Adriana C. Labarta, Danna Demezier, Alyssa A. Vazquez
Scholars, practitioners, and clients in the eating disorder (ED) treatment field emphasize the need for more culturally responsive approaches to improve care for marginalized communities. Treatment barriers, such as counselor biases, lack of access to care, and disempowering approaches, perpetuate these gaps across diverse groups with EDs. We propose that Ratts et al.’s (2016) Multicultural and Social Justice Counseling Competencies (MSJCC) can bridge these gaps by assisting counselors and other helping professionals working in ED treatment settings in deconstructing biases and implementing empowering treatment approaches for marginalized individuals with EDs. Using case vignettes, we illustrate how counselors can apply the MSJCC across counseling settings and engage in advocacy with the broader ED recovery community. We conclude by presenting implications for counselors, counselor educators, and supervisors, who all play a role in empowering clients and improving access to ED treatment for diverse populations.
Keywords: eating disorder, multicultural, social justice, marginalized, advocacy
The SWAG myth has long persisted within the eating disorder (ED) treatment field, informing research and practice and centering the experiences of “skinny, White, affluent, girls” (Sonneville & Lipson, 2018). Abundant evidence highlighting the presence and impact of EDs across diverse cultural identities now discredits this stereotype (Halbeisen et al., 2022; Huryk et al., 2021; Schaumberg et al., 2017; Sonneville & Lipson, 2018). Nonetheless, scholars, practitioners, and clients alike point to prevailing gaps impacting minoritized populations with EDs and call for more inclusive, culturally informed practice (Burke et al., 2020; Hartman-Munick et al., 2021; Labarta et al., 2023). The American Counseling Association (ACA; 2014) Code of Ethics preamble highlights the importance of “honoring diversity and embracing a multicultural approach in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts” (p. 3). Thus, multicultural competence is essential for the counseling profession to continue addressing the needs of culturally diverse clients, including social justice concerns that shape and contextualize mental health and wellness. The purpose of this article is to illuminate EDs as multicultural concerns that require counselors to challenge common, harmful stereotypes about EDs and to move toward more inclusive, culturally responsive treatment frameworks.
Multicultural Concerns Within Eating Disorders
Culturally responsive counseling requires counselors to understand clients’ diverse cultural and social identities as well as their mental health experiences (Ratts et al., 2016). Similarly, awareness of the intersection between EDs and multicultural concerns is imperative to culturally sensitive treatment. We begin with an overview of ED literature on underserved populations with particular attention to various aspects of cultural identity, including race and ethnicity, sexual orientation, gender identity, socioeconomic status and food insecurity, ability status, body size, and religion and spirituality. We conclude with a brief overview of intersectionality and ED literature.
Race and Ethnicity
Although racial and ethnic minorities experience EDs at similar rates as non-Hispanic, White individuals (Marques et al., 2011), there is a lack of ED research using racial and ethnic minority samples (Burke et al., 2020; Egbert et al., 2022; Mikhail & Klump, 2021). For instance, Egbert et al. (2022) discovered that across 377 peer-reviewed manuscripts published between 2000 and 2020 in the International Journal for Eating Disorders, only 45.2% reported demographic information related to participants’ racial/ethnic identity. In studies that reported racial/ethnic demographic data, White participants comprised about 70% of the samples. Greater representation of racial and ethnic minorities in research is imperative in order to gain insight into the etiological and maintaining factors of EDs in diverse communities (Egbert et al., 2022), particularly because counselors may hold biases that contribute to significant disparities in ED diagnosis for people of color compared to White individuals (Sonneville & Lipson, 2018). Thus, researchers underscore the importance of exploring culturally and contextually relevant factors, such as sociocultural factors and acculturative stress (Kalantzis et al., 2023; Talleyrand, 2012; Warren & Akoury, 2020) and adopting therapeutic approaches that are collaborative and culturally sensitive (Acle et al., 2021).
Sexual Orientation
Sexual minority populations experience increased risk for ED pathology and may present with higher ED pathology at admission to ED treatment compared to their cisgender, heterosexual peers (Mensinger et al., 2020). However, a recent systematic review examining ED literature from 2002 to 2022 revealed that ED risk varies across sexual minority groups (O’Flynn et al., 2023). Therefore, studies that combine sexual minority groups into one sample may provide an incomplete understanding of ED patterns across distinct identities (e.g., bisexual, gay, lesbian, pansexual). Counselors and researchers should assess sociocultural factors that influence ED risk (Engeln-Maddox et al., 2011) and minority stress experiences (Mason & Lewis, 2015; Meyer, 2003), as well as protective factors that serve as buffers against ED pathology, such as social support. It is important to move “away from heteronormative frameworks and toward more liberatory ones” (O’Flynn et al., 2023, p. 13). It is essential for counselors to recognize the expansiveness of sexuality and attraction, as well as how clients’ identities and experiences inform ED assessment and treatment approaches.
Gender Identity
EDs impact people across diverse gender identities, including gender expansive and nonbinary individuals, transgender men and women, and cisgender men and women (Hartman-Munick et al., 2021; Nagata et al., 2020). However, because of assumptions surrounding EDs as female disorders, men may delay seeking treatment (Räisänen & Hunt, 2014) and feel like “the odd one out” (Kinnaird et al., 2019, p. 848). Nonbinary and transgender individuals with EDs also experience barriers to receiving inclusive care because of gender-based stereotypes (Hartman-Munick et al., 2021). Therefore, it is important for counselors to consider gender norms, ideals, and expressions (e.g., masculinity, femininity, androgyny) that may influence ED pathology and related body image concerns. For example, although EDs are typically associated with femininity and the thin ideal, research has shown that masculinity and muscularity ideals are also risk factors (Griffiths et al., 2015). Counselors should also avoid gender binary assumptions, as individuals who adhere to androgynous ideals are often overlooked in ED assessment and treatment (Cusack & Galupo, 2021). Gender-affirming ED treatment requires deconstructing traditional female-oriented approaches and considering the varied experiences of gender-diverse individuals.
