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'Fear of Fat' and 'Feeling Fat' or 'Feeling De-Valued' and 'Fear of Fat-Bodied Marginalisation'? Are 'Fear of Fat' and 'Feeling Fat' Over-Simplified? A Proposed Extension to Eating Disorder Constructs.

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'Fear of Fat' and 'Feeling Fat' or 'Feeling De-Valued' and 'Fear of Fat-Bodied Marginalisation'? Are 'Fear of Fat' and 'Feeling Fat' Over-Simplified? A Proposed Extension to Eating Disorder Constructs.

Abstract

Weight-stigma and internalised weight-stigma are risks for EDs and suicidality. Suicidal ideation in current and lifetime EDs is directly and indirectly effected by perceived-burdensomeness. Similarly, research has linked weight-based discrimination with perceived-burdensomeness and increased suicidal ideation. Weight self-stigma has been linked with weight change, indicating the negative effects of weight self-stigma, and emphasising the central role of fear of being stigmatised by others in this process. Self-discrepancy and negative self-schemas may also include fear of an imagined fat/larger self, or fear of returning to a larger/fat body weight. Considering these factors in the relationship between weight stigma, fear of fatness, and disordered eating, it may be that fear-of-fatness and perceived burdensomeness in EDs more closely align with fear of weight-based discrimination. Pervasive, systemic devaluation of individuals in fat/larger bodies may foster internalised beliefs that one is worthless or a burden on society that praises thinness, dehumanises, pathologizes, and positions larger bodies as a moral/personal failure. This may compound minority stress and weight bias internalisation for those who face intersectional oppressions and experiences of their bodies and identities as a marginalised other. Fear of additional (weight-based) marginalisation may influence ED vulnerability for certain populations, including those who may experience intersectional marginalisation, and those in larger bodies. Insecure attachment, social anxiety, and fear of negative evaluation are also highly prevalent in EDs. It may be that these factors relate to increased awareness of the threat of weight-based marginalisation and therefore, heighten ED risk. This paper will explore the literature on ‘fear of fatness’, ‘feeling fat’, and negative ‘fat talk’ in EDs as related to internalised weight stigma, marginalisation (i.e., race/ethnicity, genders, sexualities, disability), perceived burdensomeness, and fear of stigmatisation. It will argue for the consideration of ‘fear of fatness’ and ‘feeling fat’ as central to ED within a broader context of body politics, weight-based discrimination and disordered eating as a means of coping with fear of (further) social discrimination.
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Fear of Fat’ and ‘Feeling Fat’ or ‘Feeling De-Valued’ and ‘Fear of Fat-Bodied
Marginalisation’? Are ‘Fear of Fat’ and ‘Feeling Fat’ Over-Simplified? A Proposed
Extension to Eating Disorder Constructs
Mx Rosiel Elwyn, 2021
Highlights
Discrimination and minority stress are important factors in eating disorder pathways
Intersectional discrimination and minority stressors may compound risks and pathways into
disordered eating
Awareness of and experience of weight-based marginalisation and weight discrimination may
be a key factor in the fear of fat/weight gain as a drive for disordered eating. This may be
particularly salient for individuals who experience other forms of discrimination (i.e.,
race/ethnicity-based, LGBTIQ+ based, disability and neurodivergent-based).
Feeling fat is a catch-all term that involves displacement of negative feelings onto the body.
Research into feeling fat may be grounded in weight-biased approaches, and fail to include
more diverse experiences. More research is needed to include how weight stigma, weight
discrimination, sizeism, healthism, ableism and other experiences of discrimination may be
encompassed within feeling fat as a proxy term for feeling de-valued or other displaced
feelings.
Keywords
Weight Stigma; Discrimination; Minority stress; Eating disorders; Fear of weight gain; Feeling fat;
Fat talk; COVID-19
Suggested citation:
Elwyn, R, J, D. 2021. Fear of Fat’ and ‘Feeling Fat’ or ‘Feeling De-Valued’ and ‘Fear of Fat-Bodied
Marginalisation’? Are ‘Fear of Fat’ and ‘Feeling Fat’ Over-Simplified? A Proposed Extension to
Eating Disorder Constructs [Paper presentation]. International Conference of Eating Disorders 2021,
Virtual Conference.
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Contents
‘Fear of Fat’ and ‘Feeling Fat’ or ‘Feeling De-Valued’ and ‘Fear of Fat-Bodied
Marginalisation’? Are ‘Fear of Fat’ and ‘Feeling Fat’ Over-Simplified? A Proposed
Extension to Eating Disorder Constructs. .................................................................................... 4
Abstract .................................................................................................................................................. 4
Statement on Author Perspective ........................................................................................................ 5
Weight Stigma and Disordered Eating ............................................................................................... 7
Combatting Weight Stigma in Treatment and Research Approaches ........................................... 14
Fear of Fat and Weight Gain and Feeling Fat .................................................................................. 15
Marginalised Bodies ............................................................................................................................ 17
Disordered Eating in History ......................................................................................................... 17
Minority Stress Theory ................................................................................................................... 23
Self-Concealment ............................................................................................................................ 25
Socio-Cultural Dynamics of Weight Stigma and Disordered Eating ............................................. 26
Feminine and Masculine Hegemony ............................................................................................. 26
Media and Marketing ..................................................................................................................... 28
Fear of Fat/Weight Gain ................................................................................................................ 34
The Complexities and Constructs of ‘Feeling Fat’....................................................................... 37
Weight Bias in Research on ‘Feeling Fat’ ................................................................................. 38
Fear of Fat, Fear of Marginalisation and Disordered Eating ................................................. 41
(Negative) Fat Talk, Socialising, and Belongingness.................................................................... 43
Self-Discrepancy and Fear of the Fat Self .................................................................................... 49
Weight Stigma and Suicidality....................................................................................................... 56
Disgust Sensitivity, Weight Stigma, Eating Disorders and Suicidality .................................. 57
Weight Discrimination, Disordered Eating, and Suicidality ................................................... 60
Attachment in Eating Disorders ........................................................................................................ 63
Social and Appearance Anxiety in Eating Disorders ....................................................................... 68
Weight Bias in the Eating Disorder Diagnostic System ................................................................... 72
BMI, Biases and Weight Stigma .................................................................................................... 72
Weight Stigma and Eating Disorder Subtypes ............................................................................. 76
Higher Weight/ ‘Atypical’ Anorexia Nervosa .............................................................................. 76
Anorexia Nervosa Binge-Purge Subtype ....................................................................................... 79
Avoidant Restrictive Food Intake Disorder .................................................................................. 80
Orthorexia Nervosa ........................................................................................................................ 81
Eating Disorders Without Fear of Fat/Weight Gain ................................................................... 84
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Weight Stigma, Food Insecurity, COVID-19, and Disordered Eating ........................................... 86
Food Insecurity, Race, COVID-19 and Disordered Eating ......................................................... 86
COVID-19, Weight Stigma, and Disordered Eating .................................................................... 87
Eating Disorders in Specific Populations .......................................................................................... 91
Racial/Ethnic Minorities ................................................................................................................ 91
Eating Disorders in Racial/Ethnic Minorities .......................................................................... 91
Intimate Partner Violence and Disordered Eating .................................................................. 93
Intersecting Discrimination and Disordered Eating ................................................................ 95
Gender and Sexually Diverse People (LGBTQIA+) .................................................................... 97
Eating Disorders in Cisgender Sexual Minority People .......................................................... 97
Eating Disorders in Gender Minority People ........................................................................... 98
LGBTIQ+ People of Colour ..................................................................................................... 101
LGBTIQ+ Discrimination and Disordered Eating Risk........................................................ 102
Weight Stigma in LGBTIQ+ People........................................................................................ 103
LGBTIQ+ Community Connection and Disordered Eating ................................................. 109
Gender Expression and Body Image ....................................................................................... 110
Disordered Eating During the COVID-19 Pandemic ............................................................ 112
Disability and Neurodivergence ................................................................................................... 112
Autism, ADHD and Disordered Eating ................................................................................... 112
Body Image and Intellectual and Developmental Disability ................................................. 115
Chronic Health Conditions and Physical Disability .............................................................. 118
Body Functionality and Body Image ....................................................................................... 118
Physical Disabilities and Eating Disorders ............................................................................. 121
Disability, Weight Stigma, and Eating Disorders .................................................................. 122
Conclusion ......................................................................................................................................... 125
References .......................................................................................................................................... 127
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Fear of Fat’ and ‘Feeling Fat’ or ‘Feeling De-Valued’ and ‘Fear of Fat-Bodied
Marginalisation’? Are ‘Fear of Fat’ and ‘Feeling Fat’ Over-Simplified? A Proposed
Extension to Eating Disorder Constructs.
Mx Rosiel Elwyn 2021
Abstract
Weight-stigma and internalised weight-stigma are risks for EDs and suicidality. Suicidal ideation in
current and lifetime EDs is directly and indirectly affected by perceived-burdensomeness. Similarly,
research has linked weight-based discrimination with perceived-burdensomeness and increased
suicidal ideation. Weight-self-stigma has been linked with weight change, indicating the negative
effects of weight-self-stigma, and emphasising the central role of fear of being stigmatised by others
on body image and eating. Self-discrepancy and negative self-schemas may also include fear of an
imagined fat/larger self, or fear of returning to a larger/fat body weight. Considering these factors in
the relationship between weight stigma, fear-of-fatness, and disordered eating, it may be that fear-of-
fatness and perceived burdensomeness in EDs more closely align with fear of weight-based
discrimination. Pervasive, systemic devaluation of individuals in fat/larger bodies may foster
internalised beliefs that one is worthless or a burden on society that praises thinness, dehumanises,
pathologises, and positions larger bodies as a moral/personal failure. This may compound minority
stress and weight bias internalisation for those who face intersectional oppressions and experiences of
their bodies and identities as a marginalised other. Fear of additional (weight-based) marginalisation
may influence ED vulnerability for certain populations, including those who may experience
intersectional marginalisation, and those in larger bodies. Insecure attachment, social anxiety, and fear
of negative evaluation are also highly prevalent in EDs. It may be that these factors relate to increased
awareness of the threat of weight-based marginalisation and therefore, heighten ED risk. This paper
will explore the literature on ‘fear of fatness’, and ‘feeling fat’ in EDs as related to internalised weight
stigma, marginalisation (i.e., race, genders, sexualities, disability), perceived burdensomeness, and fear
of stigmatisation. It will argue for the consideration of ‘fear of fatness’ and ‘feeling fat’ within a
broader context of weight-based discrimination and disordered eating as a means of coping with fear
of (further) social discrimination.
When we talk about fear of weight gain, ‘feeling fat’, body image, disordered eating and eating
disorders, we need to talk about body politics. We must acknowledge that socio-political hierarchies
and constructions give bodies power and meaning. Bodies can be devalued, rejected, ostracised, and
marginalised. How might disordered eating involve negotiations of the liminal powers and meanings
of bodies and identities in different spaces and environments? How might the acts of taking in food
and liquid, restricting and denying food intake, purging food, and consuming foods in large amounts
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be communicating different languages to oneself and others about deeply held feelings about the
body, identities, power, pain, shame, trauma, compassion, longing, and a need to belong? What are
the meanings and drives of trying to change one's body, and what does it signal? What do these
actions mean when a person's eating behaviours become emotionally harmful and or/medically
harmful, and persist? Identities and bodies are multidimensional and exist within the context of
societal systems. To understand the meaning of disordered eating and eating disorders, and what
drives eating disordered behaviours, we cannot erase the context of how identities and bodies are
positioned within societal structures, and of power, oppression, and food and body sovereignty.
Statement on Author Perspective
My perspective is informed by both the literature, my Lived Experience of chronic longstanding
low-weight anorexia nervosa (SEED-AN) and avoidant restrictive food intake disorder (ARFID),
experiences as an individual who identifies as non-binary, queer, and autistic, and from peer support
work in eating disorders. I acknowledge that within my experiences of inpatient and community
treatments, I have held different privileges and minority intersections of power and vulnerability in
my identity as a white, autistic (high verbal), femme-presenting LGBTQIA+ person, with class
privilege, high educational privilege, and as a person with an eating disorder at a low weight. These
experiences meant that I have been able to access treatment in the public health system in Australia,
and once in the private inpatient system. While in many cases, these treatment experiences in did not
meet my emotional needs, I was triaged for treatment that improved my medical outcomes. Many
individuals do not experience the same accessibility due to weight stigma, and intersectional identity
and experiential factors (i.e., the health system of their country, poverty, racial/ethnic bias).
This article does not seek to negate nor minimise the psychological, biological, metabolic and
genetic aspects of eating disorders. Its focus is to expand the framework of eating disorder constructs
to include political and socio-cultural factors; such as body politics in the context of how societal
institutions, power, and profit are involved in messages surrounding the value and de-valuation of
bodies, identities and their characteristics, and how these messages relate to social privileges,
oppressions, and risk for disordered eating
I use the terms ‘fat/larger bodies’ and ‘high/er weight’ in alignment with fat activists and fat
scholars, as neutral body descriptors that are divested from pejorative and stigmatising judgements,
and from the pathology of medical terms ‘obese’ and ‘overweight’. The terms ‘low weight’, ‘medium
weight’, and ‘high/er weight’ respectively will be used in place of ‘underweight’ ‘normal weight’,
‘overweight’ and ‘obese’. The latter terms (used in the BMI system and frequently in literature)
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pathologise weight ranges and suggest that there is one ideal and ‘normal’ weight range, which is
harmful for acceptance of body diversity and healing from disordered eating. In my use of fat as a
reclaimed and neutral body descriptor, I acknowledge that the stigma associated with the term ‘fat
may still be very strong and painfully present for many people, and that medical and eating disorder
literature widely use the weight terms that this paper divests from.
Similarly, in line with Lived Experience and Mad Studies literature, this paper aims to divest from
diagnostic language, the medical model, and pathologising paradigms where possible. Such as
avoiding use of the word ‘symptoms’ by instead referring to specific behaviours, emotions and
cognitions. If a specific psychiatric diagnosis is used, this will be referred to as: diagnosed with ‘…’
(e.g., diagnosed with schizophrenia, diagnosed with borderline personality disorder). This has been
intentionally done in order to shift conversation from the pathologising diagnostic language that many
people with Lived Experience find harmful and incongruent with their experiences (e.g., diagnosis of
schizophrenia as opposed to experience of voice-hearing, unusual beliefs and sensory perceptions, and
extreme states in response to trauma). However, in my experience of involvement in Lived
Experience and eating disorder advocacy, community, and treatment spaces, many who have received
a diagnosis of an eating disorder do not find the diagnostic language and associations of ‘illness’
‘disorder’ and the disease model as harmful or incongruent with their personal ways of knowing and
understanding their experiences in comparison to other co-occurring psychiatric diagnoses. While
discussing narratives and experiences of disordered eating, those with Lived Experience typically
oriented their/our experiences as meaningful and understandable coping and survival responses in the
context of traumas and sociocultural systems of oppression (i.e., systemic oppressions, discrimination,
diet culture), in alignment with individuals with other Lived Experiences and Mad Scholars who
wished to divest from diagnostic and medico-language use such as ‘disorder’, ‘illness’, and ‘disease’.
When discussing the power dynamics and linguistic associations in ‘eating disorder’, ‘illness’,
‘condition’ and ‘disease’, however, the majority of individuals with Lived Experience of complex
body-mind and food relationships (experiences of ‘eating disorders’) described feeling that the words
‘disorder’, ‘illness’, ‘condition’, (although disease to a lesser extent) depicted the overwhelming
chaos, and degree of damage inflicted on multiple areas of their lives, as well as profound internal
self-disturbance (‘disorder’). In addition, many felt that ‘disorder’, ‘illness’ and ‘condition’ reflected
that these experiences were not within their control, reflected external factors (e.g., trauma,
oppression, discrimination), and were prone to relapse. It may be that individuals with Lived
Experience feel that the word ‘disorder’ in ‘eating disorder’ is more linguistically representative of
other experiences, rather than representing a psychiatric pathology itself. The word ‘disorder’ in
‘eating disorder’ may be experienced as more linguistically representative of: the sense of disturbance
and alienation identity, lives and relationships; sense of threat, loss of control, and attempts to gain a
sense of control; experience of disturbed interoception and body-mind connection; degree of losses in
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multiple areas of life; and coping responses to external factors (e.g., traumas, systemic oppressions,
discrimination). However, in my experience of peer support, advocacy, treatment, and community
with individuals with Lived Experience of eating disorders and disordered eating, I have not seen a
current identified wish to divest from the use of ‘eating disorder/s’ as a term. Therefore, for ease of
research recognition, I will continue to use ‘eating disorder’ in this article, as opposed to alternatives
such as: (ongoing) difficulties regulating food intake; non-homeostatic eating; difficult relationship
with food/body; or other terms.
