
Those working in the field of body acceptance confirm the therapeutic value of seeing attractive images of larger-bodied people. Unfortunately, these images can still be hard to find. One must look outside of the mainstream media. With that in mind, I thought it would be useful to provide resources for beautiful, artful photos of people living in larger bodies.
During her keynote, Substantia shared photos from several of her favorite fat-positive photographers, including those that inspired her. Below I list some of the photographers she shared and where to find their photos and information about them.
The photography of Patricia Schwarz can be found in Women of Substance – Portrait and Nude Studies of Large Women, published in Japan in 1996 by The Kiyosato Museum of Photographic Arts. Little has been published about her aside from this article, which states that Schwarz, who belonged to the fat liberation community in the 1980s, specialized in full-color photography of fat women. The book features women posing in domestic, natural and urban settings in various stages of clothing and nudity.
Laura Aguilar is known for her photographs of people from various marginalized communities (including fat, lesbian, and Latina). She is particularly known for portraying her own nude body as a sculptural element in desert landscapes.
Leonard Nimoy (yes, that one) published The Full Body Project, a collection of black-and-white nude photos of members of a burlesque troupe called the Fat-Bottom Revue. According to Nimoy, the purpose of the book was to challenge the harmful beauty ideals promoted by Hollywood.
A blog post by The Militant Baker with some photos
Catherine Oakson was described in an obituary as a creator of “artistic self-portraits—some playful, some sensuous—and messages of body positivity.” Unfortunately, since her death, her photographs are extremely hard to find. Her website, “Cat’s House of Fun,” is only available via web archives (web.archive.org). Search for the website, http://catay.com and look at screen grabs prior to 2017
Shoog McDaniel, an artist and photographer living in Florida, was also present at the ASDAH conference, and their art was used in the conference program. Shoog was featured in this article in Teen Vogue which described them as “the photographer pushing the boundaries of queer, fat-positive photography.” Shoog states “the work that I do is about telling the stories of people who are marginalized and not usually put on the forefront, and whose lives are beautiful and important.”
Although Substantia’s presentation did not touch upon it, it’s worth mentioning Representation Matters, the world’s first website providing high-resolution, royalty-free, stock images of diverse bodies for commercial use. (The image in this post is from Representation Matters.) They specifically include larger bodies portrayed in a positive light. These photos are available for purchase.
Unfortunately, diet culture and thin privilege are alive and well, and those in larger bodies remain marginalized and excluded from most mainstream media. I hope you’ll check out these resources and come to appreciate the vast diversity of the human body. I purchased some photography books to share at my office. Together we need to work to challenge the notion that there is a best way to have a body and learn to celebrate the beauty of all bodies.
Baker, Cindy. 2013. “Aesthetic Priorities and Sociopolitical Concerns: The Fat Female Body in the Photography of Patricia Schwarz and Jennette Williams A Review of Patricia Schwarz: Women of Substance, by Patricia Schwarz, and The Bathers: Photography by Jennette Williams, by Jennette Williams.” Fat Studies 2 (1): 99–102. https://doi.org/10.1080/21604851.2012.709447.
This NEDAwareness week, I’ve been thinking a lot about the theme of “Let’s Get Real.” One stubborn myth about eating disorders is that they affect primarily white, upper-middle-class females.
It would take you just one afternoon at my own Los Angeles practice to discover how untrue this is. My clients are all genders, ages, and ethnicities. I accept some private insurance and one public insurance. Among my patients with eating disorders are non-native English speakers, immigrants from low SES backgrounds, and people on public assistance.
The myth that eating disorders affect only the wealthy not only makes it more difficult for patients who don’t meet the stereotype to recognize that they have a problem but affects the entire system of treatment.
Throughout the US, there is a shortage of publicly funded specialized treatment programs for eating disorders. And specialized eating disorder treatment is expensive! The residential treatment complex only serves the economically privileged.
Carolyn Becker, Ph.D. recently brought attention to the presence of eating disorders in food insecure populations. The research on which she collaborated studied adults receiving food at San Antonio area food banks. Those who had hungry children in their households (representing higher levels of food insecurity) had higher levels of binge eating, dietary restraint, weight self-stigma, worry, and overall ED pathology when compared to participants with lower levels of food insecurity
Within Los Angeles County, eating disorders are a covered diagnosis by the Department of Mental Health (DMH). However, according to a DMH district chief, there are no specialized services for eating disorders within the DMH system. I recently led a training on eating disorders at one of the county community mental health centers and a staff member there told me, “Most patients with eating disorders are seen in primary care and none of us are trained specifically in this… What we need is training in evidence-based treatment.”