Socioeconomic Status and Food Insecurity
Another common harmful stereotype is that EDs primarily impact individuals of higher socioeconomic status (SES). A recent systematic review debunked this myth when it illustrated that EDs present across varied socioeconomic backgrounds (Huryk et al., 2021). Given that the cost of ED treatment is a significant barrier to care (Ali et al., 2017), individuals of lower SES may be less likely to seek treatment or may have limited access to specialized treatment (Huryk et al., 2021; Sonneville & Lipson, 2018). Relatedly, emerging research has drawn connections between food insecurity and EDs. Existing ED assessment tools often conceptualize food restriction as driven by weight or shape concerns (Hazzard et al., 2020; Middlemass et al., 2021). Individuals experiencing food insecurity, however, may engage in periodic dietary restriction because of fluctuations in food availability, which can lead to bingeing or overeating when food is more accessible (Rasmusson et al., 2019). Given the importance of addressing nutrition in ED treatment, counselors should broach the topic of food insecurity with clients in order to understand patterns of restriction and availability of food (Hazzard et al., 2020; Middlemass et al., 2021). Overall, scholars recommend that practitioners conceptualize SES as a multidimensional construct (e.g., income, occupation, wealth) during the assessment process to determine clients’ barriers and improve access to resources (Huryk et al., 2021).
Ability Status
Individuals with disabilities are largely underrepresented in ED literature even though they are at increased risk of disordered eating behaviors (Cobbaert & Rose, 2023; Gesi et al., 2017; Nazar et al., 2016). Recent research has shown that autistic individuals experience more negative outcomes and barriers in ED treatment than neurotypical individuals (Babb et al., 2021). Cobbaert and Rose (2023) issued a call to action for ED health care professionals to engage in neurodiversity-affirming practices, specifically by rethinking the implementation and practice of ED treatment, which has historically centered the medical model and neurotypical experiences. Current recommendations include using strengths-based, trauma-informed approaches, challenging ableist expectations and treatments, and centering human rights and autonomy (Cobbaert & Rose, 2023). Research also suggests that individuals with physical disabilities have nuanced experiences with body image, which in turn can impact the development of EDs (Cicmil & Eli, 2014; Gross et al., 2000). For example, individuals may develop EDs as a means to cope with the psychological and social difficulties they experience related to living with a disability and navigating societal body image ideals and pressures (Cicmil & Eli, 2014). Ultimately, more research that examines the intersection of EDs and ability status is needed.
Body Size
People of size, or larger-bodied individuals, often experience barriers to receiving quality care, including weight bias from clinicians and delays in being referred to ED treatment (Harrop et al., 2021; McEntee et al., 2023; Puhl et al., 2014). Because of fear of experiencing weight stigma in health care settings, people of size are less likely to seek treatment for health concerns, including EDs (Mensinger et al., 2018). Counselors may perpetuate weight loss–related treatment recommendations that can negatively impact clients’ long-term well-being (Chen & Gonzales, 2022; Puhl et al., 2014). Although larger-bodied individuals may experience significant psychosocial and medical consequences as a result of an ED, research demonstrates that fewer patients are referred to appropriate treatment because of assumptions of severity based on body size (Harrop et al., 2021). Scholars and advocates recognize the need for more research among this population (Ralph et al., 2022) and recommend increased training in the use of weight-inclusive and fat liberation frameworks when working with larger-bodied clients (Matacin & Simone, 2019; McEntee et al., 2023; Tylka et al., 2014).
Religion and Spirituality
Religion and spirituality are critical sociocultural factors that can influence EDs and their treatment. Research has shown that religion and spirituality can serve positive, negative, or non-significant roles in ED recovery based on the individual’s lived experience (Akrawi et al., 2015; Buser et al., 2014; Richards et al., 2018). For example, Akrawi et al.’s (2015) systematic literature review revealed that a secure relationship with God was linked to decreased levels of disordered eating, while a doubtful or anxious relationship with God correlated with greater levels of disordered eating. Religious and spiritual coping strategies (e.g., prayer, meditation, meaning-making, and connecting with nature) can be protective in ED recovery (Buser et al., 2014; Richards et al., 2018). On the other hand, some individuals experience feelings of shame and guilt related to religious beliefs and bullying from members of their religious communities because of their ED (Richards et al., 2018). Because religion and spirituality are often personal and unique to the individual, Mintert et al. (2020) recommend that counselors explore their complex roles and potential relationship to clients’ presenting concerns and integrate evidence-based interventions affirming diverse religious and spiritual identities.
Intersecting Identities
Intersectionality theory, which originates from Black feminist scholarship, describes how multiple marginalized social identities interact and impact mental health (Crenshaw, 1989). Because individuals with marginalized social identities experience inequities related to their ED presentation, counselors must consider the intersection of such identities in order to address specific concerns that impact underserved clients’ risk, treatment process, and outcomes (Burke et al., 2020; Burke et al., 2023). An intersectional approach considers the impact of one identity on another, including how several identities work to either place individuals at risk or support their resilience (Burke et al., 2023). Although more research is needed on EDs across diverse intersecting identities (Burke et al., 2020), scholars have started to explore intersectionality (Burke et al., 2023; Calzo et al., 2017; Diemer et al., 2015). Overall, the higher rates of EDs in marginalized individuals with intersecting identities imply a need for interventions that consider the inequities faced by these individuals and the impact on their risk for EDs (Burke et al., 2023).
Applying the MSJCC to Eating Disorder Treatment
Across ED literature, scholars have advocated for the development of culturally responsive models to address ongoing treatment disparities. We believe that the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016) can serve as a powerful framework for counselors and related helping professionals who work with clients with EDs. The MSJCC, centered on the values of multiculturalism and social justice, attend to essential constructs like intersectionality, including privileged and marginalized statuses within the counseling relationship. Four developmental domains outline essential areas for counselors to explore when working with clients with cultural sensitivity: Counselor Self-Awareness, Client Worldview, Counseling Relationship, and Advocacy Interventions. The first three domains are further organized into four aspirational competencies, namely attitudes and beliefs, knowledge, skills, and action. In the sections below, we review brief case vignettes illustrating various presentations of EDs across diverse intersecting identities, the application of the MSJCC across treatment settings, and relevant resources for counselors.
Counselor Self-Awareness
Paul is a 13-year-old Hispanic, cisgender male with autism spectrum disorder (ASD). He is an only child and lives with his parents and paternal grandmother. Paul’s parents have described him as a picky eater throughout his life. He has an aversion to certain smells and/or textures in food and exhibits rigidity around mealtimes. For example, Paul rarely deviates from his comfort foods and often has the same daily meals, such as plain pasta that his mother prepares for lunch. One day at school, Paul realized that he had forgotten his lunchbox. When his teacher offered to assist him with getting food from the cafeteria, Paul became visibly distressed and began to panic. Paul’s teacher was concerned and contacted the school counselor to check in. Mrs. Walker, the school counselor, called Paul into her office and assessed his concerns, discovering his disordered eating behaviors.