Many studies describe the demographics of their participants as ‘female’, ‘male’ or ‘women’ and
‘men’ without specifying whether or not they are cisgender women/cisgender men. Many studies also
conflating sex with gender, such as reporting that there is a gendered effect, and listing the
demographics of participants as ‘female’ and ‘male’ (the sex of the participants). For this reason, I
have re-described the participants of these studies ‘cisgender women’ and ‘cisgender men’. It may be
that transgender, non-binary, and intersex people have participated in these studies and were forced to
code themselves using the gender binary and sex binary system, or it may be that none of these groups
were present. Because these factors are unknown, I have also elected to re-described these participants
in this way to highlight the predominance of literature that excludes samples of transgender, non-
binary, and intersex people and/or excludes the ability for these individuals to self-identify their
presence within their samples. This is aimed at highlighting the crucial need for greater gender
diversity in body image and eating disorder research, and the importance of intersectional factors in
research (i.e., gender identity, sexual identity, race/ethnicity, disability and neurodivergence).
Weight Stigma and Disordered Eating
Research is increasingly examining the mental and physical health impacts of weight stigma as a
normalised, widespread, and socially accepted negative attitude toward people based on their weight
(Ambwani, Thomas et al. 2014, Puhl, Latner et al. 2015, Frederick, Saguy et al. 2016), and its
association to body weight, disordered eating, eating disorders (Himmelstein, Puhl et al. 2019,
Marshall, Latner et al. 2020, Puhl and Lessard 2020, Puhl, Lessard et al. 2020, Hooper, Puhl et al.
2021, Rubin, Schvey et al. 2021). Experiencing weight stigmatisation has been found to result in two
distinct mediated pathways to disordered eating, including stress responses and social withdrawal
responses (Simone and Lockhart 2016). Among cisgender women in a nonclinical sample, stress
partially mediated the path between weight stigmatisation and emotional eating, whereas social
withdrawal partially mediated the path between weight stigmatisation and restrictive eating (Simone
and Lockhart 2016). It may be that experiencing stress and withdrawing socially in response to weight
stigma, and/or patterns of both responses lead to different eating disorder behaviours. These
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behavioural responses may then become habitual in response to repeated experiences of weight
stigma. Weight stigma is a common experience in many countries (Puhl, Lessard et al. 2021), with
high percentages of experiences of weight stigma reported from interactions with family members,
classmates, medical professionals, co-workers, and friends (Puhl, Lessard et al. 2021). For example,
the stereotype threat of weight stigma has been found to emerge early in life, and to lead to reductions
in working memory for both fat-bodied children and adults (Guardabassi and Tomasetto 2018,
Guardabassi and Tomasetto 2020). While weight discrimination may occur through unconscious,
unintentional attitudes of internalised weight bias, these experiences still create harm, irrespective of
their awareness of intention. Larger and fat-bodied people may experience overt aggression, hostility,
and intentional discrimination with the desire to harm in combination with experiences of
unconsciously enacted weight bias in a multitude of contexts (i.e., healthcare, education, workplaces,
social interactions, media).
It’s important to acknowledge that weight stigma and discrimination, regardless of whether or not
it is motivated by a conscious or unconscious intent, leads to significant and devastating harms to
mental and physical health across multiple domains. Weight-biased microaggressions involve
microinsults, microinvalidations, and microassaults, and it is their repeated occurrence, often multiple
times daily, that creates a “death by a thousand cuts” experience of cumulative stress (Nadal, Issa et
al. 2011, Munro 2017). Epistemic microaggressions in clinical encounters, for example, involve
intentional (conscious) or unintentional (unconscious) slights by healthcare providers conveyed in
speech or gesture that ridicule, invalidate, dismiss, minimise, ignore, or fail to give uptake to patient
concerns (Freeman and Stewart 2018, Siqueira, Assumpção et al. 2021). Weight stigma may be a
significant source of epistemic microaggressions (Puhl, Lessard et al. 2021) which can result in
epistemic injustices due to prejudicial stereotypes by healthcare providers (Freeman and Stewart
2018), leading to serious health outcomes and treatment barriers for larger and fat-bodied people
(Mensinger, Tylka et al. 2018, Hughes, Bombak et al. 2019, Siqueira, Assumpção et al. 2021).
Furthermore, transgender, nonbinary, intersex and cisgender lesbian, gay, bisexual and queer people
(LGBTIQ+) underutilise healthcare, and may experience healthcare provider weight bias as a barrier
to care and an additional minority stressor (Paine 2021). Individuals who already experience social
marginalisation may therefore experience multiple barriers, multiple minority stressors, and
microaggressions across many contexts, such as combinations of weight bias and
racism/ethnocentrism, LGBTIQ+ discrimination, ableism, and classism.
Weight discrimination involves both perceived and enacted weight stigma. While perceived weight
stigma cannot be confirmed as certain in intent, the perception of an individual as having been
discriminated against makes the experience harmful. When perceiving weight stigma, an individual
may attempt to receive support from their social network by talking about the experience, and may
instead experience weight stigma in the form of microaggressions or invalidation (e.g., “you’re not fat
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you’re beautiful” [suggesting the two characteristics cannot co-exist, thereby reinforcing the thin
ideal]; “I’m sure they didn’t mean it like that”), perpetuating a cycle of weight stigma and denigration
of fat bodies.
Weight discrimination is associated with significant mental health concerns and multiple co-
occurring conditions (Hatzenbuehler, Keyes et al. 2009). Social support does not safeguard against the
adverse effects of perceived weight discrimination on mental health, and the associations remain
significant after controlling for perceived stress, and body weight (measured by BMI) (Hatzenbuehler,
Keyes et al. 2009), indicating that perceived weight discrimination may have adverse mental health
impacts irrespective of weight and social support (Hatzenbuehler, Keyes et al. 2009). Weight stigma
develops as an internalisation of anti-fat attitudes and cultural norms of body politics, and hierarchical
body ideals (Lieberman, Tybur et al. 2012, Elran-Barak and Bar-Anan 2018, Wellman, Araiza et al.
2018), and includes related constructs such as internalised weight bias, fear of fat and fear of weight
gain, negative body talk/negative fat talk and ‘feeling fat’ (Chow, Ruhl et al. 2019, Mehak and Racine
2020, Mehak and Racine 2021). The impacts of intersectionality, social marginalisation, and
oppression as mediators of weight stigma on fear of fat/weight gain and ‘feeling fat’, however,
remains understudied (Himmelstein, Puhl et al. 2017, Himmelstein, Puhl et al. 2019, Wilson, Mehak
et al. 2020). Weight stigma may also lead to the under-detection of eating disorders for those in
larger/fat bodies (Head 2019) which may also intersect with other identity and social statuses (i.e.
race/ethnicity, genders, sexuality, disability, age) (Himmelstein, Puhl et al. 2017).
Weight stigma and the hyper-policing and control of fat bodies has deep roots in racism. A
foundation for ingrained pathologisation of Black, Brown and Indigenous bodies, fat, sexuality, and
cultural identity has been created over time, built on colonialist fear of the power and agency of
People of Colour (Strings 2019, Harrison 2021). The idealisation and privileging of white, thin
bodies, and pathologisation of Black, Brown and Indigenous bodies, identities and sexuality is a value
system that promotes violent ideology of white bodies as superior, and attempts to control and erase
the embodied agency of People of Colour (Strings 2019, Harrison 2021). In cultural, structural
domains of power and social codes; body politics privileges the bodies and identities of white,
cisgender, heterosexual, nondisabled, thin, and young men and women as ideal and desirable. These
systems marginalise and disenfranchise the identities and bodies of Indigenous, Black, Brown, and
other people of colour, those who are fat, transgender, non-binary, intersex, and disabled, and
subjugates those who embody multiple marginalised identities (i.e., fat, black, non-binary, disabled)
to culturally encoded and sanctioned abuse.
Experiencing weight stigma is harmful, and threatening to one’s social identity, and social safeness
and belongingness (O'Brien, Latner et al. 2016, Hand, Robinson et al. 2017, Lillis, Thomas et al.
2017, Meadows and Higgs 2019, Lillis, Thomas et al. 2020, Nichelson 2020). Body size (measured by
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body mass index [BMI]) has been found to affect social and socio-economic outcomes (Howe,
Kanayalal et al. 2019). In people of European ancestry in the U.K., greater BMI was related to higher
deprivation, lower income, fewer years of education, lower odds of degree-level education and skilled
employment (Howe, Kanayalal et al. 2019). Both low and high BMI increased deprivation and
reduced income (Howe, Kanayalal et al. 2019). In cisgender women, high BMI reduced the odds of
co-habiting with a partner or spouse, and in cisgender men, lower BMI reduced the odds of co-
habitation (Howe, Kanayalal et al. 2019). In men only, higher BMI was also related to lower
participation in social and leisure activities (Howe, Kanayalal et al. 2019). In this study, no data was
gathered on the social and socio-economic outcomes of body size for intersex, transgender and non-
binary people, and people of diverse races, and ethnic and cultural backgrounds, and it’s important to
consider how these factors may also intersect with weight stigma.
Body morphology has shown to influence the perception of threat to others, with bodies perceived
as more threatening as they increased in mass with added musculature and portliness, and less
threatening as they increased in emaciation (McElvaney, Osman et al. 2021). This may have
implications for weight bias in eating disorders that pathologises larger and fat bodies as diseased,
dangerous, and an epidemic, in comparison to the bodies of low-weight individuals with eating
disorders that are positioned as having ‘legitimate’ biopsychosocial condition which are less likely to
be met with moral aetiological paradigms. Body morphology and perceived threat may also have
implications for the intersection of racism and ethnocentrism, misogyny, heteronormativity and
cisheteronormativity and fatphobia, and gendered weight bias and musculature (Harjunen and
research 2009, Harjunen 2016, Eeltink 2017, Taylor 2018). Greater weight bias toward femme-
identifying people intersects with patriarchal and feminine and masculine hegemonic ideologies and
gender hegemony (Demetriou 2001, Schippers 2007, Zernechel and Perry 2017). Femme-identifying
people and people perceived as feminine/women at lower weights experience greater weight bias and
internalised weight bias in comparison to those who identify as or are perceived as masculine/men
(Fikkan and Rothblum 2012, Lieberman, Tybur et al. 2012, Boswell and White 2015, Gailey,
Harjunen et al. 2019).
Pervasive public health messages that de-value, de-humanise, and pathologize individuals who
embody larger/fat bodies may foster the internalisation of beliefs that fatness is a moral/personal
failure, and that living within a larger/fat body is to be worthless, or a burden on a society that praises
thinness and achievement, and de-values bodily diversity (Kyrölä 2021). In addition, the objectifying
and degrading depiction of fat-bodied people in televised/photo media as headless bodies elicits a
disease avoidance response (i.e., fear of contagion, discomfort with physical contact), a dehumanising
perception of fat people, and increased negative attitudes (Jeon, Koh et al. 2019). When seeing whole
depictions of fat people of the same gender, the disease avoidance response is alleviated and increased
social identification occurs (Jeon, Koh et al. 2019). These dehumanising depictions of fat people
11
thereby foster internalised weight stigma and anti-fat attitudes in the public, including messages that
endorse a fear of fatness, and beliefs that body fat is dangerous.
Internalisation of these public anti-fat health messages may then lead to disordered eating as a
means of coping with, and attempting to avoid the threat of weight stigma (Bristow, Meurer et al.
2020). The threat of weight stigma, weight-based marginalisation, and internalisation of weight
stigma may be compounded by experiences of manifold, intersectional oppressions and experiences of
one’s identity and body as a de-valued marginalised other. Weight discrimination and weight-based
microaggressions may be experienced differently as they intersect with other experiences of bias-
based discrimination, such as for those who are First Nation Indigenous Peoples, Black, Brown, and
other People of Colour (BIPOC); individuals of diverse and non-binary genders and sexualities
(LGBTQIA+); and disabled and neurodivergent people. Disordered eating and eating disorder risk
and experiences in marginalised populations may specifically relate to experiences of minority
distress and discrimination, such as racism (e.g., Gerbasi, Richards et al. 2014, Beccia, Jesdale et al.
2020), homophobia and transphobia (e.g., Mason, Lewis et al. 2018, Miller and Luk 2019, Panza,
Fehling et al. 2020), and ableism and masking neurodivergence (e.g., Brede, Babb et al. 2020). These
factors include how multiple marginalisation intersects with weight bias (Hart, Rotondi et al. 2015,
Coleman, O'Neil et al. 2019, Panza, Fehling et al. 2020, Taylor and Sexuality 2020). It may be that
experiencing the threat of weight stigma and weight-based marginalisation may lead to disordered
eating through pathways of internalised stigma, shame, burdensomeness, and attachment insecurity,
and as an attempt to change body morphology to increase social rank and attachment security and
therefore, reduce the threat of marginalisation.
A momentary maintenance model of dysregulated eating has been proposed to explain the impact
of stigma among marginalised and stigmatised individuals (Mason, Smith et al. 2019). The model
proposes that momentary experiences of stigma lead to emotional distress, which are associated with
strategies intended to curb future stigma. These strategies, however, increase emotional distress,
which then promotes dysregulated eating (Mason, Smith et al. 2019). The stigma control model of
dysregulated eating (Mason, Smith et al. 2019) can be used as a framework for future studies to
examine disordered eating among diverse samples. Furthermore, the stigma control model of
dysregulated eating provides further rationale and support for this paper’s argument for a proposed
extension of ‘fear of fat/weight gain’ and ‘feeling fat’ as they relate to minority stress and weight-
based marginalisation. Building on this earlier research, Mason and colleagues conducted a meta-
analysis of discrimination and eating disorder cognitive-behavioural experience (Mason, Mozdzierz et
al. 2021). A small-to-medium association was found between discrimination and having an eating
disorder. Crucially, effects were generally larger for weight discrimination. Discrimination may
therefore represent a significant contributory factor in eating disorder cognitive-behavioural
12
experience, across types of discrimination and eating disorder subtypes (Mason, Mozdzierz et al.
2021).
Qualitative analysis of people’s weight discrimination experiences (Gerend, Patel et al. 2021) has
indicated that intersections between weight discrimination and discrimination of other socially
marginalised identities (gender identity, race, ethnicity, sexual identity, disability, lower social class
or rural background) often led to amplified experiences with weight-based discrimination or
perceptions of weight-based social rejection. For example, socio-cultural pressures for thinness could
intersect with weight stigma and gendered expectations of beauty, leading to multiple aspects of
rejection for not conforming with these expectations. Gendered expectations of body and weight
ideals also intersected with racial/ethnic beauty ideals, as well as the idealised body at the axis of
sexual identity and social class (Gerend, Patel et al. 2021). Having multiple marginalised identities
also led to difficulties at times in identifying the basis for a discriminating experience (i.e., whether it
was weight-based discrimination, based on gender or racism/ethnicity, or a combination) (Gerend,
Patel et al. 2021). Structural systems of oppression (e.g., racism, cisgendernormativity, misogyny,
heterosexism, classism, ableism) that influence intersections between weight-based discrimination and
the marginalisation of other identities may therefore influence the way weight-based discrimination is
experienced and perceived.
Beccia and colleagues (Beccia, Baek et al. 2019) investigated the relationship of disordered eating
with intersecting gender and racial/ethnic identities in U.S. adolescent cisgender girls and boys. Girls
of all racial/ethnic identities and racial/ethnic minority boys had elevated risks of purging, fasting, and
any disordered eating in comparison to white boys (disordered eating in girls: 20.4% Black/African
American, 29.2% Hispanic/Latina, 21.4% white; boys: 13.4% Black/African American, 12.4%
Hispanic/Latino; 8.1% white). Hispanic/Latina and white girls were also found to have elevated risk
of diet pill use. Among Hispanic/Latina girls, positive interaction between gender and race/ethnicity
was also correlated with increased risk of any disordered eating and purging (Beccia, Baek et al.