A clinical staff member at another DMH clinic said, “Honestly, we don’t have a lot of access to resources for people with eating disorders and aren’t equipped to adequately handle serious cases at this clinic. Referrals have always been difficult and there are no reliable referral sources for our patient population. We have really only been able to connect a few of our most severe cases to any treatment at all.”
I searched the Alliance for Eating Disorder Awareness list of Medicare/Medicaid providers and facilities within 50 miles of Los Angeles and came up with only one Medicare provider and no Medicaid providers or facilities.
This blog post was inspired because as a provider for Anthem Medi-Cal, I am receiving calls from county clinics with referrals of other (non-Anthem) Medi-Cal patients with eating disorders that I can’t see. So, when faced with a patient with an eating disorder and no insurance in LA County, what’s a provider to do? Here’s what I’ve been able to find. If you have other resources, I’d love to hear about them!
CHLA takes California Medicaid for patients under age 25 needing medical stabilization.
UCLA takes California Medicaid for patients under age 25 needing hospitalization for eating disorders.
“To The Bone,” Marti Noxon’s semi-autobiographical film about her experience as a young adult living with anorexia, was released today on Netflix and has already stirred up much controversy within the eating disorder community. As a general rule, I do not see things in black and white. As with anything, I see this film in shades of grey – it handles some things well and some things poorly. Many concerns have already been aired widely in both mainstream and social media. Foremost among these concerns is the movie’s reinforcement of the anorexia nervosa stereotype by portraying an emaciated white female and the weight loss that lead actress Lily Collins underwent to play the role. I will not rehash these here; instead, I hope to shed light on some other important issues and to provide an educational piece to accompany the film.
This film may be triggering. It shows images of severe emaciation and may either be upsetting to those vulnerable to eating disorders, or inspire a competitive desire to be “as skinny”. Often, people with eating disorders don’t feel “sick enough”; anorexia nervosa can be a competitive illness. (Reports are that pro-ana sites are already using images of Lily from the film. While it’s concerning that the film adds to the available library of these sorts of images, this library is already huge – if they didn’t use this image, it would be easy to find another.) Those susceptible must exercise caution when viewing this film and if they are triggered, they should contact their treatment team or contact an organization such as the National Eating Disorders Association for help.
It is difficult to make a film that accurately portrays eating disorders. To depict eating disorders on film, behaviors must be shown. Yet much of the suffering from an eating disorder is internal and harder to depict. This film is not an educational film – it is a piece of entertainment. Nevertheless, I think it does bring eating disorders into the mainstream. The film portrays some things accurately – with others it takes great liberties. Even with these departures, I do think it has virtues that can do some good. I will discuss these more below.
This is one person’s story. Marti Noxon’s aim is to tell her story and she has a right to do so. She has been public that many years ago she suffered from an eating disorder and wanted to both shed light on and draw more attention to the issue. And that she has done! Based on the talkback I attended with Marti Noxon and actors Lily Collins and Alex Sharp, Marti recognizes that she can neither represent the diversity of all people with eating disorders nor speak for the range of people affected. She hopes that her work will open the door for others to tell their own stories, a hope I share. For those interested in a more diverse story about eating disorders, check out the work of Tchaiko Omwale, who is working to complete her film Solace. If you are committed to helping bring more diverse voices forward, you can contribute to help her complete her film.
To The Bone accurately portrays some of the aspects of living with an eating disorder. I do not believe the film overly glamorizes anorexia. It illustrates the mindset and some of the mental anguish of someone with an eating disorder. The film displays a number of common eating disorder behaviors. We see Ellen and her peers engaging in behaviors such as calorie-counting, dietary restriction, overexercise, bingeing and purging, and chewing and spitting. Chewing and spitting is displayed in a restaurant scene in which Ellen goes out to eat with Lucas, her friend from treatment. Chewing and spitting is a lesser-known, but significant eating disorder behavior that is not commonly talked about or assessed by professionals. It is a frequently associated with more severe eating disorder symptoms and suicidal ideation. However, the behavior is more likely to occur in private than in public. It can occur in the context of anorexia nervosa as well as bulimia nervosa or other disorders.
Eating disorders are serious mental illnesses and can be life-threatening. The movie shows Ellen and some of her peers needing medical attention and carefully balances showing the gravity of their situation with building hope for recovery.