Although Mrs. Walker had experience working with students with ASD, she found herself initially dismissing concerns related to his eating behaviors. After further reflection, Mrs. Walker recognized that her own cultural beliefs and biases related to gender were impacting her ability to fully assess his presenting ED symptoms. For example, she noticed that she held the erroneous belief that males don’t struggle with food. She consulted a colleague on next steps, as she did not want to violate any ethical codes or unintentionally harm Paul. Mrs. Walker began adjusting her attitudes and beliefs. She was surprised to find literature on EDs in males and learned about the unique experiences of those with ASD. Mrs. Walker reflected on internalized stereotypes of gender, disability, and mental health. She was challenged to consider Paul’s unique experience as a young Hispanic male with ASD and the cultural implications of ASD and EDs. To do so, she practiced cultural humility and reflected on her own cultural identities and biases and how they shaped her worldview.
Mrs. Walker sought to learn specific information about the intersection of ASD and EDs, such as their common comorbidity and clinical presentations like sensory sensitivities that may lead to food avoidance (Bourne et al., 2022). Mrs. Walker also used various resources to increase her knowledge of the risk factors of EDs in males, recognizing that risk factors often differ in females. She identified a need to take an individualized approach and developed skills to work with Paul through a culturally responsive lens. Specifically, Mrs. Walker implemented a tailored intervention to empower him and his family to connect with community referrals in order to support his recovery.
Mrs. Walker took action to support her work with Paul by sharing her newly attained knowledge about the intersection of disability and EDs. She initiated a campaign in her school to raise awareness of EDs and gender and disability biases, as well as the challenges that individuals with ASD face during their recovery process. These interventions allowed Mrs. Walker to work toward systemic change surrounding stigma on EDs, males, and people with ASD. She shared a list of local and national organizations that specialize in ASD or EDs (specifically, avoidant/restrictive food intake disorder, or ARFID) with Paul and his family to ensure that they had access to therapeutic support. Examples included Different Brains (https://differentbrains.org) for ASD and the National Alliance for Eating Disorders (https://www.allianceforeatingdisorders.com). Mrs. Walker remains in contact with Paul’s community mental health counselor to understand how she can support him within the school setting. After this experience, Mrs. Walker reflected on the importance of developing her own self-awareness as a counselor, which allowed her to challenge her biases and cultivate more meaningful relationships with diverse students.
Client Worldview
Anita is a 19-year-old Black woman. Growing up in a low-income household, she and her family often struggled with food insecurity, leading to a scarcity mindset around food. Despite these challenges, Anita has always had a close, loving relationship with her family. About one year ago, she came out as pansexual to her parents and a few close friends. Although the experience was positive and empowering, Anita worries about her upcoming transition to college, being away from her family and friends, and connecting with other LGBTQ+ students on her campus. During her first semester, she would binge eat when feeling lonely or stressed. This was usually followed by intense feelings of guilt and shame which led to restriction of food. Anita decided to schedule an intake appointment at her college counseling center; she is scheduled to meet with Dalton, a new counselor who started his position this semester.
Dalton’s goal for the intake appointment is to gain a deeper understanding of Anita’s worldview. Although Dalton has experience working with clients with eating concerns in different settings, he has maintained an assumption that EDs primarily occur in affluent, White populations. Dalton recognizes the importance of challenging his attitudes and beliefs about EDs that could negatively interfere with the treatment process. As Anita shared her story, Dalton intentionally bracketed his biases and remained open to learning about her lived experience. After the session, he engaged in reflective practice by processing his reactions with a colleague at the center with expertise in EDs.
Pulling from his knowledge of culturally responsive theories, Dalton identified the role of intersectionality in Anita’s presenting concerns. As a pansexual woman of color raised in a low-income household, Anita’s experiences may be understood by considering her multiple minority identities. Anita faced significant challenges throughout her life (e.g., food insecurity, the coming out process, and recent transition to college), which may have led to an increased risk of developing an ED. Despite these risk factors, Dalton recognized that an intersectional approach also considers Anita’s strengths and protective factors (Chan et al., 2019), such as strong family support and willingness to seek counseling. Dalton used these insights to conceptualize Anita’s concerns and treatment plan from a strengths-based, culturally responsive lens.
Building on his understanding of theory, Dalton reflected on essential skills to help Anita in counseling. Dalton understood that it may take time for Anita to feel comfortable processing her experiences and sharing parts of her identity. Anita may fear rejection or misunderstanding from Dalton, particularly if he has a different upbringing or cultural background. Dalton understood that experiences of oppression can influence clients’ worldviews and experiences, potentially leading to feelings of disconnection. Given Anita’s complex relationship with food throughout her life, bingeing and restriction may have served as coping mechanisms to deal with uncertainty, loneliness, and fear of rejection. Thus, Dalton remained aware of the inherent power dynamic in the counseling relationship and intentionally shared power with Anita as she navigated her healing process (e.g., co-constructing the therapeutic focus and remaining open to feedback from Anita).
Dalton recognized the need for ongoing commitment, or action, to education and engagement with diverse communities. He sought opportunities to attend workshops or webinars on EDs in underserved populations in order to acquire more awareness, knowledge, and skills related to culturally sensitive approaches. Dalton learned about virtual LGBTQ+ support groups offered by Fighting Eating Disorders in Underrepresented Populations (FEDUP; https://fedupcollective.org) and shared this resource with Anita to expand her social support network. Dalton also reached out to organizations on campus, such as LGBTQ+ and Black, Indigenous, and people of color (BIPOC) student groups, to learn more about their experiences and needs as college students. He consulted with his new colleagues to familiarize himself with student resources, such as on-campus food pantries for food-insecure students. These action-based efforts allowed Dalton to deepen his understanding of Anita’s worldview, immerse himself in the campus community, and advocate for diverse students’ needs.
Counseling Relationship
Jenna is a 40-year-old Jewish Orthodox, heterosexual, cisgender woman who identifies as having a larger body. She experienced significant trauma from her father as a teenager and is now estranged from her immediate family. This has impacted her body image and overall sense of self. Since being estranged, she has struggled with her religious and spiritual identity. Growing up, she learned to cope with difficult emotions with food. She experienced periods of bingeing to help soothe and numb her feelings, as well as periods of significant restriction stemming from attempts to control her body shape. She has reported significant shame regarding her body size and ED symptoms and has avoided seeking counseling because of perceived stigma. Jenna has decided to seek outpatient treatment to help manage ED behaviors after the urging of a friend. When beginning counseling, she realized that she may need to unpack some of her past trauma as well as how religious beliefs have shaped her relationship with food. Jenna began seeing Emily, an agnostic, gay, cisgender female counselor who identifies as “straight-sized,” or a person in a smaller body (Ashwell, 2020). Emily has been working in the field of ED for over 10 years.