2019). These findings indicate that multiple marginalised identity (i.e., gender and racial/ethnic
minority) is associated with increased risk of disordered eating, with Hispanic/Latina girls as a
population at particularly heightened vulnerability of disordered eating due to multiply marginalised
identity. Building on the findings of this study, Beccia and colleagues (Beccia, Baek et al. 2021)
examined how the social patterning of eating disorders and disordered eating in young people in the
U.S. varied across the intersections of gender identity, sexual identity, and weight status. Participants
from the Growing up Today Study (GUTS; N = 11,09013,307) were nested within social strata in
order to conduct an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory
Accuracy (MAIHDA) defined by intersecting gender identity, gender expression, sexual identity, and
weight status categories in a sequence of multilevel logistic models for four outcomes (past-year
purging, overeating, and binge eating; lifetime eating disorder diagnosis). A complex social pattern of
13
disordered eating was found by the intersectional MAIHDA. Several multiply marginalised strata
showed disproportionately elevated prevalence of disordered eating (e.g., those including gender
nonconforming, sexual minority, and/or larger-bodied girls/women), although all estimates were
driven by additive effects. Critically, the unitary and conventional intersectional analyses obscured
these patterns (Beccia, Baek et al. 2021). These findings emphasise the heightened vulnerability to
disordered eating for multiply marginalised groups according to gender identity, sexuality, and weight
status, and the need for future research to examine disordered eating using an intersectional approach
with appropriate methodology.
Social identity and minority stress theories provide a framework for how societal weight stigma
may be internalised or resisted, as a pathway to body dissatisfaction and disordered eating. Exposure
to weight stigma, internalised weight stigma, and fear of stigma have been linked to disordered eating,
and fear of enacted stigma has been found to predict worsened disordered eating over time (Meadows
2018). Fear of enacted stigma from others also appears to be a more powerful driver of maladaptive
coping for individuals with higher body weights than self-devaluation (internalisation of negative
beliefs about oneself and association with negative characteristics due to the stigmatisation)
(Meadows 2018), likely reflecting a greater perceived threat of enacted stigma from others. Fear of
enacted weight stigma and weight self-stigma (self-devaluation) are strongly correlated with each
other, and associated with more eating disorder cognitions and behaviours (Lillis, Thomas et al.
2020). Fear of enacted weight stigma by others but not weight self-stigma (self-devaluation) has also
been associated with less weight loss in a self-help behavioural weight loss program, with a stronger
effect for cisgender women than men (Lillis, Thomas et al. 2020). This effect has been suggested to
reflect a powerful demotivating process through worry and concern about experiencing hurt, rejection,
and discrimination by others, which can result in maladaptive coping by avoidance, poorer treatment
engagement, or disordered eating (Schvey, Puhl et al. 2011, Meadows 2018, Lillis, Thomas et al.
2020). Furthermore, Rodgers and colleagues have developed a scale to measure the sociocultural
influences on fear of fat (SI-FAT) (Rodgers, Fischer et al. 2021). The SI-FAT demonstrated 4-factor
structure with influences from media, peers, family, and partners. The SI-FAT demonstrated
convergent validity with fear of fat, body dissatisfaction, and rigid dietary control, as well as weight-
based teasing. There was additional evidence of divergent validity with anti-fat attitudes and
incremental validity with prediction of dietary restriction above and beyond anti-fat bias. The SI-FAT
may therefore be a useful measure for assessment of sociocultural influences on fear of fat (Rodgers,
Fischer et al. 2021). These findings provide some evidence that body dissatisfaction, fear of fat/weight
gain and disordered eating is associated with fear of enacted stigma from others. It may be that fear of
weight-based marginalisation is a significant factor in the discrimination and minority stress pathways
to disordered eating.
14
Combatting Weight Stigma in Treatment and Research Approaches
Treatment approaches that aim to de-pathologise the body and eating are associated with improved
psychological wellbeing, including weight stigma resistance, body acceptance/appreciation, intuitive
eating, weight-neutral and Health-at-Every-Size (HAES®) models (Bacon, Stern et al. 2005, Gagnon-
Girouard, Bégin et al. 2010, Mensinger, Calogero et al. 2016, Linardon and Mitchell 2017, Meadows
2018, Hall 2019, Dugmore, Winten et al. 2020, Hazzard, Telke et al. 2021, O’Hara, Ahmed et al.
2021, Raffoul and Williams 2021). A new paradigm has also been applied as a call to action for
public health bodies and health professionals regarding discrimination and weight stigma; with
Indigenous ways of knowing and body sovereignty, and the HAES® model (Cyr and Riediger 2021).
Other interventions may also improve nutrition knowledge and decrease weight bias in health
professionals by targeting weight discrimination and fat stereotyping at an educational level
(Werkhoven 2020), with the aim of reducing the likelihood of provider weight discrimination.
Therapist matching for fat clients may also allow for psychological kinship, solidarity and therapeutic
work in healing and exploring the self, body image and the body-self relationship, weight
discrimination and oppressions, affirmative work, and reimagining fatness in relationship dynamics
(Fahs 2020). These interventions may be an important method of combatting weight discrimination
and internalised weight stigma as a means to improving psychological wellbeing and mind-body
relationship in a weight-stigmatising sociocultural environment, particularly when considering the
relationship of weight stigma relationship to suicidality (Brochu 2020, Daly, Robinson et al. 2020).
It is important to note that there is a dominant recovery rhetoric (Rollin 2016) that suggests that
although “eating disorders are not a choice, ... you do have a choice to recover... choosing to recover
from an eating disorder, or not, is a choice you make. You have the power to choose” (Eating
Recovery Center 2016). It is this paper’s position that this rhetoric is reductionist, and may be harmful
for many people, particularly for minority and marginalised groups. It is difficult to heal in an unsafe
environment, where threats to one’s wellbeing and survival persist. Socio-cultural and political factors
(social determinants) are external factors that may have a significant role in the development of an
individual’s disordered eating. One cannot ‘decide’ to stop being oppressed, to stop facing barriers to
healthcare, to stop facing discrimination and the threat of verbal and physical violence based on their
identity/identities and personal characteristics. Resistance against oppression and minority stress
requires ongoing emotional labour. For those who face intersectional oppressions and marginalisation,
the nexus of these stressors can create additional emotional labour, taxes to personal grit and
emotional fortitude, and constitute a multifaceted barrier to healing. The concept of healing and
recovery as a ‘choice’, is therefore complex, and the external and distal factors involved in being safe
to begin healing and recovery, and to access support to do so, must be acknowledged, in addition to
factors such as personal, internal factors (i.e., willingness, motivation). Although some using the
15
‘recovery as choice’ rhetoric acknowledge that there are contributing life circumstances one may have
been faced with that were not a choice (Schaefer and Rutledge 2014), others fail to acknowledge these
dynamics (Rollin 2016). As stated by Carmen Cool, at a therapeutic level: “The goal of therapy
should never be to adjust to oppression” (Cool, n.d.) (Maine, McGilley et al. 2019).
It is crucial that eating disorder research is informed by social justice and intersectional
perspectives that are collaborative, interprofessional, and multiculturally sensitive, in order for
research to remain relevant, action-oriented (Russell-Mayhew, Stewart et al. 2008). This way,
research can better advance the understanding of body image and EDs in diverse populations, inform
treatment needs, improve outcomes, and close disparities in care accessibility. The literature provides
support for this paper’s rationale that central eating disorder constructs ‘fear of fat/weight gain’ and
‘feeling fat’ may involve mechanisms of sociocultural impacts, and may in fact, reflect a fear of
weight-based stigma and fear of (greater) weight-based marginalisation. These effects may be
reflected through known relationships in eating disorder cognitions and behaviours, such as minority
stress, self-concealment, psychological inflexibility, insecure attachment, social anxiety and social
appearance anxiety, fear of negative evaluation and engagement in negative fat talk. Understanding
central eating disorder experiences of ‘fear of fat/weight gain’ and ‘feeling fat’ through a macro level
of societal structures that positions an individual within a system of body-identity politics rather than
a micro individual level of causality (Rose 1985, Medvedyuk, Ali et al. 2018) allows for an
understanding of the social determinant factors and potential drives and mechanisms of these
behaviours as a coping response to threat. Furthermore, a minority stress and intersectional framework
addresses the specific risk factors faced by marginalised people and minority groups through a dose
response of minority stress and intersectional marginalisation. This conceptual model also addresses a
potential link to the high rates of suicidality in eating disorders, via fear of weight-based
marginalisation and weight stigma as a risk factor for the suicide through perceived burdensomeness
and thwarted belongingness. Macro level, minority stress and intersectional research can help in
understanding how individuals, particularly those who are multiply marginalised, may have
fragmented identities, and “how social constructs are internalised by individuals” (Williams 2005,
p.280) (such as disordered eating and unhealthy exercise behaviour), in order to maintain “a sense of
wholeness in an oppressive cultural environment” (Williams 2005, p.280).
Fear of Fat and Weight Gain and Feeling Fat
Fear of fat/weight gain and ‘feeling fat’ have been found to be among the most central eating
disorder cognitions of anorexia nervosa (Elliott, Jones et al. 2019). The constructs of fear of
fat/weight gain and ‘feeling fat’ can be regarded as oriented in factors that occur in the individual,
16
such as the development of weight concerns, dieting, internalisation of weight stigma and thinness,
negative body image, perfectionism, disordered eating, and emotional dysregulation that is specific to
the individual. According to the multi-level model of causality (Rose 1985), the highest level, the
macro level, involves factors relating to social structures and position, such as ethnicity and race,
genders, sexuality, disability, social class, education, and age. Macro level social structures also
involve systems of power, culture, politics, and social messaging regarding body fat (i.e., the “obesity
epidemic/war on fat” and moral panic) (Medvedyuk, Ali et al. 2018). Social and political
constructions create identity and body hierarchies and dichotomies that ascribe values and differences
to bodies, and prescribe how bodies “ought to look”. For example, Fat/thin; fit/unfit;
feminine/masculine; strong/weak; cisgender, non-cisgender, nonheterosexual/heterosexual;
disabled/nondisabled; neurodivergent/neurotypical; young/old. These socio-political constructions
involve racism and violence against Indigenous, Black, Brown, Asian and other People of Colour,
refugees and migrants, constructions of gender expression, relationships and roles, anti-fat attitudes
and discrimination, ableism, classism, education and food/health education, family/caregiver values,
and involve roles and expectations of identity and the body. These constructed dichotomies are used
as a means to justify discrimination, marginalisation, and regulation of identities and bodies. They are
used to recognise and deny human and constitutional rights, equality and equity, due process, and
norms and expectations based on whether embodied identities transgress or conform with cultural,
social, and political boundaries (Clare 2001, Soldatic and Fiske 2009, Clare 2015, Rice, Chandler et
al. 2015, Strings 2019, Brownstone, DeRieux et al. 2020, Rice, Jiménez et al. 2020). Furthermore,
these dichotomous constructions inform socio-political hierarchies of body/identity politics, that also
involves spectrums of discriminations (e.g. sizeism, colorism) (Hunter 2007, Hunter 2013, Pausé,
Lupton et al. 2021).
Body politics and diet culture create an socio-cultural-political environment that increases risk for
disordered eating. Identities and personal characteristics that are valued and de-valued increase risk
for dieting, weight cycling, and disordered eating through factors such as minority stress,
discrimination, internalised oppression (self-stigma) and negativity, anticipated discrimination, and
fear of marginalisation. Macro level factors such as social and political dynamics influence and shape
experiences at lower levels of causality. The second highest level, the mezzo level, involves
neighbourhoods, schools, universities and other educational institutions, workplaces and medical
centres, that are shaped by the higher macro level social structures, which in turn shapes experiences
at the individual level. The micro level involves individual environments. Eating disorder prevention
programs typically target the micro level, focusing on individual causality without addressing multi-
level socio-cultural and political environmental factors (Rose 1985, Piran 2010).
Shifting the orientation of ‘fear of fat/weight gain’ and ‘feeling fat’ from a micro level that focuses
on an individual cause of incidence to a macro level cause of incidence can highlight society’s norms
17
of behaviour that puts specific populations at heightened risk. This reorientation can then move the
emphasis from individual vulnerability and attribution of these central eating disorder constructs to a
societal responsibility to address. This can create a greater call to attention in the eating disorder field
regarding marginalisation and intersectionality. It can create a call to action to un-learn weight bias,
focus on social justice and disparities and their relationships to eating disorders, and lead to a focus on
how this is a collective problem that requires widespread preventative action.
Marginalised Bodies
Disordered Eating in History
Researchers and physicians have examined the history of eating disorders in historical and medical
literature (Dinicola 1990, Vandereycken 2002, Brenneman 2009). Historical commonalities have been
found among in eating disorder terms and descriptions that have spanned cultures and eras (i.e. self-
starvation in adolescence, body image and appetite disturbance, hyperactivity, food avoidance and
obsession, vomiting, unusual food selection, lack of concern for physical state, dissociation, self-
injury, social isolation, family problems) (Dinicola 1990, Vandereycken 2002). These commonalities
have been suggested to indicate socio-political-historical evolutions in how anorexia nervosa as a
phenomenon has been conceptualised, that are reflective of the period and socio-political climate (e.g.
religion/spirituality, medical orientation, social norms, values, and customs) (Dinicola 1990,
Vandereycken 2002).
Bulimia nervosa (BN) is a recent modern term, however reports of disturbed appetite, eating
unusually large amounts, vomiting, and extreme emotions have been reported in early medical
literature, with some reports distinguishing different types of BN, and differing interpretations of the
cause, such as dysregulations and dysfunction of the stomach, appetite, and emotions (Vandereycken
2002). The spread of Gnostic philosophy and Judeo-Christian religious doctrine lead to a promotion
of dichotomy between the soul as ‘holy’, the body/flesh as worldly and sinful, and the material world
as evil, and a self-starvation as a method of bodily purification (Fox 1987, Bemporad 1996, Bemporad
1997). Saint Augustine and Saint Jerome promoted the belief of ascetic living as a holier, purer state
to Roman women in the 4th Century (Fox 1987, Brenneman 2009). Following the teaching of Saint
Jerome, a Roman girl died of self-starvation (Wallman 1967, Fox 1987, Bemporad 1996, Bemporad
1997). Augustine promoted a patriarchal society and a belief system that positioned women as
depraved and immoral, and as corrupting men through their sexuality (Saint Augustine trans. 1997).
According to his doctrine, women were only morally and spiritually redeemed when they take a vow
of virginity and eat only when to prevent death (Saint Augustine trans. 1997, p. 155-156).
Augustine’s archetype of starvation for women’s spiritual and moral ‘salvation’ was further
disseminated through the doctrines of Luther, Calvin, and the Puritans (Brenneman 2009). It has been
18
suggested that self-starvation in Western countries has its roots in the widespread indoctrination and
popularity of Gnostic and Judeo-Christian beliefs (Banks 1996, Bemporad 1997, Brenneman 2009).
Christian dieting books are evidence of the perpetuation of the feminine starvation archetype into
modern times. Many Christian diet books are aimed primarily at women and are published by
fundamentalised church-affiliated presses (Ortlund 1977, Chapian and Coyle 1979, Omartian 1984,
Cook 1986, Smith 1990, Ashcroft 1991, Brestin and Johnston 1993, Baldinger 1994, Liebengood
1994) allowing them to be quickly and widely available at churches and Christian bookshops.
Thinness and low-fat foods are argued to equate to the higher ‘spiritual kingdom’ and body fat and
high-fat foods represent ‘defilement’ (Chapian and Coyle 1979, Cook 1986). Women are encouraged
to substitute real food and eating with a consumption of symbolic biblical images and the power of
the Holy Spirit, to feast on the Spiritrather than to eat in the flesh/body (Chapian and Coyle 1979
p. 61, 70). The proposed imagery that women mediate on in order to avoid eating food includes
imagery that opposes the body, body fat, food, and fats, and elevates spiritual lightness and The
Promised Land (Cook 1986). The body is rendered as defiling and sinful, and spiritual meditation
and fasting as moral, good, beautiful, and pure (Chapian and Coyle 1979, Cook 1986). Weight loss
has also turned been used as a basis for a religious movement, in the teachings of the Remnant
Fellowship Church, argued to be a cult, founded by Gwen Shamblin, who authored the ‘Weigh Down
diet workshops as a belief system and diet plan (Shamblin 2009, Ross 2017, Bentley-York 2021).