To the Bone paints a very Hollywood picture of recovery. While the movie adequately portrays Ellen’s ambivalence about treatment, it implies that things shift when Ellen “decides” she wants to recover. It disturbs me greatly that Dr. Beckham tells Ellen, “I’m not going to treat you if you aren’t interested in living.” Many people with anorexia nervosa have anosognosia, a symptom that causes patients to deny their illness and refuse treatment as a result. We now know that enough food, weight gain, and a cessation of eating disorder behaviors are prerequisites for recovery from anorexia nervosa. Usually some physical restoration is required before a patient can really want to recover – Dr. Ovidio Bermudez calls this a “brain rescue.”
The movie does not model modern eating disorder treatment practices. But realistic treatment would probably not make a good Hollywood story. For starters, I would never suggest a therapy patient change his/her name! More seriously, in eating disorder treatment we prioritize nutritional recovery. This refers not to specific nutrients, but to the development of healthy eating habits including regular meals and adequate amounts of food. This applies to people with all eating disorders, not just anorexia nervosa. People with eating disorders need as a primary element of treatment food – balanced, sufficient, and regular eating. The movie portrays the patients in the residential treatment center as each able to choose their own food. While some patients eat some portion of the meals served, other patients eat nothing (or the one character with BED repeatedly eats only peanut butter out of the jar). I know of no treatment setting that would not have a primary focus on structured regular meals and patients having requirements for meals that can become less restrictive as they progress in treatment.
I worry that the portrayal of Ellen’s family reinforces old myths about eating disorders being caused by families. To reiterate, families do not cause eating disorders. Ellen’s father is unavailable (and never even appears), her mother has had mental health problems (and is involved in a new relationship) and no one is really there for Ellen, except her stepmother who takes her to treatment and her half-sister. I do love the portrayal of the relationship between Ellen and her half-sister. I think this relationship captures the mixture of love, concern, and anger experienced by siblings.
The movie misses the opportunity to depict the family as important allies in treatment. No one is really involved in Ellen’s treatment beyond the family session, and Dr. Beckham states there is no need for any future family sessions on the basis of how badly it went. None of the young people in this house have their parents involved in their treatment (at least that we see). This is very unrealistic in this day and age. Almost every treatment center involves family members to a greater or lesser degree. In reality, parents can play a central role in the treatment of adolescents and young adults, are usually included in treatment, and can even drive the treatment when their youngsters are incapable of seeking treatment on their own or have anosognosia. Parents can also help with nourishing their youngsters back to health (but not in the dramatic way it was portrayed in the film…with a baby bottle). Family-based treatment (also referred to as the Maudsley method and mentioned in passing in the scene where the moms are in the waiting room waiting for their daughters to have an intake with Dr. Beckham as something they have tried) is actually the leading treatment for adolescents and is also effective for many young adults. It focuses on empowering the family to be an important part of the treatment team and able to fight for recovery on behalf of an unwilling or unmotivated youngster and also provide meal support.
Three Things I really like about the film:
I love that Dr. Beckham says, “There is never one cause.” This is true.
I love that it builds hope for recovery by showing Lucas as doing well and actively working on recovery.
I love that it shows a male and an African-American with eating disorders.
Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.
Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.
Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.
Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.
Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.
Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.
Truth #7: Genes and environment play important roles in the development of eating disorders.
Truth #8: Genes alone do not predict who will develop eating disorders.
Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.
Produced in collaboration with Dr. Cynthia Bulik, PhD, FAED, who serves as distinguished Professor of Eating Disorders in the School of Medicine at the University of North Carolina at Chapel Hill and Professor of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, Sweden. “Nine Truths” is based on Dr. Bulik’s 2014 “9 Eating Disorders Myths Busted” talk at the National Institute of Mental Health Alliance for Research Progress meeting.
In the wake of the premiere on Netflix of another eating disorder film, my friend, JD Ouellette, reminded me that the frustration over another stereotypical narrative about eating disorders could provide an opportunity. At the NEDA Conference in 2014, both JD and I (as well as many other attendees) were impressed by Tchaiko Omawale’s sharing of her inspiring story of recovery on the Friends and Family Panel. Later, we learned about her work (writing, directing, and producing) on Solace, a coming of age feature film inspired by Tchaiko’s journey with an eating disorder and self-harm. In April, I had the opportunity to attend a fundraiser for Solace and preview a scene. I spoke about the need for more films, stories, and images of people from diverse backgrounds with eating disorders, reading some parts of this article.