While completing the intake assessment with Jenna, Emily asked questions to understand Jenna’s multicultural background. Emily reflected upon her own intersectional identities and how the differences in marginalized and privileged identities may impact the client–counselor relationship. Emily realized that Jenna holds more privilege as a heterosexual woman yet experiences more marginalization because of her Jewish Orthodox identity and larger body size. After the intake session, Emily reflected upon her own attitudes and beliefs about Jenna’s identities, critically evaluating her biases and assumptions, and considered how being in a straight-sized body may impact her client’s comfort or discomfort in the counseling relationship. Emily used curiosity and open communication to strengthen the counseling relationship.
After reflecting on her own attitudes and beliefs, Emily recognized that it was essential to increase her knowledge of her client’s experiences as a Jewish Orthodox woman. Emily learned about Jewish Orthodox beliefs and customs as well as the oppression and discrimination these communities may face. This knowledge was integral to establishing a connection with Jenna and preventing possible microaggressions (Mintert et al., 2020). Because of Jenna’s reported experience with her religious and ethnic background impacting her relationship with food, Emily also focused on exploring intersections between food, body image, and her cultural background.
Emily then explored skills for cultivating an open space for dialogue, particularly those related to addressing how different worldviews between the counselor and client could impact the counseling relationship. Emily demonstrated curiosity and avoided making assumptive statements regarding Jenna’s experiences, understanding the importance of broaching cultural differences in the client–counselor relationship (Day-Vines et al., 2007). Emily’s experience in the ED field prepared her to support clients in challenging diet culture in multiple ways, including discussing the impact of fat-oppressive culture on emotional health, being mindful of her language regarding body size, and creating an inclusive office space for clients in different bodies (Kinavey & Cool, 2019). When Jenna shared discomfort in working on body image issues with an individual in a “straight-sized” body, Emily utilized validation and reflecting skills to process these differences in lived body experiences, which helped Jenna feel safe to further process her body image experiences despite their differences.
Emily took action by holding more conversations with other professionals, joining online communities, and continuing her research to understand how to continue supporting clients of different religious and spiritual backgrounds and body sizes. Emily also supported Jenna in becoming more involved in advocacy, which Jenna found to be empowering and liberating and helped her to improve her relationship with her body. Emily provided resources for Jenna to learn about fat liberation through the Association for Size Diversity and Health (https://asdah.org) and the National Association to Advance Fat Acceptance (https://naafa.org). Emily also connected Jenna to an ED support group, the Larger Bodied Individuals Support Group offered by the National Alliance for Eating Disorders. Emily found that the counseling relationship was strengthened by advocating and taking action with and on behalf of her client.
Advocacy Interventions
Ratts et al. (2016) indicated that counseling and advocacy interventions can occur at several levels (i.e., intrapersonal, interpersonal, institutional, community, public policy, international or global) on behalf of clients or counselors. Counselors are encouraged to consider contextual factors, such as client identities and counseling settings, and to determine the most appropriate and responsive advocacy interventions. The sections above covered several examples of intrapersonal and interpersonal advocacy efforts for counseling clients with diverse intersecting identities. Regarding counselor advocacy, another important intrapersonal consideration is the role of self-care in sustaining social justice and advocacy efforts (Mitchell & Binkley, 2021). The intensive nature of ED treatment (e.g., high mortality and relapse rates; Graham et al., 2020; Warren et al., 2013) emphasizes the need for self-care to maintain vitality and ensure ethical, culturally responsive care. Counselors can also reinforce the significance of wellness practices within their interdisciplinary collaborations that foster interpersonal advocacy within the ED treatment environment.
Counselors can critically evaluate the practices and policies within their institutions and counseling settings to foster inclusion beyond the counseling room. For example, Akoury et al.’s (2019) qualitative study discovered that some women of size experienced physical barriers in therapy waiting rooms, such as unaccommodating furniture. Ensuring that waiting areas and clinical settings accommodate clients of all sizes and abilities is essential to cultivating an affirming environment. It is also worth noting that there are institutional training gaps related to ED education, including within counseling programs (Labarta et al., 2023). Counselor educators and supervisors can address these gaps by adopting a culturally responsive approach to teaching about EDs, improving students’ awareness of EDs across populations, and advocating for the inclusion of ED education across curricula.
Counselors play an essential role in addressing their communities’ mental health needs. The majority of EDs go untreated, especially in minoritized populations (Bryant et al., 2022); thus, community–based advocacy is crucial. One method to more deeply assess these needs is community-based participatory research (CBPR). Because of its strengths-based, collaborative approach, CBPR presents an opportunity for culturally responsive research to address health inequities and disparities impacting underserved groups (Rodriguez Espinosa & Verney, 2021). The core tenets of CBPR involve research with communities, implying shared power in the research process and giving marginalized communities a voice to express their perceptions on gaps and immediate needs (Hays, 2020). CBPR can be a powerful alternative to traditional methods in ED research, which have historically excluded the perspectives and experiences of marginalized groups. Action research methods allow researchers, practitioners, clients, and other stakeholders to collaborate and bridge research–practice gaps, which can improve access to ED and mental health treatment (Rodriguez Espinosa & Verney, 2021).
In addition to CBPR, counselors and other practitioners interested in community-based advocacy for EDs may partner with organizations to raise awareness regarding treatment barriers and challenges. Counselors can support underserved clients with accessing care through organizations like Project HEAL, with its mission to improve equitable treatment access (https://www.theprojectheal.org). Counselors may engage in targeted initiatives (e.g., mental health literacy) to reduce barriers that impact individuals who have an ED that is not yet diagnosed (Griffiths et al., 2018). Culturally responsive awareness campaigns can be initiated and situated within the community to reach individuals who may otherwise not have access to such information. In addition to settings like schools and community agencies, counselors may reflect on specific community venues to support marginalized individuals impacted by EDs, such as barbershops, hair salons, churches, and afterschool centers. Treatment recovery is sustained through early intervention, and increasing awareness may support treatment initiation (Griffiths et al., 2018).
On a larger scale, counselors can engage in public policy initiatives that advocate for improvements in health insurance coverage for ED treatment and research funding (Streatfeild et al., 2021), particularly because ED research remains underfunded compared to other mental health conditions (Austin et al., 2019). Further, remaining up to date on legislation impacting clients with advocacy organizations, such as the National Eating Disorders Coalition (https://www.eatingdisorderscoalition.org), can assist with advancing public policy efforts. Given that EDs are also global issues, international collaborations across disciplines may enhance ED prevention and intervention efforts, allowing for diverse cultural perspectives, deepening our understanding of sociocultural contexts, and extending the impact and reach of social justice and advocacy initiatives.