Shamblin believed she was a prophet, that thinness was akin with greater spiritual purity, professing
ideology such as “over-eaters are courting eternal damnation”, and crusading against the evils of
pornography and ‘homosexuality’ (Ross 2017). In interview, she defended her for-profit enterprise
and endorsement of self-starvation as a means of getting into heaven, claiming her belief that genetics
had no role in weight loss were supported historically by evidence of the starvation torture of Jewish
people in Nazi concentration camps (Williams 2021). The success of Shamblin’s books is an example
of the modern starvation archetype and how weight stigma can intersect with misogyny, racism, and
homophobia. Body-mind dualism encodes ascetism about food, the body, and appetites of physical
and sexual hunger as evil, encouraging a devaluation of these aspects of self and a division of physical
and emotional needs and associated characteristics (i.e., body fat, sexual characteristics) and external
objects (i.e., food). Control over food and the body are then grounded in religious demarcation
between the body and spirit, good and bad, purity and defilement, morality and immorality/sin,
heaven and earth/death, and religious faith VS those who are not religious or not truly faithful
(Banks 1996). Through the popularity of these books and beliefs systems, purity and rigid dietary
control over food and the (fat) body may therefore be interpreted as prerequisites for getting into
heaven (Banks 1996).
19
In earlier Judeo-Christian traditions (e.g. between 50 A.D. and 450 A.D.), for some religious
women and men, fasting was the primary expression of their ascetism, and dietary restriction, periods
of renunciation of food and sexual renunciation and virginity occurred together during this period
(Brown 1988). It has been suggested that fasting and dietary restrictions were common within
Christian practice by the middle of the fifth century continence, and persisted into the Middle Ages
(Brown 1988). Many now retrospectively regard the experiences of women and men abstaining from
food in the Middle Ages, and medieval women experiencing ‘anorexia mirabilis’ (miraculous lack of
appetite), ‘inedia prodigiosa’ (or prodigious abstinence) or ‘virtuous self-abnegation’, fasting, and
self-inducing vomiting (in some cases, until death), as consistent with anorexia nervosa in a different
sociocultural context (Harvet 1597, Lentulus 1604, Grant 1878, van Deth and Vandereycken 1992,
McAvoy 2004, Bell 2014, Harris 2014, Dell’Osso, Abelli et al. 2016, Sukkar, Gagan et al. 2017).
Reports of anorexia mirabilis have included characteristics that are regarded as consistent with
modern concepts of eating disorders, including: progressive food restriction, self-flagellation and
other forms of self-injury, living a life of poverty and denial, and experiencing ecstasy (possibly
associated with food deprivation), sleep deprivation, food obsession, and experiencing visions and
voices, and ‘possession’ by another force (which may be retrospectively interpreted as the ED
voice/self) (Grant 1878, Hammond 1879, McAvoy 2004, Jorgensen 2012, Bell 2014, Harris 2014,
Sukkar, Gagan et al. 2017, Timoclea 2018). These experiences may also have included differences
relevant to the social context, such as striving for both aesthetically valued beauty and ‘spiritual
beauty’ (Brumberg 1989, Gooldin 2003). It has also been argued, however, that modern concepts of
anorexia nervosa often fail to give due recognition to spiritual, moral, ascetic, existential and ‘quest’
aspects of the experience, with greater emphasis placed on biological pathology (Bordo 1993, Peters
1995, Garrett 1996, Banks 1997, Boyatzis and McConnell 2006, Fassino, Pierò et al. 2006, Boyatzis
and Quinlan 2008, Witztum, Stein et al. 2016).
In the Middle Ages, reports of food abstinence were characterised by women and men
experiencing ‘hysteria’, aversion to food and nausea and vomiting when attempting to eat, progressive
food restriction, living an increasingly isolated life, and in some cases, reportedly subsisting on
nothing but water and the Eucharist for prolonged periods (Hammond 1879). Food abstinence and
isolation from the company of others could be regarded as sign of demonic possession; by contrast,
surviving on sacramental bread alone could be interpreted as power and holiness, and was reported by
a number of saints (Hammond 1879). The belief that withstanding prolonged starvation was caused by
demonic or divine power in the Middle Ages shifted as a representation of the times and socio-
political-spiritual climate, and reports of ‘fasting girls and women’ in the Victorian era represented a
less religious-oriented interpretation, with a deeper grounding in ‘hysteria’ (e.g. ‘hysterical’ self-
starvation following traumatic accidents, trauma), medical pathology, abnormality, oddity, and
‘invalids’, and psychic gifts (Hammond 1879, Dailey 1894, Tromp 2011).
20
The feminine ideal of beauty slowly shifted from the mid-18th century to a progressively slender
and thinner silhouette. This intersected heavily with classist ideology and privilege, as
industrialisation led more women (particularly those who were poor and from lower social classes) to
work. The 19th Century feminine beauty ideal began to encompass an ethereal, pale, frail beauty
‘untouched’ by the coarseness of work, the harshness of weather, and of hardened muscle created
through hard labour. Delicate, frail feminine beauty became an embodied social signalling of upper-
class wealth, privilege, and prosperity, and the ability to engage in leisure and creative pursuits
(Veblen 1899, Paterson 1982, Vandereycken and van Deth 1996, Harris 2014). Strict dieting and
strenuous physical activity in the pursuit of thinness was popularised, and information on diets were
distributed to the public that demonised corpulence, connecting body fat with humiliation, low status,
illness, degeneracy, and evil (Miller 2014). Notable figures of the times increased the adoption of
diets and disordered eating, including Lord Byron, Empress Elizabeth of Austria, and William
Banting (Paterson 1982, Baron 1997, Miller 2014).
The British ‘Banting’ diet developed by Victorian undertaker William Banting and physician
William Harvey became a cultural craze, which was then imported to India, becoming a new
manifestation of colonial oppression, and emblem of the English perception of Imperialist identity and
success (Miller 2014). Banting identified fatness as a parasite, and added fat politics to British
colonial racial ideology, promoting anti-fat attitudes as a means of maintaining a morally pure
European self that nullified the threat of cultural contagion (Stoler 2002). Asceticism, specifically
dietary restriction and exercise, was espoused as evidence of superior British temperament and
constitution through endurance against deprivation (Davis 2000), in a racial and classist rhetoric of
Indian people as naturally unhealthy, and prone to disease and succumbing to the devastation of
famine (Watts 1997). The importation of the Banting diet to India was a means of enforcing power
and control through indefinite, continually reinscribed discipline (Miller 2014). The spread of the
Banting diet by colonial and military authorities can be seen through art during the period, and in
diaries where adopting the dietary practice was used as a means of attempting to gain greater social
status in the British hierarchy (Rudolph, Rudolph et al. 2002). The anti-fat, racist, and classist roots of
body politics in Victorian era diet culture also intersected with social positioning of bodily conformity
and non-conformity.
Bodily difference in particular, and fascination during the Victorian era with the ‘grotesque’ and
‘abnormal’ included perceiving bodies as a spectacle of entertainment and a ‘natural wonder’ when
regarded as deviant (i.e. littleness, fatness, emaciation, androgyny and the gendered spectrum, body
hair, disability, bodily mutability, tattooing) (Ward 1813, Cheesman 1996, Gooldin 2003, Tromp
2011), which echoes contemporary media ‘consumption’ of bodies and changing weight as
entertainment and profit in magazines. Similar to the morbid attraction gained by ‘fasting girls and
21
women’, during the same period, ‘living skeletons’ were predominantly men who performed in
Victorian freak shows in continental Europe, Britain, and the U.S., providing their bodies as a source
of gazed-at entertainment of deviance for profit, with stage names such as ‘Shadow Harry’ and ‘Ohio
Skeleton’ (Gould and Walter 1897, Gooldin 2003). In contrast to ‘fasting girls and women’, however,
‘living skeletons’ and later ‘hunger artists’ were both oriented in commercial enterprise within
infamy, whereas ‘fasting girls and women’ attracted notoriety and received payment from visitors,
although monetary gain may not have been a primary motivation (Gooldin 2003).
‘Living skeletons’ have been suggested to represent ‘respectable freaks’; showmen who gained
acceptance, normality, respectability, and social status through their bodily deviance as a source of
wonder and awe (Gould and Walter 1897, Bogdan 1988). One of the most famous ‘living skeletons’,
Claude Seurat, for example, toured Europe as a ‘freak’ showman, and performed for the British royal
family (Gooldin 2003). The ‘Ohio Skeleton’ show played on fascination with the concept of a living
(social) persona within a dead (physical) body, and severe emaciation as the ‘living dead’ (Gooldin
2003). In this manner, ‘living skeletons’ were able to fascinate their audiences by occupying liminal
corporeality between life and death, real and unreal, and the physical word and questions of the
afterlife (Vandereycken and van Deth 1996, Gooldin 2003). The ‘living skeletons’ shows have been
suggested to inspire wonder through their depiction of the spectacle of body and mind and a source of
both the mundane and extraordinary (Bogdan 1988). The emaciated body is presented as a cause of
curiosity and awe, while the simultaneous ability for the ‘living skeleton’ to lead what is described as
a healthy, productive, and social life, and to be able to reproduce (the ordinary) is made extraordinary,
and simultaneously mundane (Bogdan 1988).
Like ‘living skeletons’, ‘hunger artists’ (documented in the 17-19th century, but peaking in
popularity in the late 19th century) were predominantly men, and performers that displayed an
emaciated body, however their performance centred on the act of fasting, survival, the days of
surviving without food, and overcoming the experience of hunger itself, rather than their body-as-
deviance (Gooldin 2003). In contrast to ‘fasting girls and women’ and ‘living skeletons’, however,
‘hunger artists’ centred their experience of fasting in the embodiment of suffering, pain, and
overcoming desire, rather than the absence of them, and were suggested to embody a modern
spectacular of performed restraint, achievement and transcendence of the will over the body, need,
and suffering, and of the disciplined self (Gooldin 2003). Like ‘living skeletons’, ‘fasting girls and
women’ are suggested as being similarly positioned as corporeal embodiments in a transition and
displacement of wonder in spirituality vs the secular, scientific body and nature, and the mundane of
illness, bodily need, manipulation/fraud, and social pressure, agency, rebellion, and subordination
(Gould and Walter 1897, Gooldin 2003).
In the 14th century, a Cartesian theoretical understanding of gender equated masculinity with the
intellect and spirit, and femininity with the body, flesh, and body fat; masculinity was therefore,
22
perceived as inherently closer to moral goodness and godliness, and femininity with absence of
intellect, immorality, sin (such as Eve and eating the fruit of knowledge in the Garden of Eden),
fertility, subservience, and gluttony (Sukkar, Gagan et al. 2017). Cartesian theory conceptualises the
mind and body as distinct entities, however Merleau-Ponty, Jean Paul Satre, and Embodiment theory
regard the mind-body as an intertwined, inseparable embodied object or “lived body”, that an
individual is aware of, has a connection to, experiences dis/satisfaction to and experience being
within, and is aware of being looked at by others as a body-object (Fusar-Poli and Stanghellini 2009,
Stanghellini, Castellini et al. 2012). When compared to modern concepts of eating disorders, historical
self-starvation including anorexia mirabilis, ‘fasting girls and women’, ‘living skeletons’, and ‘hunger
artists’ are lived experiences of the body-object, and the different gazes it attracts in liminality, and of
the ‘spectacle’ of hunger, desire, needs, the body and identity and their value, that are socially
embedded in their respective time (Gooldin 2003, Gooldin 2008). In the 14th century, objectified body
consciousness in this context, therefore, could lead to body-shame associated with fleshliness and
embodied femininity grounded in morality, spirituality, intellect, and ascetism/hedonism (Bynum
1985, Sukkar, Gagan et al. 2017). Critically, in cases of ‘anorexia mirabilis’ in medieval women,
young women used fasting and giving food to the sick and poor as a demonstration of agency and a
form of social protest against injustice and loss of freedom, such as a rejection of familial bond, the
behaviour of a male spouse or patriarchal family member, to protest against forced marriage, sex in
marriage and the dangers of pregnancy, and to reject, protest against, or align with the power
dynamics of the Church and Crown (Bynum 1985, Yoder 2002, Harris 2014, Sukkar, Gagan et al.
2017).
Reports of Victorian ‘fasting girls and women’ intersected with allegations of abuse, neglect,
familial food deprivation, and fraud (Henderson 1813, Lewis 1870, Tivy-side Advertiser. 1870,
Fowler 1871, Hammond 1879, The Boston Daily Globe. 1889, Brumberg 1989, Gooldin 2003). This
interpretation of eating disorders is important in the context of the social value/de-valuation of trauma
(particularly for women), disability and body differences, and fear and control of women’s bodies and
sexuality (i.e. appetite and food, particularly meat, perceived as ‘carnal’; bodily processes perceived
with disgust; sexual non-conformity), poverty and using starvation to gain notoriety and fortune,
perfectionism and aesthetics of the time and interest it mortality and illness, and the social positioning
and freedom of women (Brumberg 1989, Van Deth and Vandereycken 2000, Gooldin 2003, Du
Plessis 2020, Du Plessis 2021). From the socio-cultural-political factor in the development of
disordered eating, Victorian girls and women could therefore use food consumption or denial as a
means of asserting agency over and transforming their bodies and social perception, embodying
corporeal liminality (Gooldin 2003). Given that perceived purity, penance, and a zealous, ascetic life
was a pathway to notoriety and respect as a holy figure, some women who engaged in ‘holy fasting’
in the Middle Ages also had to defend themselves socially against accusations of fraudulence and
pursuing suicide, which was regarded as a mortal sin (Espi Forcen 2013).
23
Collectively, these elements of historical disordered eating are consistent with modern concepts of
disordered eating as embodied liminality (Yoder 2002, Eli 2018), and emphasises the importance of
considering body politics, socio-political, and cultural factors in disordered eating; that the meaning of
an individual’s disordered eating must not be divested from the context of the time, political climate,
and social and cultural context that an individual exists. This includes how their body and identity
may have been valued, devalued and/or denied rights and liberty, and how disordered eating and the
changing or starving body may impact negotiations of social power.
Minority Stress Theory
Minority Stress Theory (Meyer 2003) and Gender Minority Stress Theory (Testa, Habarth et al.
2015) propose that people of minority groups are subjected to individual and social stressors that are
not experienced by those in dominant groups. This creates a minority stress, which intersects with
multiple marginalisation (Singh 2013, Burke, Hazzard et al. 2021). These stressors include external or
distal stressors (e.g., institutionalised ideologies and social norms, social stigma, discrimination and
micro-aggressions), and internal or proximal stressors (e.g. (e.g., internalized stigma, expectations of
rejection/rejection sensitivity, concealment of one’s sexual/gender identity) (Meyer 2003, Riggs,
Ansara et al. 2015, Testa, Habarth et al. 2015). Experiencing minority stress is implicated in the
development of disordered eating and eating disorders (Lefevor, Boyd-Rogers et al. 2019, O'Flynn
2019, Beccia, Jesdale et al. 2020, Panza, Fehling et al. 2020, Panza, Olson et al. 2020), and may be a
causal factor in higher risk and rates of eating disorders in particular populations (i.e., LGBTQIA+
people, individuals with autism). Minority stress regarding body ideals may also be related to the
development of negative body image and disordered eating for those with physical disabilities
(Jackson 2016, Aldalur and Schooler 2018, Ünal 2018, Thomas 2019, Aldalur 2020, Aldalur, Pick et
al. 2020), including multiple minority stress status on disordered eating (Payne 2020). Body
dissatisfaction and disordered eating may be considered in a wider sociocultural-political context of
how the aesthetics of disability are constructed and in relation to other bodies, such as deviant and un-
beautiful, as opposed to embodying a unique and powerful beauty (Nario-Redmond, Noel et al. 2013,
Rice, Chandler et al. 2015, Siebers 2017, Rice, Chandler et al. 2018, Ünal 2018, Douglas, Rice et al.
2021, Rice, Riley et al. 2021). Minority stress may also explain pathways to internalised weight bias,
body dissatisfaction, and disordered eating through racism, displacement, colonialist violence, and
acculturative stress (Pepper and Ruiz 2007, Mussap 2009, Burt, Mitchison et al. 2020).
Hatzenbuehler (Hatzenbuehler 2009) proposed that distal stressors such as discrimination lead to
changes to general psychological processes (e.g., rumination, social isolation) and group-specific
mechanisms (e.g., internalized homonegativity, rejection sensitivity). The development of mental
health concerns such as body image dissatisfaction and disordered eating then occurs due to changes
24
in these processes, leading to higher risk and rates among sexual and gender minorities (McLaughlin,
Hatzenbuehler et al. 2012, Dyar, Feinstein et al. 2018, Ramirez and Paz Galupo 2019, Panza, Fehling
et al. 2020, Panza, Olson et al. 2020). Consistent with these theorised mechanisms and minority stress
theory, sexual and gender identity-related discrimination are associated with internalising processes
including rumination, social isolation, internalising homo- and trans-negativity, and internalising
sociocultural standards of body ideals (Hatzenbuehler, McLaughlin et al. 2008, Berghe, Dewaele et al.