As summarized in Truth #5 of the collaborative consensus document, the Nine Truths, “Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.” When I work with people of diverse backgrounds, they consistently tell me they are frustrated that mainstream eating disorder narratives do not portray people who resemble them. Not only the popular media — television, film, print articles, online publications — but even the marketing materials of many eating disorder treatment centers continue to depict eating disorder sufferers mostly as the common stereotype: female, white, and thin.
To those interested in supporting a film that doesn’t reinforce stereotypes, Tchaiko Omawale has made such a film. She needs additional funding to complete the film, which is in post-production. Visit Solace Film page to learn more and, if you are so inclined, join me in supporting this important project. She has a donation page.
I am excited to announce the next 3 upcoming meetings of the Los Angeles County Psychological Association Eating Disorder Special Interest Group (LACPA ED SIG). We have amazing speakers lined up. The LACPA membership year begins in September, so now is the time to join or renew to maximize your benefits. SIG events are open only to LACPA members, but are FREE. For information on membership, see the LACPA website. www.lapsych.org. One does not need to be a psychologist to join LACPA; other professionals may join as well.
Date: Thursday, August 28th
Title: Does Every Woman Have an Eating Disorder? Challenging Our Nation’s Fixation with Food and Weight
Presenter: Stacey Rosenfeld, Ph.D.
Location: The office of Stacey Rosenfeld, PhD (2001 S. Barrington Avenue, Suite 114, Los Angeles)
BIO: Stacey Rosenfeld, PhD, is a clinical psychologist, licensed to practice in New York and California, who treats patients with eating disorders, anxiety/depression, substance use issues, and relationship difficulties. A certified group psychotherapist, she has worked at Columbia University Medical Center in NYC and at UCLA in Los Angeles and is a member of three eating disorder associations. The author of the highly-praised Does Every Woman Have an Eating Disorder? Challenging Our Nation’s Fixation with Food and Weight, inspired by her award-winning blog of the same name, she is often interviewed by media outlets as an expert in the field.
Dr. Rosenfeld is also the founder of the LACPA ED SIG but will be leaving the group in the fall due to relocation. This will be a unique opportunity to hear her speak and also to acknowledge the contributions she has made to the Los Angeles community during her fruitful three years here.
Date: Tuesday, September 16th
Title: Pregnancy & Eating Disorders: Journey Through the Facts and Recovery
Presenter: Maggie Baumann, MFT, CEDS
Location: The office of Stacey Rosenfeld, PhD (2001 S. Barrington Avenue, Suite 114, Los Angeles)
Bio:Maggie Baumann is a psychotherapist in Newport Beach who specializes in treating people struggling with eating disorders, including pregnant women and moms with eating disorders. She is a former board member for the Orange County Chapter of the International Association of Eating Disorder Professionals (IAEDP) and serves as a committee member on the national IAEDP certification board.
Maggie has been a featured guest on nationwide talk shows and TV segment profiling pregorexia and moms with eating disorders. She was a mental health blogger for Momlogic.com, where she shared her own story of suffering from pregorexia over twenty-five years ago. Additionally, Maggie serves as a guest eating disorder expert for KidsinTheHouse.com, a video parenting resource. She is also authoring a chapter on eating disorders and pregnancy for an upcoming book on Eating Disorders in Special Populations (publication date: 2015). Now, Maggie has partnered with Chicago-based residential treatment center, Timberline Knolls, in hosting their Lift the Shame eating disorder support group the first web-based support group for pregnant women and moms with eating disorders. Lift the Shame, is a free group and has members from across the US and abroad.
Date: Thursday, October 23
Time: 7- 8:30 pm
Title: TRANSforming Eating Disorder Recovery: Deconstructing the Overrepresentation of Eating Disorders in Trans and Gender Diverse Individuals, and How Healthcare Professionals Can Better Serve Our Communities
Presenter: Dagan VanDemark
Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles)
Bio: Dagan VanDemark is the Founder and Executive Director of the pending non-profit T-FFED: Trans Folx Fighting Eating Disorders, based in LA but quickly gaining national reach. Dagan, a genderqueer trans boi, battled bulimia/EDNOS for fifteen years. They have a B.A. in Gender Studies from CSULB, a certificate in Grant Writing and Administration from CSUDH, and they are enrolled in both the Non-Profit Management certificate program at UCLA and a transgender leadership initiative through Gender Justice LA. They speak on university panels about gender variance and sexual diversity, and write/blog extensively about transgender communities’ experiences with eating disorders.
Please RSVP for any or all of the 3 events to firstname.lastname@example.org