Implications for Counseling and Counselor Education
Counselors have an ethical responsibility to address the pervasive gaps impacting minoritized clients with EDs (ACA, 2014). The MSJCC are a comprehensive framework that assists counselors with exploring the client’s unique lived experience in addition to relational, systemic, and contextual factors influencing the treatment process (Ratts et al., 2016). The MSJCC can be easily integrated into a counselor’s theoretical approach, leading to a more robust, culturally responsive conceptualization and treatment plan. However, it is essential to note that nuances exist across ED treatment settings, particularly depending on the treatment approach used (e.g., manualized protocols versus individualized treatments). Thus, more extensive conversations within organizations may be necessary, including ways to make the treatment more accessible and inclusive to diverse clients. The MSJCC can serve as a resource to guide these discussions, allowing for a deeper understanding of issues at several levels of treatment (e.g., clients’ experiences, clinicians’ experiences, agency policies and procedures, community issues). For example, FEDUP (formerly Trans Folx Fighting Eating Disorders, 2020) presented a call to action in an open letter to ED organizations, providing essential recommendations, including, but not limited to, the following: hiring more diverse staff at treatment centers, moving away from gender-specific treatment, including inclusive language in handouts and resources (e.g., not defaulting to “she”), establishing scholarships for BIPOC and gender-diverse clients, and developing safe spaces for marginalized clients to connect.
Counselor educators and supervisors also play a role in bridging ED graduate training gaps by utilizing culturally responsive approaches when teaching and supervising ED concerns (Labarta et al., 2023). Suggested pedagogical strategies include applying deliberate practice, addressing countertransference issues, offering specialized coursework, infusing ED education across the curriculum, and collaborating with interdisciplinary professionals to serve as guest lecturers or speakers (Irvine & Labarta, 2024; Labarta et al., 2023; Levitt, 2006). Integrating the MSJCC into the counseling curriculum can assist educators and supervisors in enhancing ED training through a social justice lens. For example, a counselor educator teaching a psychopathology course can encourage counseling trainees to explore how diagnoses can perpetuate weight bias, such as with atypical anorexia nervosa (Harrop et al., 2021), a specified presentation of other specified feeding or eating disorder (OSFED). Counselor educators and supervisors can facilitate discussions on the historical and cultural context of idealized appearance norms, introduce weight-inclusive terminology, explore the limits of research related to weight and health, consider emerging research on fat scholarship, and help trainees remain accountable to their own weight bias and stigmas when working with clients of size (Muzacz et al., 2024; Rothblum & Gartell, 2019). In this way, educators and supervisors encourage trainees to remain critically reflexive of prevalent ED treatment practices and empower their diverse clients with EDs across the lifespan.
Future Research Directions
Scholars have offered several recommendations to enhance culturally informed ED research by creating more inclusive demographic questionnaires and improving reporting in manuscripts (Burnette et al., 2022; Egbert et al., 2022), developing more inclusive assessment tools (Alexander et al., 2024), and designing outcomes-based studies with underrepresented samples (Emelianchik-Key et al., 2023). ED researchers can also use the MSJCC framework to ground their research. For example, counseling researchers have called for more research partnerships between academics and practitioners that can bridge existing research–practice gaps (Barrio Minton et al., 2021; Hays et al., 2019). Related research methods, such as CBPR, can meet this need and incorporate participant perspectives into the research process. Within ED research, this has important implications for marginalized populations who experience barriers to accessing treatment and are often underrepresented in treatment settings. Therefore, moving beyond clinical settings is critical to understanding the unmet needs of community members who may benefit from prevention-based interventions.
Conclusion
In this article, we presented the integration of the MSJCC (Ratts et al., 2016) into the treatment of EDs with marginalized clients. We believe that the MSJCC’s flexibility and social justice lens can assist counselors with bridging the existing gaps and empowering underserved clients across treatment settings. Furthermore, counselor educators and supervisors can utilize the MSJCC as a framework to reconceptualize ED training across counseling curricula, which will play a role in deconstructing dominant narratives on EDs and potentially improving the quality of care for marginalized communities.
Conflict of Interest, Funding Disclosure, and Author Note
The authors reported no conflict of interest or funding
contributions for the development of this manuscript.
The authors would like to thank Hayley Lovelace for
her insights and contributions during the initial
stages of this project.
References
Acle, A., Cook, B. J., Siegfried, N., & Beasley, T. (2021). Cultural considerations in the treatment of eating disorders among racial/ethnic minorities: A systematic review. Journal of Cross-Cultural Psychology, 52(5), 468–488. https://doi.org/10.1177/00220221211017664
Akoury, L. M., Schafer, K. J., & Warren, C. S. (2019). Fat women’s experiences in therapy: “You can’t see beyond…unless I share it with you.” Women & Therapy, 42(1–2), 93–115. https://doi.org/10.1080/02703149.2018.1524063
Akrawi, D., Bartrop, R., Potter, U., & Touyz, S. (2015). Religiosity, spirituality in relation to disordered eating and body image concerns: A systematic review. Journal of Eating Disorders, 3(1), Article 29. https://doi.org/10.1186/s40337-015-0064-0
Alexander, T., Burnette, C. B., Cory, H., McHale, S., & Simone, M. (2024). The need for more inclusive measurement to advance equity in eating disorders prevention. Eating Disorders, 32(6), 798–816. https://doi.org/10.1080/10640266.2024.2328460
Ali, K., Farrer, L., Fassnacht, D. B., Gulliver, A., Bauer, S., & Griffiths, K. M. (2017). Perceived barriers and facilitators towards help-seeking for eating disorders: A systematic review. International Journal of Eating Disorders, 50(1), 9–21. https://doi.org/10.1002/eat.22598
American Counseling Association. (2014). ACA code of ethics. https://bit.ly/acacodeofethics
Ashwell, S. J. (2020). Body size. In G. M. Banik, G. Baysinger, P. V. Kamat, & N. J. Pienta (Eds.), ACS guide to scholarly communication. American Chemical Society. https://doi.org/10.1021/acsguide.60112
Austin, S. B., Hutcheson, R., Wickramatilake-Templeman, S., & Velasquez, K. (2019). The second wave of public policy advocacy for eating disorders: Charting the course to maximize population impact. Psychiatric Clinics of North America, 42(2), 319–336. https://doi.org/10.1016/j.psc.2019.01.013
Babb, C., Brede, J., Jones, C. R. G., Elliott, M., Zanker, C., Tchanturia, K., Serpell, L., Mandy, W., & Fox, J. R. E. (2021). “It’s not that they don’t want to access the support…it’s the impact of the autism”: The experience of eating disorder services from the perspective of autistic women, parents and healthcare professionals. Autism, 25(5), 1409–1421. https://doi.org/10.1177/1362361321991257
Barrio Minton, C. A., Gibbons, M. M., & Hightower, J. M. (2021). Community-engaged research and evaluation in counseling: Building partnerships and applying program evaluation. Journal of Counseling & Development, 99(2), 210–220. https://doi.org/10.1002/jcad.12368
Bourne, L., Mandy, W., & Bryant-Waugh, R. (2022). Avoidant/restrictive food intake disorder and severe food selectivity in children and young people with autism: A scoping review. Developmental Medicine & Child Neurology, 64(6), 691–700. https://doi.org/10.1111/dmcn.15139
Bryant, E., Spielman, K., Le, A., Marks, P., National Eating Disorder Research Consortium, Touyz, S., & Maguire, S. (2022). Screening, assessment and diagnosis in the eating disorders: Findings from a rapid review. Journal of Eating Disorders, 10(1), Article 78.