2010, Brewster and Moradi 2010, Cox, Vanden Berghe et al. 2010, Kuyper and Fokkema 2011,
Lehavot and Simoni 2011, Brewster, Velez et al. 2019). This association is directly and indirectly
explained by links to body surveillance, body dissatisfaction, and disordered eating via internalisation
through mechanisms of minority stress; such as dehumanisation, sexual objectification,
discrimination, internalised sigma, rejection sensitivity, rumination, and social isolation
(Hatzenbuehler, McLaughlin et al. 2008, Feinstein, Goldfried et al. 2012, Brewster, Velez et al. 2019).
Embodied differences, corporeality and selfhood (like race/ethnicity, gender, sexuality, disability,
fatness and size, class, and age) encompass differing levels of mutability, malleability, and
removability in different contexts. Through body politics, and movement through different spaces, the
embodied self is made valuable, powerful, visible and invisible (Kyrölä and Harjunen 2017). It may
be that individuals who experience de-valuation and stigmatisation of their identities and bodies,
particularly across multiple domains, experience minority stress-related rejection sensitivity (Dyar,
Feinstein et al. 2018) through repeated exposure to anticipated and felt stigma, discriminations,
microaggressions, and oppressive social structures and culture. Eating disorders may therefore
develop, in part, as an embodied liminality in response to, and as a reflection of oppression, structural
violences, threat to identity, and the loss of personal freedoms (Eli 2018).
Internalisation of weight stigma may lead to existing in a fat body as involving experiencing
fatness as a liminal state that is not considered a permanent, valuable, part of ones’ identity (Harjunen
and research 2009, Kyrölä and Harjunen 2017). Fat-bodied individuals may perceive their bodies as
an ‘unreal’ fat self that exists as a phantom, ‘removable’ self that has overtaken or contaminated their
‘real’ thin self that they are ‘waiting’ to transform into in order to live in an imagined future (Kyrölä
and Harjunen 2017). For example, the ‘before-and-after’ weight loss narratives in media that
stigmatise, pathologise and marginalise fat bodies, presenting fatness as a ‘project’ of transience and
rectification (Maor 2014), increase weight stigma and maintain damaging stereotypes (Geier,
Schwartz et al. 2003). Through these experiences, a person may become alienated from their fat body
or ‘fat’ parts of their body, disconnecting from lost/phantom body parts that are threatening and
abstract flesh they associate with shame and a barrier to a meaningful, fulfilling life lived now (Kyrölä
and Harjunen 2017). These narratives are important to consider for living within fat and larger bodies,
in terms of sizeism and weight stigma, discrimination, and body alienation experiences that may
increase/decrease with different spectrums of weight and size. Including how sizeism impacts fear of
25
weight-based marginalisation and self-discrepancy, such as fear-of-the-fat(ter)/imagined self (Chrisler
and Barney 2017, Fahs and Swank 2017, Wilson 2020).
Self-Concealment
In the context of minority Stress Theory (Meyer 2003) and Gender Minority Stress Theory (Testa,
Habarth et al. 2015) the internal or proximal stressors involved in concealment of one’s authentic
identity (e.g. concealment of one’s sexual/gender identity, neurodivergence, disability or chronic
health condition, or cultural identity) may heighten risk for disordered eating and the development of
eating disorders.
However, it is not necessarily harmful to one’s health to have a secret and to attempt to keep it
from others (Kelly 2002). This may be particularly relevant in sociocultural contexts where to do so is
culturally supported and valued (Hayes, Muto et al. 2011). It may be that self-concealment becomes
distressing through a relationship with difficulty in regulating emotion and behaviour (Masuda, Tully
et al. 2017), and becomes linked to distress through psychological inflexibility (Hayes, Levin et al.
2013). The relationship of self-concealment to psychological distress appears to be partially mediated
by psychological inflexibility (Mendoza, Tully et al. 2018), which is a factor in disordered eating.
Psychological inflexibility has been found to mediate the association between self-concealment and
disordered eating (Masuda, Boone et al. 2011) controlling for gender, ethnicity, and BMI. Self-
concealment has been shown to be positively correlated to disordered eating, and negatively
associated with psychological flexibility. Psychological flexibility was inversely associated with
disordered eating (Masuda, Boone et al. 2011). Furthermore, within eating disorder cognitions, fear of
fat/weight gain and body image inflexibility are uniquely positively related to self-concealment
(Masuda, Latner et al. 2018).
Among individuals with eating disorders, greater psychological inflexibility and greater self-
concealment are associated with a more severe eating disorder; including greater severity in restrictive
eating, and weight and shape concerns (White 2018). The extent to which a person self-conceals can
explain the relationship between psychological flexibility and ED severity (White 2018). Whether an
individual has been in treatment also mediates the relationship between psychological flexibility and
ED severity (White 2018). In addition, self-concealment is positively correlated with disordered
eating behaviour, and self-critical perfectionism is positively correlated with self-concealment and
disordered eating behaviour (Kim, Shin et al. 2018). The relationship between self-critical
perfectionism and disordered eating found a partial mediating effect on self-concealment, meaning
that self-critical perfectionism increased disordered eating behaviour through high levels of self-
concealment (Kim, Shin et al. 2018).
Individuals with autism often conceal and mask their neurodivergence, which constitutes an
internal minority stress that has been linked to disordered eating in this population (Brede, Babb et al.
26
2020). Body dissatisfaction and disordered eating may also be connected to visible and invisible
disability through minority stress and concealment of mental, emotional and bodily differences and
needs, and experiences such as pain (Lingsom 2008, Cook, Germano et al. 2016, Wakefield, Puhl et
al. 2021). For Latinx individuals, self-concealment has shown a direct effect on depression, and large
indirect effects on general distress, somatisation, and anxiety through the mediating effect of
psychological inflexibility (Mendoza, Goodnight et al. 2018), which has implications for disordered
eating in this population. Black/African American and white American students with a sexual
minority identity have been found to demonstrate greater psychological inflexibility than their
heterosexual peers (Mendoza, Tully et al. 2018), which has been suggested to reflect attempts to cope
with the cultural challenges faced with having a sexual minority identity, such as marginalisation,
discrimination, and the threat of increased violence and verbal abuse by others (Hatzenbuehler 2009,
Leleux-Labarge, Hatton et al. 2015, Masuda, Tully et al. 2017). Among transgender and non-binary
people, both psychological flexibility and inflexibility moderated the relationship between internalised
transphobia and life satisfaction, as well as the relationship between nondisclosure of gender identity
and life satisfaction (Flynn and Bhambhani 2021), which has implications for the high levels of
disordered eating in these populations. For sexual minority women of higher body weight, disordered
eating was related to internalised homophobia, sexual orientation concealment, and experiences of
enacted weight discrimination and internalised weight bias (Panza, Fehling et al. 2020), highlighting
the impact of minority stress and multiple marginalisation on eating disorder risk. Collectively, in the
context of minority stress, factors such as self-concealment and high levels of psychological
inflexibility may further explain risk for disordered eating for minority and marginalised groups.
Socio-Cultural Dynamics of Weight Stigma and Disordered Eating
Feminine and Masculine Hegemony
One functional aspect of eating disorders is as a means of avoiding marginalisation and social
defeat by changing the perception of the individual’s body and expressed identity, and therefore their
social value within socio-political hierarchies. Social kindling aspects of eating disorders can be seen
in diet culture, and in other aspects of socio-political dynamics and experiences. Diet culture as a
system of beliefs that: worships thinness and equates health with moral virtue; endorses and reveres
thinness; promotes weight loss as a means of attaining higher social status and promotes the
denigration and pathologisation of fat bodies; vilifies some ways of eating and elevates others;
demonises some types of food as ‘unhealthy’ and promotes a ‘good/bad’ food dichotomy; oppresses
people who don’t meet the supposed thin ideal which is conflated with ‘health’ (Harrison , Lupton
1995, Jovanovski 2017, Pausé, Lupton et al. 2021).
27
Disordered eating in girls and women-identifying people typically has a drive for thinness and
weight loss, although fitness and wellness culture has now intersected toward thinness, lean
muscularity, and weight loss. High exposure to fitness content and thin body ideals results in negative
emotions, and objectification, sexualisation, upward and downward social comparisons, and attempts
to lose weight through dieting, disordered eating, excessive exercise, and substance abuse (Arya and
Rai 2017). Girls, and women-identifying people are subjected to messages of rigid and ‘toxic
femininity’ within the gender binary that conflates womanhood with harmful politics of femininity in
relationship to subservience to masculinity, submission to men’s domination and aggression, and
gender expectations that keep girls and women-identifying people as quiet, subservient, submissive
(McCann 2020), and as commodified, objectified, sexualised and dehumanised beings that are
positioned as objects of consumption. Gender inequity and inequality, including restriction on rights,
liberties and activities leads to disempowerment. Girls and women-identifying people can be
positioned as being owned by their family members, typically fathers, and if in heterosexual
marriages, owned by their husbands, which may lead to feelings of commodification (Piran 2010).
The commodification of women has been implicated in the earliest documentation of disordered
eating, with Medieval women using self-starvation as a means of protest against the behaviour of their
men in their families, to protest against forced marriage, sex in marriage, and the dangerous of
pregnancy, and to protest against or align themselves with the church and/or religious and moral
virtue (Bynum 1985, Yoder 2002, Harris 2014, Sukkar, Gagan et al. 2017). Victorian women were
also reported to use self-starvation to gain greater independence, agency, and financial freedom,
increase social standing, and escape poverty (Brumberg 1989, Gooldin 2003). This highlights how
disordered eating can be used to as a means of embodied protest, and/or to physically disrupt power
(Van Deth and Vandereycken 2000, Du Plessis 2021). Disordered eating can therefore be used as an
agent to changing one’s social position and to re-assert body and identity ownership when life and
liberty is endangered, and may represent an act of survival and fight for freedom and escape.
Exposure to violence and abuse, harassment, violations, and rape culture, and gendered denigration
are ongoing threats, traumas and risks factors to disordered eating and eating disorders, and act as
pervasive cultural violences (Harned and Fitzgerald 2002, Piran and Thompson 2008, Molendijk,
Hoek et al. 2017, Gay 2018, Monteleone, Tzischinsky et al. 2021). Collectively, these experiences and
messages may also become internalised through a dissociative process that comes to form the ‘eating
disorder voice’ or ‘eating disorder self’ (Pugh, Waller et al. 2018, Pugh 2020). Emphasis on the
fundamental importance of girls and women’s perceived attractiveness to others, their sexuality as
consumption rather than for one’s own pleasure and personal growth, early sexualisation, and the
importance of youth and withstanding ageing are other important factors in eating disorder risk (Piran
2010). Girls and women-identifying people are socialised into hegemonic expectations of femininity
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that normalise the constant pursuit of beauty ideals, including ‘fighting fat’ and ‘fighting ageing’
(Chrisler 2011). The bodies of girls, women-identifying people, and people with female body
characteristics are positioned as disgusting uteruses, menstruation, lactation, and female/intersex
genitalia are rendered as revolting, and avoided and degraded with euphemistic and denigrating
language (Chrisler 2011), fostering body shame, objectification, self-objectification, and self-
alienation. Patriarchal culture and society perceives girls and women-identifying people, and their
bodies and power as threatening, and normalises a response of denigration, bodily control, and
oppression (Chrisler 2011). These socially normalised responses position girls and women-identifying
people as lesser beings within patriarchal society, and encourage a process of striving for bodily
‘improvement’, and a social acceptability for bodily commentary, consumption, and vilification. In
addition, post-feminist discourses in the media on body acceptance such as celebrating the body,
resisting (negative) ‘fat talk’, and embracing femininity have become paradoxically weaponized by
the beauty industry as a new means of silencing the expression and exploration of body
dissatisfaction, while simultaneously demanding performative confidence and a ‘beautiful mind’ (Gill
and Elias 2014). These discourses in media position the dominant reason to pursue and perform body
acceptance and body confidence as to be “sexy (Gill and Elias 2014), thereby reinforcing the sexual
objectification, body surveillance, and accepting one’s body primarily in order to appeal to the
gratification of others.
Media and Marketing
The aggressive, targeted marketing of weight-loss, diet-food, fitness, aesthetic/cosmetic surgery,
make-up, and the fashion industry to girls and women-identified people is a socio-cultural factor in
eating disorders (Hesse-Biber, Leavy et al. 2006). Despite the fact that aesthetic surgeries are
predominantly marketed toward women-identifying people, they are increasingly marketed more
generally, notably regarding weight (i.e., body sculpting, liposuction, abdominoplasty, muscle
implantation, bariatric surgery/partial stomach amputation), and are widespread multinationally
(International Society of Aesthetic Plastic Surgeons ISAPS 2011). Research suggests that the vast
majority of those who undergo aesthetic surgeries are cisgender women, with internalisation of
sociocultural attitudes and paternal attitudes found to be significant positive predictors of acceptance
of and desire for aesthetic surgery procedures (Henderson-King and Brooks 2009), in addition to body
dissatisfaction, appearance investment, and television exposure as unique predictors of both
endorsement of social motivations for and actual consideration for aesthetic surgery, and aging
anxiety as a predictor for endorsement for social motivations for aesthetic surgery (Slevec and
Tiggemann 2010). Acceptancy of aesthetic surgery and cisgender women’s belief in beauty as
currency has also been found to be mediated by self-objectification and body surveillance (Wang,
Zheng et al. 2021). Critically, cisgender women with higher body weights (measured by BMI), greater
29
body surveillance, body shame, and greater engagement in unhealthy eating behaviours with the
intention of weight management were found to be more interested in undergoing aesthetic surgery
(Gillen and Markey 2021).
Body appreciation was significantly negatively associated with interest in aesthetic surgery but did
not predict it when other factors were considered in a regression model (Gillen and Markey 2021).
Collectively, these results suggest that beauty ideals, and thin ideals in particular, may be particularly
important in cisgender women’s consideration of aesthetic surgery. Weight stigma internalisation and
experiences of enacted weight stigma were not examined in these studies. It may be, however that
cisgender women of higher body weight are more likely to be interested in pursuing aesthetic surgery
in relationship to weight stigma internalisation and experiences. Abdominoplasty and liposuction are
among the most common ‘body contouring’ aesthetic surgical procedures, and are increasingly being
performed (The American Society for Aesthetic Plastic Surgery 2016). According to the American
Society for Aesthetic Plastic Surgery (ASAPS), in 2001 the most popular aesthetic procedure for both
cisgender women and men was liposuction (The American Society for Aesthetic Plastic Surgery
2016). Cisgender women have been found to seek liposuction on the lateral thighs and hips, and
cisgender men have been found to seek liposuction on the waist-hip area (The American Society for
Aesthetic Plastic Surgery 2016). These findings suggest undergoing aesthetic surgery is closely
related to weight stigma and related factors (likely, fear of weight-based marginalisation), which
interacts with gendered body ideals.
Aesthetic surgery advertising and aesthetic surgery makeover television shows have a negative
impact on the body image and weight satisfaction of cisgender women and girls, an effect which
includes media that does not involve idealised models (Ashikali 2014). The reminder of cultural
beauty ideals alone, therefore, may serve as to prime cisgender women and adolescent girls on their
perceived problems in appearance based on these cultural beauty ideals. Exposure to aesthetic surgery
media leads to increased body dissatisfaction (Henderson-King and Henderson-King 2005, Sarwer,
Cash et al. 2005, Mazzeo, Trace et al. 2007, Markey and Markey 2009, Sperry, Thompson et al. 2009,
Ashikali 2014) including weight dissatisfaction (Ashikali 2014), as well as greater perceived pressure
from the media to be thin, increased endorsement of ability to control their appearance (Mazzeo,
Trace et al. 2007), and increased desire and willingness to undergo aesthetic procedures (Delinsky
2005, Crockett, Pruzinsky et al. 2007, Nabi 2009, Sperry, Thompson et al. 2009, Markey and Markey
2010). Weight dissatisfaction has been found to be greater in cisgender girls exposed to risk
information, suggesting that risk information highlighted dangers and barriers to using aesthetic
surgery to embody an idealised weight, thereby leading to greater dissatisfaction with current weight
(Ashikali 2014). Exposure to aesthetic surgery media advertising and makeover shows also led to
greater body-related anxiety, and weight and appearance-related self-discrepancies in cisgender
women. For cisgender girls high on appearance as a source of self-worth, exposure to aesthetic
30
surgery media advertising and makeover shows lead to greater weight dissatisfaction (Ashikali 2014).