https://doi.org/10.1186/s40337-022-00597-8
Burke, N. L., Hazzard, V. M., Schaefer, L. M., Simone, M., O’Flynn, J. L., & Rodgers, R. F. (2023). Socioeconomic status and eating disorder prevalence: At the intersections of gender identity, sexual orientation, and race/ethnicity. Psychological Medicine, 53(9), 4255–4265. https://doi.org/10.1017/S0033291722001015
Burke, N. L., Schaefer, L. M., Hazzard, V. M., & Rodgers, R. F. (2020). Where identities converge: The importance of intersectionality in eating disorders research. International Journal of Eating Disorders, 53(10), 1605–1609. https://doi.org/10.1002/eat.23371
Burnette, C. B., Luzier, J. L., Weisenmuller, C. M., & Boutté, R. L. (2022). A systematic review of sociodemographic reporting and representation in eating disorder psychotherapy treatment trials in the United States. International Journal of Eating Disorders, 55(4), 423–454. https://doi.org/10.1002/eat.23699
Buser, J. K., Parkins, R. A., & Buser, T. J. (2014). Thematic analysis of the intersection of spirituality and eating disorder symptoms. Journal of Addictions & Offender Counseling, 35(2), 97–113. https://doi.org/10.1002/j.2161-1874.2014.00029.x
Calzo, J. P., Blashill, A. J., Brown, T. A., & Argenal, R. L. (2017). Eating disorders and disordered weight and shape control behaviors in sexual minority populations. Current Psychiatry Reports, 19(8), Article 49. https://doi.org/10.1007/s11920-017-0801-y
Chan, C. D., Henesy, R. K., & Erby, A. N. (2019). Toward praxis, promise, and futures of intersectionality in multimethod counseling research. Counseling Outcome Research and Evaluation, 10(1), 12–18. https://doi.org/10.1080/21501378.2018.1562845
Chen, C., & Gonzales, L. (2022). Understanding weight stigma in eating disorder treatment: Development and initial validation of a treatment-based stigma scale. Journal of Health Psychology, 27(13), 3028–3045. https://doi.org/10.1177/13591053221079177
Cicmil, N., & Eli, K. (2014). Body image among eating disorder patients with disabilities: A review of published case studies. Body Image, 11(3), 266–274. https://doi.org/10.1016/j.bodyim.2014.04.001
Cobbaert, L., & Rose, A. (2023). Eating disorders and neurodivergence: A stepped care approach. https://nedc.com.au/assets/NEDC-Publications/Eating-Disorders-and-Neurodivergence-A-Stepped-Care-Approach.pdf
Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1989(1), 139–167. https://chicagounbound.uchicago.edu/cgi/viewcontent.cgi?article=1052&context=uclf
Cusack, C. E., & Galupo, M. P. (2021). Body checking behaviors and eating disorder pathology among nonbinary individuals with androgynous appearance ideals. Eating and Weight Disorders, 26(6), 1915–1925. https://doi.org/10.1007/s40519-020-01040-0
Day-Vines, N. L., Wood, S. M., Grothaus, T., Craigen, L., Holman, A., Dotson-Blake, K., & Douglass, M. J. (2007). Broaching the subjects of race, ethnicity, and culture during the counseling process. Journal of Counseling & Development, 85(4), 401–409.
https://doi.org/10.1002/j.1556-6678.2007.tb00608.x
Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. Journal of Adolescent Health, 57(2), 144–149. https://doi.org/10.1016/j.jadohealth.2015.03.003
Egbert, A. H., Hunt, R. A., Williams, K. L., Burke, N. L., & Mathis, K. J. (2022). Reporting racial and ethnic diversity in eating disorder research over the past 20 years. International Journal of Eating Disorders, 55(4), 455–462. https://doi.org/10.1002/eat.23666
Emelianchik-Key, K., Labarta, A. C., & Gill, C. S. (2023). The mediating role of transdiagnostic factors in a clinical sample of Black, Indigenous, and people of color with eating disorders. Journal of Mental Health Counseling, 45(4), 340–356. https://doi.org/10.17744/mehc.45.4.04
Engeln-Maddox, R., Miller, S. A., & Doyle, D. M. (2011). Tests of objectification theory in gay, lesbian, and heterosexual community samples: Mixed evidence for proposed pathways. Sex Roles, 65(7–8), 518–532. https://doi.org/10.1007/s11199-011-9958-8
Gesi, C., Carmassi, C., Luciano, M., Bossini, L., Ricca, V., Fagiolini, A., Maj, M., & Dell’Osso, L. (2017). Autistic traits in patients with anorexia nervosa, bulimia nervosa or binge eating disorder: A pilot study. European Psychiatry, 41(S1), S100. https://doi.org/10.1016/j.eurpsy.2017.01.310
Graham, M. R., Tierney, S., Chisholm, A., & Fox, J. R. E. (2020). The lived experience of working with people with eating disorders: A meta-ethnography. International Journal of Eating Disorders, 53(3), 422–441. https://doi.org/10.1002/eat.23215
Griffiths, S., Murray, S. B., & Touyz, S. (2015). Extending the masculinity hypothesis: An investigation of gender role conformity, body dissatisfaction, and disordered eating in young heterosexual men. Psychology of Men & Masculinity, 16(1), 108–114. https://doi.org/10.1037/a0035958
Griffiths, S., Rossell, S. L., Mitchison, D., Murray, S. B., & Mond, J. M. (2018). Pathways into treatment for eating disorders: A quantitative examination of treatment barriers and treatment attitudes. Eating Disorders, 26(6), 556–574. https://doi.org/10.1080/10640266.2018.1518086
Gross, S. M., Ireys, H. T., & Kinsman, S. L. (2000). Young women with physical disabilities: Risk factors for symptoms of eating disorders. Development and Behavioral Pediatrics, 21(2), 87–96. https://doi.org/10.1097/00004703-200004000-00002
Halbeisen, G., Brandt, G., & Paslakis, G. (2022). A plea for diversity in eating disorders research. Frontiers in Psychiatry, 13, 820043. https://doi.org/10.3389/fpsyt.2022.820043
Harrop, E. N., Mensinger, J. L., Moore, M., & Lindhorst, T. (2021). Restrictive eating disorders in higher weight persons: A systematic review of atypical anorexia nervosa prevalence and consecutive admission literature. International Journal of Eating Disorders, 54(8), 1328–1357. https://doi.org/10.1002/eat.23519
Hartman-Munick, S. M., Silverstein, S., Guss, C. E., Lopez, E., Calzo, J. P., & Gordon, A. R. (2021). Eating disorder screening and treatment experiences in transgender and gender diverse young adults. Eating Behaviors, 41, 101517. https://doi.org/10.1016/j.eatbeh.2021.101517
Hays, D. G. (2020). Multicultural and social justice counseling competency research: Opportunities for innovation. Journal of Counseling & Development, 98(3), 331–344. https://doi.org/10.1002/jcad.12327
Hays, D. G., Bolin, T., & Chen, C.-C. (2019). Closing the gap: Fostering successful research-practice partnerships in counselor education. Counselor Education and Supervision, 58(4), 278–292. https://doi.org/10.1002/ceas.12157
Hazzard, V. M., Loth, K. A., Hooper, L., & Becker, C. B. (2020). Food insecurity and eating disorders: A review of emerging evidence. Current Psychiatry Reports, 22, 74. https://doi.org/10.1007/s11920-020-01200-0
Huryk, K. M., Drury, C. R., & Loeb, K. L. (2021). Diseases of affluence? A systematic review of the literature on socioeconomic diversity in eating disorders. Eating Behaviors, 43, 101548. https://doi.org/10.1016/j.eatbeh.2021.101548
Irvine, T. J., & Labarta, A. C. (2024). Enhancing counselor trainee preparedness for treating eating disorders: Recommendations for counselor educators. The Professional Counselor, 14(2), 212–225. https://doi.org/10.15241/tji.14.2.212
Kalantzis, M. A., Chung Xiann Lim, S., Dauber, A. K., Studer-Perez, E. I., Silverman, Z. J., & O’Brien, W. H. (2023). Acculturative stress and eating disorder psychopathology: A meta-analysis. Eating Behaviors, 48, 101694. https://doi.org/10.1016/j.eatbeh.2022.101694
Kinavey, H., & Cool, C. (2019). The broken lens: How anti-fat bias in psychotherapy is harming our clients and what to do about it. Women & Therapy, 42(1–2), 116–130. https://doi.org/10.1080/02703149.2018.1524070
Kinnaird, E., Norton, C., Pimblett, C., Stewart, C., & Tchanturia, K. (2019). “There’s nothing there for guys”. Do men with eating disorders want treatment adaptations? A qualitative study. Eating and Weight Disorders, 24(5), 845–852. https://doi.org/10.1007/s40519-019-00770-0
Labarta, A. C., Irvine, T., & Peluso, P. R. (2023). Exploring clinician attitudes towards treating eating disorders: Bridging counselor training gaps. Journal of Counselor Preparation and Supervision, 17(1). https://digitalcommons.sacredheart.edu/jcps/vol17/iss1/2
Levitt, D. H. (2006). Eating disorders training and counselor preparation: A survey of graduate programs. The Journal of Humanistic Counseling, Education and Development, 45(1), 95–107. https://doi.org/10.1002/j.2161-1939.2006.tb00008.x
Marques, L., Alegria, M., Becker, A. E., Chen, C., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44(5), 412–420. https://doi.org/10.1002/eat.20787
Mason, T. B., & Lewis, R. J. (2015). Minority stress and binge eating among lesbian and bisexual women. Journal of Homosexuality, 62(7), 971–992. ttps://doi.org/10.1080/00918369.2015.1008285
Matacin, M. L., & Simone, M. (2019). Advocating for fat activism in a therapeutic context. Women & Therapy, 42(1–2), 200–215. https://doi.org/10.1080/02703149.2018.1524071
McEntee, M. L., Philip, S. R., & Phelan, S. M. (2023). Dismantling weight stigma in eating disorder treatment: Next steps for the field. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1157594
Mensinger, J. L., Granche, J. L., Cox, S. A., & Henretty, J. R. (2020). Sexual and gender minority individuals report higher rates of abuse and more severe eating disorder symptoms than cisgender heterosexual individuals at admission to eating disorder treatment. International Journal of Eating Disorders, 53(4), 541–554. https://doi.org/10.1002/eat.23257
Mensinger, J. L., Tylka, T. L., & Calamari, M. E. (2018). Mechanisms underlying weight status and healthcare avoidance in women: A study of weight stigma, body-related shame and guilt, and healthcare stress. Body Image, 25, 139–147. https://doi.org/10.1016/j.bodyim.2018.03.001