Greater internalisation of the thin ideal is also linked to more favourable attitudes to aesthetic surgery
(Sarwer, Cash et al. 2005, Henderson-King and Brooks 2009, Markey and Markey 2009, Swami
2009), and cisgender women with high internalisation show lower self-esteem following exposure to
an aesthetic surgery show (Mazzeo, Trace et al. 2007). Other research has indicated that focusing on
one’s appearance in order to gain self-worth is associated with negative responses to media body
ideals, as well as weight dissatisfaction (e.g., Grossbard, Lee et al. 2009, Overstreet and Quinn 2012).
As body dissatisfaction and weight stigma/thin-ideal internalisation is linked to risk for harmful
behaviours including disordered eating, it’s important to consider that exposure to aesthetic surgery
media content may not necessarily result in undergoing aesthetic surgery to cope with increased body
dissatisfaction, however individuals may engage in other behaviours that harm their wellbeing, such
as disordered eating. For example, cisgender women who restricted their eating had greater weight
dissatisfaction than those not attempting to lose weight, and this difference became greater after
exposure to aesthetic surgery advertising that involved discount incentives or risk information
(Ashikali 2014). Although few studies have investigated eating disorders and aesthetic surgery, a
higher interest in and tendency to undergo liposuction has been reported in individuals with EDs,
consistent with weight and shape concerns (Jávo and Sørlie 2010, Jávo, Pettersen et al. 2012). In a
survey of cisgender women with a prior history of inpatient ED treatment, 12% reported having
undergone at least one aesthetic surgery, with 4% reporting having undergoing multiple aesthetic
procedures (Coughlin, Schreyer et al. 2012). Those who had undergone aesthetic surgeries tended to
have a higher BMI, to be older, and to have a purging diagnosis (specifically, diet pill and laxative
use), in comparison to those who had not undergone aesthetic surgeries (Coughlin et al., 2012),
suggesting possible risk factors according to internalised weight bias and experiences of enacted
weight bias, and internalisation of gendered and age-related body ideals. In people with a current ED
and a lifetime history or bulimia nervosa (BN) or binge-eating disorder (BED) (D’Souza, Hay et al.
2020) individuals who planned or received bariatric surgery or cosmetic surgery including weight-
related procedures were more likely to be cisgender women compared to cisgender men, have a
higher BMI, to have a poorer mental health-related quality of life, and a current ED, lifetime BN or
BED, or features of EDs (D’Souza, Hay et al. 2020). Collectively, these research findings have
important implications for aesthetic surgery media in perpetuating the thin idealised body, weight
stigma, and body and weight dissatisfaction, which may increase risk for disordered eating, in
addition to the vulnerability of people with EDs in seeking aesthetic surgery as a means of coping
with body and weight dissatisfaction.
People with eating disorders (EDs) should be considered in screening and referral guidelines for
aesthetic surgeries and aesthetic procedures (Craddock 2019), particularly considering negative body
31
image as a motivator for these procedures, its relationship as a risk and maintaining factor in EDs, the
medical risks associated with both EDs and aesthetic surgeries, and the numerous adverse impacts of
EDs on mental and physical wellbeing and quality of life. Unregulated advertising, televised
marketing and makeover reality shows “prey on the vulnerabilities of a society increasingly obsessed
with physical perfection” (British Association of Aesthetic Plastic Surgeons (BAAPS) 2004, British
Association of Aesthetic Plastic Surgeons (BAAPS) 2012, British Association of Aesthetic Plastic
Surgeons (BAAPS) 2012), depicting aesthetic surgeries as able to reduce body dissatisfaction, and
improve overall life, while minimising the risks of these procedures and increasing unrealistic
expectations (Lee 2009, Nabi 2009).
Research into aesthetic surgery often discusses ethnic factors in Black, Asian, and other women of
colour, and discusses cosmetic surgery in white women as a gender issue, however aesthetic surgery
always intersects with race in beauty ideals, with idealisation of Eurocentric features (Heyes 2009,
Aquino and Steinkamp 2016). Aesthetic surgery also involves socio-political identity and body
hierarchies, such as race/ethnicity, weight, and disability, such as pursuit of the ‘normative’ and able
body, and the thin body.
Body politics in the beauty industry includes the marketing of make-up based on colourism and
class, and fashion marketing that intersects with weight bias, classism, racism, sexism, and ageism. In
addition to the thin ideal, beauty ideals across and within racial identities operate to establish
standards for skin tone, hair texture, and shape of specific body features associated with racial/ethnic
identity, particularly the nose, lips, and eyes (Lamb, Roberts et al. 2016). Decades of colonial rule in
different parts of the World, such as Africa and Asia, created a racial hierarchy stratifying skin colour
within societal value, and endorsing a belief that fair skin is linked to higher social status, prosperity,
and wealth (Hall 2003). Skin tone ideals are perpetuated by societal and media influences that idealise
white skin and Eurocentric features over People of Colour (Craddock 2016). The perpetuation of skin
tone ideals is evident in the marketing of products based on skin tone dissatisfaction, such as skin-
lightening/bleaching products and tanning products and procedures (Craddock 2016). Advertising
skin lightening products influences attitudes toward fair skin (Charles 2010, Shroff, Diedrichs et al.
2018, Olatunji, Popoola et al. 2019), fostering beliefs that fair skin is associated with better prospects
and skin bleaching practices is a means of achieving this success (Hunter 2007, Peltzer and Pengpid
2017). In accordance with this belief, the practice of skin lightening/bleaching may be motivated by
achieving greater social belongingness and approval (Lewis, Robkin et al. 2011, Alaa, Anthony et al.
2021). Skin lightening/bleaching is also correlated with low self-esteem, history of trauma,
depression, and body image disturbances (Alaa, Anthony et al. 2021). Critically, knowledge about the
active ingredients (e.g. mercury) and side effects of skin-lightening products does not prevent People
of Colour from using it (Charles 2010), emphasising the powerful role of colourism and beauty ideals
centering on race/ethnicity.
32
For People of Colour, internalisation of Eurocentric-ideals and pressures for Eurocentric ideals
positively predict Eurocentric body dysmorphic concerns (e.g., dissatisfaction with skin colour, eye
size/ shape, hair), and engagement in harmful practices such as skin bleaching (Akoury 2019, Harper
and Choma 2019). Experiencing colourism, a form of discrimination based on skin colour, therefore
represents a serious risk to physical and mental health, by fostering skin tone dissatisfaction, and risk
of engaging in practices such as skin-lightening, which may result in depression, skin damage, and
kidney failure (Craddock, Dlova et al. 2018). Disordered eating has also been associated with both
weight dissatisfaction and skin tone dissatisfaction, as well as increased use of skin-lightening
products (Harrison, James Bateman et al. 2020). Internalisation of Eurocentric-ideals and
acculturative stress may also predict Eurocentric body dysmorphic concerns and disordered eating
(Akoury 2019). These factors underscore the need for guidelines and research into media and beauty
ideals to broaden the focus of thin ideals in the risk for body dissatisfaction and disordered eating to
include cultural beauty ideals intersecting with race, ethnicity, and class (Rongmuang, Corte et al.
2011). Greater diversity in media is needed, including greater racial/ethnic diversity and diverse body
sizes in order to combat the perpetuation of both skin tone and thin ideals.
Conforming to dominant body ideals can provide access to social and psychological privileges, as
well as material privileges and accessibility that is denied to larger and fat-bodied people (i.e.,
clothing accessibility/in-accessibility) (Christel and O’Donnell 2016, Bishop, Gruys et al. 2018).
Material privileges and accessibility of spaces and clothing for fat people has sequential effects for
classism (e.g., higher cost for plus-size clothing), and weight bias in employment (ability to be
dressed well for work, ability to travel safely and comfortably, lower employment of fat-bodied
people). Clothing for larger and fat bodies is often labelled as ‘plus’ and ‘outsize’, suggesting that
embodying these measurements is on the margins of, or outside of style, sizing, comfort, equal
pricing, and the need for equal, abundant access and stock in-stores (Colls 2006). Available fashion
for fat-bodied people may also aim to hide the fat body under tent-like garments, or to torture the fat
body into styled submission of an illusion of thinness through cinching, ‘control garments’, and
‘tactful styling’ (Peters 2014). This reinforces the hierarchy of thinness as the body ideal, and that to
be to be fat should be to pursue a lifelong goal of attaining thinness. Weight discrimination is also
present in aesthetic labour (Gruys 2014), where workplaces reproduce and legitimise gendered,
racialized, and class discrimination in order for employees to embody the ‘right aesthetic’ for their
brand, which is typically conformity to white, middle class, hegemonic gender binary beauty ideals
(Williams and Connell 2015).
Food marketing is also heavily gendered and weight-biased. For example, meat, protein powders,
and ‘big’ portions are overwhelmingly marketed toward men-identified people, in comparison to how
vegetarian, dietary foods, and weight loss products are marketed toward women-identified people
33
(Adams 2015, Jovanovski 2017). Particularly for women-identified people and people perceived as
women, the fat body is de-sexualised or hypersexualised (Saguy 2002, Swami and Tovée 2009, Kwan
2010, Colls 2012), erased, racialized, viewed as a necessary for control, moralised and ridiculed,
necessitating a negotiation of conformity and resistance to these normative ideals (Tate 2015, Stone
2017, Williams 2017, Biefeld, Stone et al. 2021). The location and distribution of body fat (shape) on
the bodies of women-identified people and people perceived as women is also the subject of social
devaluation, self-devaluation, weight stigma, objectification and sexualisation (Barlev, Ko et al. 2021,
Krems and Neuberg 2021). Observers have been found to de-value the bodies of cisgender women
with an abdominal weight distribution to a much greater severity (above and beyond weight amount)
than the bodies of those with a gluteofemoral weight distribution, indicating a relationship of weight-
based social valuation of the bodies of cisgender women that depends on body shape and weight
distribution above and beyond weight amount (Krems and Neuberg 2021). Women with an abdominal
weight distribution report greater perceived social devaluation and self-devaluation compared to those
with a glutefemoral weight distribution (Barlev, Ko et al. 2021). Controlling for body fat, weight
labelling (by others and the self) and wanting to lose weight was also significantly related to weight
location in cisgender women (Barlev, Ko et al. 2021). Perception of body fat and sexualisation
therefore intersects with weight stigma, sizeism, and gender. Weight stigma and sexualisation may
also intersect with body politics involving racism, transphobia and homophobia, ableism, classism,
and ageism.
Disordered eating in boys and men-identified people often involves a muscle orientation, such as
pursuit for weight loss and muscle definition, and muscle gain (Lavender, Brown et al. 2017, Nagata,
Ganson et al. 2020). Likely related to pressure to conform to muscularity ideals, there has been an
increase in cosmetic surgery in men, notably in muscle implantation (Benito-Ruiz 2003).
Vulnerability to muscle-oriented disordered eating in men-identified people may be related to socially
prescribed perfectionism in particular, as well as self-oriented perfectionism (Dryer, Farr et al. 2016).
This suggests that men-identified people who have internalised gendered ideals of hegemonic
masculinity may be more vulnerable to developing muscle dysphoria and disordered eating. Western
culture socialises boys early into hegemonic masculine norms, roles, and expectations, including
expectations of restricted emotional expression and platonic intimacy, and the perception of emotional
vulnerability and physical limitations as a personal weakness (Connell and Messerschmidt 2005,
Schippers 2007, Charlebois 2010, Christensen and Jensen 2014). Hegemonic masculinity is also
termed ‘toxic masculinity’ and ‘fragile masculinity’, in order to give greater awareness and
prioritisation to the systemic oppressive harms created and maintained by hegemonic masculinity,
including men’s violence against women-identifying people, and men’s violence against marginalised
groups, as well as the use of hegemonic masculinity in order for men in political power to “sell”
political policies and wars, thereby camouflaging political motivations and practices by harnessing
34
masculine identities and fears (Messerschmidt 2015, Salter and Blodgett 2017, Daddow and Hertner
2019, Waling 2019). It has been argued, however, that to position masculinities as ‘toxic’ or ‘healthy’
continues to maintain rather than breakdown gender binaries and inequalities, and to set up
masculinity as the only available expression of gender that men-identifying people can legitimately
engage in (Waling 2019). This therefore reinforces beliefs that femininity, and androgynous
expressions of gender, and women and non-binary people are less valued than masculinity and men.
Boys and men experience early sexualisation through expectation to engage and revel in
heteronormative sexual activity, which includes exposure to pornography, rape culture, rape myths,
‘lad culture’, and benevolent, hostile, and everyday sexism (Henry and Powell 2014, Fraser 2015,
Phillips 2016, Jeremy 2017, Johnson and Johnson 2017, Gay 2018, Phipps, Ringrose et al. 2018).
Together these factors can be understood as a social hegemonic feminine and masculinity norm
factors that impact eating disorder risk, within a wider social kindling of body norms, body
hierarchies and body politics, which have different meanings and stressors for certain populations.
Fear of Fat/Weight Gain
Appearance-focused media has also been found to partially moderate the relationship between
weight bias and fear of fat/weight gain (Bennett, Wagner et al. 2020). This suggests that negative and
stigmatising portrayals of fat-bodied people in the media are fostering discrimination and fears of
gaining weight. Given the prevalence of weight stigma across different forms of media, the high
levels of media consumption particularly among young people, this has particular importance for
eating disorder development. Young people are particularly vulnerable to the development of
disordered eating during adolescence and young adulthood, and these ages are associated with identity
development and seeking peer acceptance. The media may therefore be perpetuating fear of weight-
based marginalisation through weight bias, leading to greater fear of weight gain. Perceptions of
weight stigma have been associated with increased restrained eating, binge-eating, and emotional
eating, with fear of fat/weight gain and perceived control significantly mediating these relationships
(Pardo 2019). These findings indicate that greater perceived control over weight status
(blame/attribution attitudes) and greater fear of fat/weight gain, likely indicating higher internalised
weight bias, increase risk for disordered eating. This has important implications for weight
stigmatising messages, such as those in media that attribute blame for higher weight status.
Public service announcements (PSA) influence the emotional processing of the subsequent food
commercials seen by viewers, which has important implications for eating behaviour and eating
disorder risk after seeing stigmatising and anti-fat PSAs (Jeon and Lang 2020). Viewers have
demonstrated more negative feelings during anti-fat PSAs compared to non anti-fat PSAs, and
consequent more negative feelings when watching commercials that followed anti-fat PSAs
35
advertising high-calorie foods compared to low-calorie foods (Jeon and Lang 2020). Individuals of
differing weight categories also showed less positive explicit attitudes toward high-calorie foods (Jeon
and Lang 2020). Those of a medium weight demonstrated lower implicit attitudes toward high-calorie
foods (Jeon and Lang 2020). Those of a larger weight showed greater implicit attitudes toward high-
calorie foods (Jeon and Lang 2020). Together, this indicates stronger intentions to moderate eating,
which may indicate internalised weight bias according to one’s own weight status, and possibly,
different attempts to cope. These findings have further implications for PSAs during COVID-19
(SARS-CoV-2 virus) pandemic, and risk for development of or exacerbation of disordered eating.
The COVID-19 pandemic has resulted in a dramatic rise in urgent and routine referrals for child
and adolescents to eating disorder and inpatient services (Solmi, Downs et al. 2021, Spettigue, Obeid
et al. 2021). Among the factors associated with increased risk for emerging and greater disordered
eating, increased weight stigma and rhetoric during the COVID-19 pandemic may have increased
barriers to help-seeking, and increased shame, internalised weight stigma, and linked fear of weight
gain with fears of contagion (Solmi, Downs et al. 2021). Public health messages and PSAs
emphasised that greater body fat increased the risk of COVID-19 infections and worsened outcomes
(Solmi, Downs et al. 2021), and incited weight stigma-based panic in the general public.