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. https://doi.org/10.1037/0033-2909.129.5.674
Middlemass, K. M., Cruz, J., Gamboa, A., Johnson, C., Taylor, B., Gomez, F., & Becker, C. B. (2021). Food insecurity & dietary restraint in a diverse urban population. Eating Disorders, 29(6), 616–629. https://doi.org/10.1080/10640266.2020.1723343
Mikhail, M. E., & Klump, K. L. (2021). A virtual issue highlighting eating disorders in people of Black/African and Indigenous heritage. International Journal of Eating Disorders, 54(3), 459–467. https://doi.org/10.1002/eat.23402
Mintert, J., Tran, A. G. T. T., & Kurpius, S. (2020). Religious and/or spiritual social justice advocacy: Guidance from the multicultural and social justice counseling competencies. Counseling and Values, 65(1), 2–14. https://doi.org/10.1002/cvj.12119
Mitchell, M., & Binkley, E. (2021). Self-care: An ethical imperative for anti-racist counselor training. Teaching and Supervision in Counseling, 3(2), Article 5. https://doi.org/10.7290/tsc030205
Muzacz, A. K., Emelianchik-Key, K., Labarta, A. C., & Litherland, G. (2024). A scoping review of sizeism in peer-reviewed journal articles: Where is counseling? Journal of Counselor Leadership and Advocacy, 11(2), 124–137. https://doi.org/10.1080/2326716X.2024.2342823
Nagata, J. M., Ganson, K. T., & Murray, S. B. (2020). Eating disorders in adolescent boys and young men: An update. Current Opinion in Pediatrics, 32(4), 476–481. https://doi.org/10.1097/MOP.0000000000000911
Nazar, B. P., Bernardes, C., Peachey, G., Sergeant, J., Mattos, P., & Treasure, J. (2016). The risk of eating disorders comorbid with attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. International Journal of Eating Disorders, 49(12), 1045–1057. https://doi.org/10.1002/eat.22643
O’Flynn, J. L., Nowicki, G. P., Laveway, K., Gordon, A. R., & Rodgers, R. F. (2023). Toward inclusivity: A systematic review of the conceptualization of sexual minority status and associated eating disorder outcomes across two decades. International Journal of Eating Disorders, 56(2), 350–365. https://doi.org/10.1002/eat.23830
Puhl, R. M., Latner, J. D., King, K. M., & Luedicke, J. (2014). Weight bias among professionals treating eating disorders: Attitudes about treatment and perceived patient outcomes. International Journal of Eating Disorders, 47(1), 65–75. https://doi.org/10.1002/eat.22186
Räisänen, U., & Hunt, K. (2014). The role of gendered constructions of eating disorders in delayed help-seeking in men: A qualitative interview study. BMJ Open, 4(4), e00434. https://doi.org/10.1136/bmjopen-2013-004342
Ralph, A. F., Brennan, L., Byrne, S., Caldwell, B., Farmer, J., Hart, L. M., Heruc, G. A., Maguire, S., Piya, M. K., Quin, J., Trobe, S. K., Wallis, A., Williams-Tchen, A. J., & Hay, P. (2022). Management of eating disorders for people with higher weight: Clinical practice guideline. Journal of Eating Disorders, 10, Article 121. https://doi.org/10.1186/s40337-022-00622-w
Rasmusson, G., Lydecker, J. A., Coffino, J. A., White, M. A., & Grilo, C. M. (2019). Household food insecurity is associated with binge-eating disorder and obesity. International Journal of Eating Disorders, 52(1), 28–35. https://doi.org/10.1002/eat.22990
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and social justice counseling competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48. https://doi.org/10.1002/jmcd.12035
Richards, P. S., Caoili, C. L., Crowton, S. A., Berrett, M. E., Hardman, R. K., Jackson, R. N., & Sanders, P. W. (2018). An exploration of the role of religion and spirituality in the treatment and recovery of patients with eating disorders. Spirituality in Clinical Practice, 5(2), 88–103. https://doi.org/10.1037/scp0000159
Rodriguez Espinosa, P., & Verney, S. P. (2021). The underutilization of community-based participatory research in psychology: A systematic review. American Journal of Community Psychology, 67(3–4), 312–326. https://doi.org/10.1002/ajcp.12469
Rothblum, E. D., & Gartrell, N. K. (2019). Sizeism in mental health training and supervision. Women & Therapy, 42(1–2), 147–155. https://doi.org/10.1080/02703149.2018.1524
Schaumberg, K., Welch, E., Breithaupt, L., Hübel, C., Baker, J. H., Munn-Chernoff, M. A., Yilmaz, Z., Ehrlich, S., Mustelin, L., Ghaderi, A., Hardaway, A. J., Bulik-Sullivan, E. C., Hedman, A. M., Jangmo, A., Nilsson, I. A. K., Wiklund, C., Yao, S., Seidel, M., & Bulik, C. M. (2017). The science behind the Academy for Eating Disorders’ Nine Truths About Eating Disorders. European Eating Disorders Review, 25(6), 432–450. https://doi.org/10.1002/erv.2553
Sonneville, K. R., & Lipson, S. K. (2018). Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students. International Journal of Eating Disorders, 51(6), 518–526. https://doi.org/10.1002/eat.22846
Streatfeild, J., Hickson, J., Austin, S. B., Hutcheson, R., Kandel, J. S., Lampert, J. G., Myers, E. M., Richmond, T. K., Samnaliev, M., Velasquez, K., Weissman, R. S., & Pezzullo, L. (2021). Social and economic cost of eating disorders in the United States: Evidence to inform policy action. International Journal of Eating Disorders, 54(5), 851–868. https://doi.org/10.1002/eat.23486
Talleyrand, R. M. (2012). Disordered eating in women of color: Some counseling considerations. Journal of Counseling & Development, 90(3), 271–280.
https://doi.org/10.1002/j.1556-6676.2012.00035.x
Trans Folx Fighting Eating Disorders. (2020). An open letter to eating disorder organizations & institutions in response to statements published about diversity campaigns & solidarity with Black lives. https://bit.ly/3ESeDT4
Tylka, T. L., Annunziato, R. A., Burgard, D., Daníelsdóttir, S., Shuman, E., Davis, C., & Calogero, R. M. (2014). The weight-inclusive versus weight-normative approach to health: Evaluating the evidence for prioritizing well-being over weight loss. Journal of Obesity, 2014(1), 1–18.
https://doi.org/10.1155/2014/983495
Warren, C. S., & Akoury, L. M. (2020). Emphasizing the “cultural” in sociocultural: A systematic review of research on thin-ideal internalization, acculturation, and eating pathology in US ethnic minorities. Psychology Research and Behavior Management, 13, 319–330. https://doi.org/10.2147/PRBM.S204274
Warren, C. S., Schafer, K. J., Crowley, M. E. J., & Olivardia, R. (2013). Demographic and work-related correlates of job burnout in professional eating disorder treatment providers. Psychotherapy, 50(4), 553–564. https://doi.org/10.1037/a0028783
Adriana C. Labarta, PhD, NCC, ACS, LMHC, is an assistant professor at Florida Atlantic University. Danna Demezier, PhD, NCC, LMHC, is an assistant professor at Liberty University. Alyssa A. Vazquez, LMFT, is a doctoral student and adjunct faculty at Barry University. Correspondence may be addressed to Adriana C. Labarta, 777 Glades Rd., Bldg. 47, Rm. 274, Boca Raton, FL 33431, alabarta2018@fau.edu.