Dehumanising depictions of fat people in the media (i.e., visual imagery of fat bodies without heads
and faces shown) may also endorse disease avoidance responses to fat bodies (Jeon, Koh et al. 2019),
and internalisation of beliefs that fat bodies are dangerous and should be avoided, which has further
implications for weight stigma, fear of fat/weight gain, and eating disorder risk during the COVID-19
pandemic. Together the internalisation of these messages may have increased the impacts of weight
stigma and fears of infection, particularly for young people, leading to disordered eating to cope
(Puhl, Lessard et al. 2020, Pearl and Schulte 2021). Despite the known vulnerability of the childhood
developmental period for the development of EDs, and the rapid emergence and exacerbation of
disordered eating and EDs among youth during the COVID-19 pandemic (Ünver, Rodopman Arman
et al. 2020, Forbes 2021, Spettigue, Obeid et al. 2021), fear of fat/weight gain in children and the
‘obesity epidemic’ has been used as a justification for weighing children and policing body
composition in some schools (Henzen 2018, Simpson 2021). Concerns have been raised that weighing
children at school may trigger body image concerns and eating disorders, in addition to heightened
racial discrimination based on racial bias in BMI calculation (Simpson 2021). In addition, some
government’s release of strategies proposed to address the so-called ‘obesity pandemic’ alongside
weight stigmatising health messages included the promotion of weight-loss and food intake tracking
apps, and adding caloric information to food outlet menus (Department of Health and Social Care
2020). These factors may increase risk for eating disorder development in the general population, and
lead to worsened course and outcomes for those with eating disorders.
36
Correlational studies have consistently found that experiences with weight stigma are linked to
unhealthy eating behaviours and disordered eating (such as skipping meals and binge eating),
(Vartanian and Porter 2016). The results varied according to the samples studied, the stigma
constructs and the eating behaviour constructs being assessed (Vartanian and Porter 2016). Whether
or not the impact of weight stigma has been accurately captured by these studies in unclear, however
experimental studies find that using manipulations such as social exclusion, priming weight
stigmatising stereotypes, and exposure to stigmatising content lead to increased food intake
(Vartanian and Porter 2016). It is the position of this paper that weight stigma leading to internalised
weight bias, and fear of fat/weight gain are representative of the deeper drive of fear of weight-based
marginalisation, or social exclusion due to weight discrimination.
An investigation into the mechanisms of fear of fat/weight gain (Levinson, Williams et al. 2020)
found fears of negative evaluation and depression were uniquely associated with fears of fat/weight
gain, and shame prospectively predicted fear of fat/weight gain (Levinson, Williams et al. 2020).
Feelings of worthlessness have been found to have the highest bridge centrality connecting depression
to anorexia nervosa (Elliott, Jones et al. 2019), which may explain a pathway to depression and fear of
fat/weight gain in those with anorexia nervosa, possibly via internalised weight stigma and fear of
negative evaluation.
Fear of fat/weight gain has also been found to be related to both disordered eating, weight gain,
and perceived weight stigma (Wellman, Araiza et al. 2018). Fear of fat/weight gain was found to
mediate the positive relationship between perceived weight stigma and restrained eating (Wellman,
Araiza et al. 2018). Perceived weight stigma was also found to predict weight gain, mediated by both
fear of fat/weight gain and rigid restraint of eating, with flexible restraint and emotional eating
behaviour not found to mediate the relationship between perceived weight stigma and weight gain
(Wellman, Araiza et al. 2018). Perceived weight stigma may therefore lead to disordered eating and
weight gain through a process of fear of fat/weight gain. It may be that this process indicates a fear of
weight-based marginalisation or further marginalisation, and an attempt to avoid the harms of these
outcomes.
For individuals who perceive themselves to be ‘overweight’, the impact of perceived weight
stigma has been found to be related to eating behaviour (Araiza and Wellman 2017). Participants read
about discrimination against an out-group, and discrimination against individuals with a higher body
weight (Araiza and Wellman 2017). The higher participants were in perceived weight stigma (i.e., the
closer the threat of weight-based discrimination), the more poorly they performed on an inhibitory
control task, and the more calories they ordered when they read about discrimination against
individuals with a higher body weight (Araiza and Wellman 2017). Consuming more calories in
response to weight discrimination indicates a stress-based emotional eating response (Simone and
Lockhart 2016). These relationships were not found when participants read about discrimination
37
against an out-group (Araiza and Wellman 2017). The study findings have important implications for
weight stigma and disordered eating. Greater perceived closeness to the threat of weight based-
marginalisation may lead to greater risk for disordered eating (i.e., stress-based disordered eating
patterns). It may be that fear of fat/weight gain in eating disorders is related to greater perceived
closeness of the threat of weight discrimination, or greater fear of the threat of weight-based
marginalisation.
The Complexities and Constructs of ‘Feeling Fat’
‘Feelings of fatness’ has received low attention in the literature; research, however suggests that
‘feeling fat’ may be a central experience of eating disorders for both adults and adolescents (Linardon,
Phillipou et al. 2018, Christian, Williams et al. 2020, Levinson, Vanzhula et al. 2020, Messer and
Linardon 2021).‘Feeling fat’ is associated with the tendency to engage in social comparison and
feeling sociocultural pressures to conform to the thin-ideal, in addition to interoceptive cues and felt
experiences of the body (Roth and Armstrong 1993, Mehak and Racine 2020). In a study of
undergraduate women (Tiggemann 1996), ‘feeling fat’, was found to be predicted by dietary restraint,
self-esteem, and depressed affect (Tiggemann 1996). ‘Feeling fat’ has been found to be significantly
correlated with all eating disorder cognitions and behaviours (Linardon, Phillipou et al. 2018, Mehak
and Racine 2021, Messer and Linardon 2021), including cognitive restraint, dietary restriction, binge
eating and purging), and was not moderated by (cis) gender identification in adults (Mehak and
Racine 2021). In adolescents, however, (cis) gender identification was found to mediate the
association between ‘feeling fat’ and dietary restraint (Lam, Stewart et al. 2002).
In a study of high school age adolescents in Hong Kong (Lam, Stewart et al. 2002), for adolescent
cisgender girls, ‘feeling fat’ mediated the effect of body satisfaction and BMI on pressure to diet. By
contrast, no such relationship was found for adolescent boys. For adolescent cisgender boys, pressure
to diet was influenced by BMI independently of ‘feeling fat’ (Lam, Stewart et al. 2002). This indicates
that the construct feeling fat may have transdiagnostic relevance to eating disorder cognitions and
behaviours (Mehak and Racine 2021), but may have an effect on gender according to age (Lam,
Stewart et al. 2002). Further research is needed to investigate the experience of ‘feeling fat’ and
disordered eating for transgender and non-binary adults and adolescents, including its relationship to
minority stress, discrimination, gender dysphoria, and pressure to conform to gender binary
expectations of body ideals. Asking an individual how intensely they felt statements such as “I feel
fat” also appears to be a strong indicator of the likelihood the person has an eating disorder (Zhang,
Burns et al. 2021), suggesting that ‘I feel fat’ has common linguistic use for people with eating
disorders to communicate experiences and/or vulnerabilities associated with disordered eating.
38
However, questions must be raised regarding the construct and current conceptualisation of feeling
fat itself.
The potential mechanisms of ‘feeling fat’ may reflect displacement of negative affect onto the
body (Eldredge, Wilson et al. 1990, Taylor and Cooper 1992, Bruch 2001, Coelho, Carter et al. 2008,
McFarlane, Urbszat et al. 2011, MacDonald and Paper 2012, Levinson, Williams et al. 2020, Mehak
and Racine 2020), such as feeling shame, feeling de-valued, awareness of weight stigma and
increased body surveillance/scrutiny, self- and other- objectification. ‘Feeling fat’ and displacement of
negative affect onto the body may be a mechanism of internalised weight stigma (e.g., “[Feeling fat]
means … I’m incompetent, I’m lazy and I don’t have self-control or self-discipline, that I’m
physically unattractive, that I’m a bad person”); alexithymia (e.g., “I’m not very good at being aware
of my emotions … sometimes complicated difficult emotions get condensed in my mind into ‘I feel
fat’”); and internalised socio-cultural values of capitalism and ableism (e.g., “[When working] I didn’t
feel fat crawling up me, I didn’t feel any of that, as long as the next day I was able to be up, at work
early and perform”) (Major, Viljoen et al. 2019). Feeling fat’ has been linked to a negative sense of
self, feeling out of control, and depression. It has also been linked to physical sensations that may be
linked to impaired interoceptive awareness; such cognitive distortion connected to imagined/actual
consumption of food, and feeling full or bloated (Murphy, Straebler et al. 2010, Major, Viljoen et al.
2019, Levinson, Williams et al. 2020, Mehak and Racine 2020, Mehak and Racine 2021).
‘Feeling fat’ may therefore represent a ‘catch-all phrase’ for multiple, complex emotional and
embodied experiences, which may be reflective of internalised weight stigma, body disturbance, and
alexithymia in eating disorders (Murphy, Straebler et al. 2010). Feelings of worthlessness may
connect depression to displacement of negative affect onto the body (i.e. shame, feeling de-valued,
sense of negative evaluation), leading to the experience of ‘feeling fat’ (Elliott, Jones et al. 2019).
When negative fat talk is used, and the term “I feel fat” or “I feel too fat” is made, an individual may,
in fact, be making an emotional and reflective comment about their social and cultural position in
society (Probyn 2009), such as feeling shame, or feeling de-valued. For cisgender women with
anorexia nervosa in emaciated bodies, and those who embody fat bodies, bodily shame is felt and
experienced through their relationships with their body-selves, food, and eating, demonstrating how
shame is made corporeal (Moola and Norman 2016). This is important when considering ‘feeling fat’
in the context of weight discrimination and fear of weight-based marginalisation, and the experiences
of intersecting oppressions and discrimination for individuals in minority and marginalised groups.
Weight Bias in Research on Feeling Fat
39
Zhang, Burns and Touyz (Zhang, Burns et al. 2021) conducted three studies in order to develop a
7-item measure for an individual’s current state ‘feelings of fat’ (SFF; State Feelings of Fat). It’s
important to note, however, that all of their studies concentrated on cisgender women only, which
limits the understanding and applicability of these experiences to diverse gender groups (transgender
and non-binary people, men). Furthermore, all three samples were recruited from first year
psychology classes, which there likely includes a bias for higher socio-economic background and
educational privilege. Race/ethnicity of participants was not comprehensively reported, other than a
statement that there was some heterogeneity in the samples, and that the ethnic background of
participants was somewhat varied, with the largest non-native English speaker group in the studies
reporting that Chinese was their first language. It was unknown in these students were Australian
residents from immigrant families or non-residents studying on student visas. The study reported that
of the Chinese native speakers included, a similar correlation was found between the SFF (based on
the first seven items) and the EDE-Q as the full sample, suggesting that the ‘feelings of fat’ measured
by the scale may generalise for cisgender women students of Chinese native-speaking and English-
speaking backgrounds (Zhang, Burns et al. 2021). Given that the sample was recruited from first year
psychology classes, however, it must be considered that there is an overrepresentation of white
participants and underrepresentation of some racial/ethnic minorities.
In addition, in all three study samples, participants had an average BMI of around 21, with a range
from 14.4 at the lowest to 34.9 at the highest, and under 4 standard deviations in each sample (Zhang,
Burns et al. 2021). The displacement of negative feelings onto the body involved in ‘feeling fat’ must
be regarded when considering weight status, weight stigma, and sizeism. The fact that the BMI range
in this study did not include higher BMI statuses means that the study may not have captured
experiences of fat-bodied people in the construct of feeling fat. It is likely that experiences of
‘feeling fat’ may differ significantly according to weight status and experiences of enacted weight
stigma. Larger and fat people, may therefore have very different experiences of both embodying a
larger/fat body, and experiencing displacement of negative feelings that may be encompassed into
‘feeling fat’, such as: displacement of negative feelings onto the body from enacted weight stigma,
sizeism and feelings of having the body de-valued. A small portion of sample participants reported a
current or previous eating disorder diagnoses, which may also limit some applicability of these
‘feelings of fat’ experiences to ED patients (Zhang, Burns et al. 2021).
Questions used in studies to develop the scale may also have induced gendered and objectification
effects e.g. “how do you feel about your thighs” vs questions on body functionality, or embodiment
(for example, “how do you feel within your body?”; “How do you feel about different parts of your
body when you walk, run, sit, or stand?”; “When you ‘feel fat’ is this related to some parts of your
body more than others?”). Other questions may have cued weight stigma e.g. question 9: “I feel like
blobs of fat are attaching themselves to my body”. The word ‘blobs’ may have increased the salience
of weight stigmatising stereotypes associated with laziness and other negative connotations and
40
imagery. The SFF scale may also include gendered and objectification effects in its questions (i.e.,
Question 4: ‘I feel my thighs are thick and heavy’) and questions that cue sizeism and weight stigma:
(Question 3: ‘I feel that my face is round and chubby’, Question 5: ‘I feel my entire body is wide’).
The SFF correlated highly with EDE-Q scores, with each increased level of response associate
with a clear increase in EDE-Q mean scores. The single item of ‘I feel fat’ alone correlated with .793
on EDE-Q scores in the combined sample, and it was suggested that ‘feelings of fat’ and a potential
screen for an eating disorder could be used by this question alone. The EDE-Q was used as the only
measure of disordered eating which was a potential limitation, although the EDE-Q is also often used
as a sole measure of disordered eating in research. Participants reporting a current or former ED
diagnosis were found to have higher SFF scores than those reporting having never received a
diagnosis, and those reporting a former diagnosis had lower SFF scores than those reporting a current
diagnosis, suggesting that the degree of ‘feeling fat’ is a marker of degree of ED healing and recovery,
and that SFF scores may be predictive of prognosis (Zhang, Burns et al. 2021).
The development of the SFF is an important step in developing measures for the experience of
‘feeling fat’, and understanding the relationship of ‘feeling fat’ to ED recovery. However, the state of
‘feeling fat’ involves liminal movement through different contexts, relation to others, and the position
of one’s identity/body in society (body politics). Within the experiences of displacement of negative
feelings onto the body, especially when considering weight stigma, and alexithymia, it is critical that
the context of weight bias, weight discrimination, oppression and minority stress is not overlooked in
the experience of one’s body.
A study used a social comparison manipulation in the form of vignettes to induce sensations of
‘feeling fat’, in addition to self-reported measures of alexithymia, interoceptive sensibility, physical
appearance comparison, and perfectionism (Pink, Williams et al. 2021). A greater tendency to ‘feeling
fat’ was associated with alexithymia, interoception, and perfectionism. Alexithymia moderated the
effect of social comparison on ‘feeling fat’. The effect of social comparison on ‘feeling fat’ was also
moderated by socially-prescribed perfectionism. In the social comparison manipulation, the ‘feeling
fat’ scores increased following the Negative Social Comparison vignette condition and the Negative
General condition, and decreased in the Positive Social Comparison condition, however these effects
were not significant. The authors suggested that social comparison may therefore only be a
vulnerability factor for certain individuals, or that other factors influence this relationship (Pink,
Williams et al. 2021). However, both the Negative Social Comparison and Positive Social
Comparison vignettes reinforced weight stigma, ‘good/bad’ food dichotomy, the thin ideal, and
potentially the threat of weight-based marginalisation. This may have confounded results by priming
participants with the need to maintain thinness in order to be accepted in both of these conditions. The
Negative Social Comparison condition vignette involved enacted weight stigma; “When the food
41
arrives your friends makes a comment, “that's really unhealthy, should you really be eating such fatty
foods?” You look around and feel everyone's eyes on you. You notice they have ordered salads.
Looking around the table you realize you are the biggest person there and your clothes look much
tighter. You go bright red and feel embarrassed.” In comparison, the ‘Positive’ Social Comparison
condition involved weight stigma that similarly reinforced the thin ideal, the thin body as social
capital, and ‘good/bad’ food dichotomy, however praised the target’s body for being thin; “You are
eating out with a group of close friends. You decide to order a burger and fries. You are very hungry
and looking forward to a nice meal. When the food arrives, your friend makes a comment, “you are so
lucky you can eat fatty foods and still look amazing!” You look around and everyone is nodding in
agreement with her. You feel confident in yourself and happily enjoy the meal with your friends. You
can't help but notice how well your clothes fit compared to some of your other friends.” This
condition however, reinforces weight stigma and the thin ideal, and is threatening, as it suggests that if
the individual does not maintain their thin body, they will not ‘look amazing’, feel confident, or be as
able to enjoy the meal without the assurance that they can maintain thinness. Furthermore, their
comparison to their clothes fitting well in comparison to friends suggests that they are obtaining a
sense of body confidence from weight-based comparisons. These factors may therefore cue
perfectionistic drive to maintain thinness in order to maintain in-group acceptance, avoid social
marginalisation, and to uphold social value. The overall findings of the study indicated that both
alexithymia and socially-prescribed perfectionism may increase a person's vulnerability to ‘feeling
fat’. However as both the Negative Social Comparison condition and Positive Social Comparison
condition reinforced weight stigma, ‘good/bad’ food dichotomy, and the thin ideal, these factors may
have influenced findings.
Fear of Fat, Fear of Marginalisation and Disordered Eating
For cisgender women with anorexia nervosa, interpretive phenomenological analysis found
‘feeling fat’ to be associated with key themes, including a negative sense of self, feeling out of
control, engagement with eating disorder and other behaviours to cope with feeling fat, and that
making sense of ‘feeling fat’ is complex (Major, Viljoen et al. 2016, Major, Viljoen et al. 2019).
‘Feeling fat’ was found to be a multi-dimensional experience that encompassed a negative sense of
self, bodily hyperawareness, cognitive distortions, and a displacement of negative emotions onto the
body (Major, Viljoen et al. 2016). Feeling out of control in a multitude of areas was linked to ‘feeling
fat’, including body image concerns associated with physical changes in puberty, not having lost
expected weight, not feeling like oneself, extreme negative emotions (condensed and expressed as
‘feeling fat’, and lack of control in treatment (Major, Viljoen et al. 2016). Critically, ‘feeling fat’ was
also linked to a perceived sense of inadequacy and a fear of being judged by others (Major, Viljoen et
al. 2016), which supports the conceptual argument that fear of fat/weight gain and ‘feeling fat’ may be
42
related to fear of weight-based marginalisation. To cope with ‘feeling fat’, cisgender women with AN
reported engaging in unhelpful behaviours such disordered eating, and helpful behaviours such as
self-distraction and findings self-worth unrelated to weight and shape (Major, Viljoen et al. 2016).
Making sense of ‘feeling fat’ was reported to be complex and difficult to articulate, with cisgender
women with AN often feeling misunderstood by others when trying to talk about ‘feeling fat’, such as
experiencing responses of reassurance that they were not fat, or dismissing their experience (Major,
Viljoen et al. 2016).
Exposure to body images of thin-ideal non-conforming bodies has been found to produce higher
state ‘feeling fat’ than thin-ideal conforming bodies (Wilson, Mehak et al. 2020), suggesting an effect
of body comparison, fear of negative evaluation, and possibly, fear of weight-based marginalisation.
Feeling fat’ is linked with sociocultural pressures to conform to the thin-ideal and the tendency to
engage in social comparison (Striegel-Moore, McAvay et al. 1986, Roth and Armstrong 1993, Major,
Viljoen et al. 2019). Feeling fat’ is linked to both fear of fat/weight gain and fear of negative
evaluation (Calugi, El Ghoch et al. 2018, Major, Viljoen et al. 2019, Levinson, Williams et al. 2020).
‘Feeling fat’ in response to thin-ideal non-conforming images may therefore reflect internalised
weight stigma (e.g., Mehak, Friedman et al. 2018) manifested as a desire to avoid becoming larger/fat,
and/or fear of becoming the larger/fat self (eg., Wilson 2020) as opposed to the desire to attain
thinness. Furthermore, body weight ideals change rapidly depending on the size of available reference
bodies an individual is exposed to for social comparison, with cisgender women exposed to a greater
diversity of large body types found to idealise a thin body less (Aniulis, Sharp et al. 2021), and
improve in state body appreciation (Williamson and Karazsia 2018). The shifting of ideal body
perceptions indicates a reflection of current societal standards. Exposure to greater body diversity and
reduced focus on the thin body likely results in corresponding reduced perceived social value of the
thin body, and therefore, reduced fear of weight-based marginalisation.
Critically, a recent study (Trolio, Mehak et al. 2021) examined whether negative affect and
‘feeling fat’ mediated the relationship between interpersonal problems and disordered eating. Cross-
sectional path analysis revealed significant indirect effects of ostracism on both restrictive and binge
sequentially via negative affect and ‘feeling fat’. Ostracism related to negative affect, which related to
‘feeling fat’, which was ultimately correlated with disordered eating behaviours. Longitudinal path
analysis replicated the significant indirect effects of ostracism on binge eating sequentially via
negative affect and ‘feeling fat’. Disordered eating may occur through a process of displacement of
negative feelings of experiencing ostracism onto the body, which then triggers ‘feeling fat’, and leads
to engagement in disordered eating (Trolio, Mehak et al. 2021). The findings that experiencing
ostracism is connected to ‘feeling fat’ and disordered eating supports the proposed concept that
‘feeling fat’ may be related to fear of negative evaluation, weight-based marginalisation, feeling de-
43
valued, and minority stress. Further research is needed to examine ‘feeling fat’ within conceptual
approaches of minority stress and intersectional frameworks, including the relationship of ‘feeling fat’
to enacted and felt stigma and ostracism, minority group identification, and minority stress. It may be
that the construct and experience of ‘feeling fat’ encompasses complex emotional and embodied
experiences not currently measured involving the right to take up space and have physical and
emotional needs (such as shame about having needs, asking for help); feeling a sense of devaluation
about one’s identity and body; feeling a sense of pressure to change one’s identity and body; feeling
heightened sense of awareness of one’s body and bodily processes (interoception, self and other
objectification, social comparison, self-comparison to other time points); and falling short of one’s
own expectations (self-discrepancy and the feared self; including feared consequences of weight
gain).
(Negative) Fat Talk, Socialising, and Belongingness
Negative fat talk is a term used to denote appearance-focused self-degrading remarks and
comparisons made to other people concerning one’s body/weight/shape and size, and may also
include comparisons, critique and judgement of food intake and exercise (Martz, Curtin et al. 2012,
Shannon and Mills 2015, Martz 2019). Among these comments and content, negative fat talk includes
comments that express a fear of weight gain and becoming fat(ter) (Ousley, Cordero et al. 2007).
Research has investigated the relationship between negative fat talk and three key theories in body
image research (Arroyo 2014); self-discrepancy theory (Higgins 1987), social comparison theory
(Festinger 1954), and objectification theory (Fredrickson and Roberts 1997). Body dissatisfaction was
found to significantly mediate the relationships between negative fat talk, weight discrepancy, body
surveillance, and upward comparison (Arroyo 2014). Negative fat talk may be normative and occur in
people of all body weights and sizes (Britton, Martz et al. 2006, Martz, Petroff et al. 2009, Barwick,
Bazzini et al. 2012) and across the lifespan (Martz, Petroff et al. 2009, Engeln and Salk 2016, Miller
2019). Negative fat talk may also indicate internalised weight bias as well as beliefs about negative
appearance comments. For example, an individual may believe that they should make positive
comments about the appearance of others, but make modest or self-depreciating comments about their
own appearance (Paddock and Bell 2021), thereby perpetuating weight stigma through engagement in
negative fat talk.
Although negative fat talk may occur irrespective of weight and size, research suggests that
individuals in larger/fat bodies may engage in greater frequency of negative fat talk compared to
thinner peers (Engeln and Salk 2016), and feel more pressure to engage in negative fat talk (Martz,
Petroff et al. 2009). Change in frequency of negative fat talk is associated with change in weight
concerns (Vanderkruik, Conte et al. 2020), therefore greater engagement in negative fat talk may
44
heighten risk for weight/shape concerns and disordered eating to cope. Engagement in both positive
and negative talk have been associated with increased drive for thinness, dietary restraint, and binge-
purge behaviour for those with a higher body weight (Hart, Chow et al. 2017). For those with a lower
body weight, however, high engagement in positive/accepting body talk was protective against
disordered eating (Hart, Chow et al. 2017). Individuals in larger/fat bodies may therefore face higher
vulnerabilities to the impacts of hearing and engaging in body talk and its normalisation, such as
internalised weight bias, body dissatisfaction, and disordered eating.
Negative fat talk appears to be socially normalised among women in Western societies (Martz,
Petroff et al. 2009), and common among young and middle-aged women up to the age of 60 (Martz,
Petroff et al. 2009, Becker, Diedrichs et al. 2013), indicating body ideals that involve internalised
weight bias and ageism for women in negative body talk. Research suggests that negative fat talk is
more prevalent in younger than older women (Tzoneva, Forney et al. 2015, Engeln and Salk 2016),
and in white, non-Hispanic, Hispanic, and Asian women than Black women (Fiery, Martz et al. 2016).
Negative fat talk has also been found to be more common among undergraduate students who have
been diagnosed with an eating disorder (Ousley, Cordero et al. 2007). Negative fat talk appears to be
more prevalent in cisgender women than men (Martz, Petroff et al. 2009, Payne, Martz et al. 2011),
and no known research has investigated negative fat talk in transgender and non-binary people.
Transgender and non-binary people experience higher rates of body dissatisfaction and eating
disorders (Nagata, Ganson et al. 2020), which includes vulnerability factors related to pressures to
conform to gender binary expectations and cis-normative body ideals. Research is needed to
investigate transgender and non-binary peoples’ experience of negative fat talk, which may intersect
with cis-normative gendered body ideals, gender dysphoria, and weight bias.
Negative fat talk is linked to disordered eating for both cisgender women and men (Tzoneva,
Forney et al. 2015), and has been associated with increased body dissatisfaction, dieting, drive for
thinness, and bulimic behaviours (Arroyo and Harwood 2012, Tzoneva, Forney et al. 2015). For
cisgender women, the harmful impacts of negative fat talk have been causally and correlationally
related to multiple body-image related variables, including internalization of the thin ideal, low body
esteem, body dissatisfaction, depression, body-related cognitive distortions, drive for thinness,
disordered eating, and lower rates of exercising (Warren, Holland et al. 2012, Rudiger and Winstead
2013, Sharpe, Naumann et al. 2013, Shannon and Mills 2015, Mills and Fuller-Tyszkiewicz 2016,
Arroyo, Segrin et al. 2017).
Verbally participating in negative fat talk has been found to lead to greater body dissatisfaction,
drive for thinness, and dietary restraint for cisgender women in comparison to listening to friends
engage in negative fat talk (Lin and Soby 2017). However, hearing negative fat talk has also been
shown to lead to greater engagement in negative fat talk and greater experiences of body
45
dissatisfaction and guilt (Salk and Engeln-Maddox 2012). Furthermore, higher state and trait body
dissatisfaction and greater guilt have been found in those who engaged in fat talk, and engaging in fat
talk mediated condition and state body dissatisfaction and guilt (Salk and Engeln-Maddox 2012).
Engagement in negative fat talk, therefore, may be indicative of body insecurity and internalised
weight bias, and re-confirm feelings and beliefs about oneself and diet culture values related to bodies
and nutrition. Women’s engagement in negative fat talk may be driven by a motivation to fit in with
social groups or to conform to expected social standards (Britton, Martz et al. 2006). Negative fat talk
may also have several functions, including engaging in social comparison in order to assess the
relationship of one’s own body, body image and eating habits to others (Corning and Gondoli 2012,
Pollet, Dawson et al. 2021), impression management, anxiety reduction, and group cohesion (Nichter
2000, Shannon and Mills 2015).
Negative fat talk among cisgender college women (Salk and Engeln-Maddox 2011) has been
found to be common, with 93% of participants reportedly engaging in negative fat talk, and frequent
or very frequent engagement reported by one third (Salk and Engeln-Maddox 2011). The most
common responses to a negative fat talk remark were to deny that a friend was fat, typically leading to
a back-and-forth conversation where two women of medium weight denied that the other was fat
while claiming to be fat themselves (Salk and Engeln-Maddox 2011). Negative fat talk was linked
with greater internalisation of the thin-ideal and greater body dissatisfaction, but not BMI (Salk and
Engeln-Maddox 2011), indicating that negative fat talk has harmful effects for women’s body
satisfaction and internalisation of weight bias irrespective of weight status. Despite the relationship
between negative fat talk and body dissatisfaction, however, over half of participants reported that
they believed that engaging in negative fat talk made them feel better about their bodies (Salk and
Engeln-Maddox 2011). This suggests that challenging beliefs about engaging socially in negative
body talk (i.e., bonding, self-esteem) and challenging social norms of negative fat talk may be targets
for changing engagement.
Negative fat talk and muscle talk in cisgender college men (Engeln, Sladek et al. 2013) has been
linked to appearance investment, drive for muscularity, and disordered eating. Hearing negative fat
talk and muscle talk led to decreased state appearance self-esteem and increased state body
dissatisfaction (Engeln, Sladek et al. 2013). Cisgender men may engage in more positive body talk
compared to cisgender women (Lin, Flynn et al. 2021). Negative fat talk in cisgender men may also
differ to that of negative fat talk amongst cisgender women (SturtzSreetharan, Agostini et al. 2020).
Among cisgender men engaging in a discourse completion tasks depicting interlocutors of differing
sizes, comments such as “I need to lose some weight” elicited responses that varied according to the
depicted body mass of the speaker (SturtzSreetharan, Agostini et al. 2020). Individuals with a smaller
body size elicited responses of denial and reassurance, in comparison to offers of weight-loss
solutions and advice for cisgender men depicted with a larger body size (SturtzSreetharan, Agostini et
46
al. 2020). Appearance conversations may also explain differences in body dissatisfaction between
cisgender gay and heterosexual men (Jankowski, Diedrichs et al. 2014). Frequency of appearance
conversations has been found to mediate the relationship between sexuality and body dissatisfaction,
with cisgender gay men reporting more frequent engagement in both positive and negative appearance
conversations, appearance orientation, internalisation of appearance ideals, and body dissatisfaction
than cisgender heterosexual men (Jankowski, Diedrichs et al. 2014). Normative body talk may
therefore have important group differences according to gender and sexual identification, which may
increase vulnerability to body dissatisfaction.
Differences have been found in the frequency of engagement and impact of body commentary for
women according to race/ethnicity (Fiery, Martz et al. 2016, Herbozo, Stevens et al. 2017). Black
women in U.S. have reported experiencing less negative fat talk compared to Latina, Asian, and white
American women (Fiery, Martz et al. 2016). Conversely, Black and Latina women have reported
more experience with self-accepting body talk in comparison to white women (Fiery, Martz et al.
2016), suggesting greater norms of negative fat talk among white American women. Contrary to these
findings, a study found that while Black, Latina, and white American women did not differ in the
frequencies of negative, positive, and general body talk (controlling for BMI) (Herbozo, Stevens et al.
2017), Black and Latina women reported stronger negative responses to positive weight/shape
commentary than white women (Herbozo, Stevens et al. 2017). Negative responses to positive
weight/shape commentary were linked with more body dissatisfaction in Black women, after
controlling for frequency of the commentary (Herbozo, Stevens et al. 2017). Positive weight/shape
commentary may therefore be associated with more negative outcomes for ethnic minority women
(Herbozo, Stevens et al. 2017). This may be a reflection of minority stress, such as positive
weight/shape commentary being associated with neo-colonialist body ideals, or intersections of
gendered and racial body ideals. Building on these findings, further research may examine whether
positive weight/shape commentary for ethnic minority women leads to associations with and recall of
gendered and racial discrimination that may intersect with body commentary. Research is also needed
for the experiences of transgender and non-binary women, and intersections of gender, gender binary
expectations, weight stigma, and race/ethnicity.
Body commentary may also differ among men according to race/ethnicity (Fiery, Martz et al.
2016). A study found Asian American men reported more experience of both negative fat talk and
self-accepting body talk in comparison to white men (Fiery, Martz et al. 2016). Black men reported
more experience of self-accepting body talk in comparison to white men (Fiery, Martz et al. 2016). A
study of negative body talk among cisgender women and men of diverse ethnic-racial identities
(adjusting for BMI) found few differences with small effect sizes (Sladek, Salk et al. 2018). Two
negative body talk measures were found to be equivalent for Asian, Latinx, and white university
47
students (Sladek, Salk et al. 2018). In addition to few differences across ethnic group comparisons,
women’s ethnic-racial identity was associated with less frequent negative body talk for Asian and
Latina women, and men’s ethnic-racial identity was associated with more frequent negative body talk
for Asian men, adjusting for BMI (Sladek, Salk et al. 2018). These findings echo previous studies of
differences in body talk according to gender and race/ethnicity (Fiery, Martz et al. 2016, Herbozo,
Stevens et al. 2017). Further research is needed to examine the intersections of race/ethnicity and
body talk on multiple factors of body image in diverse samples, including transgender, non-binary,
and intersex people and experiences of hetero- and cisnormativity. In addition, research is needed into
body talk and negative fat talk among diverse people with disabilities. Body image interventions have
included therapeutic targets of improving body dissatisfaction by shifting focus onto appreciating
body functionality (Alleva and Tylka 2021). Research has shown that the body image of disabled
people involves body functionality and sociocultural expectations of the ideal ‘functional/able’ body,
conformity, and reactions to bodily difference (Vinoski Thomas, Warren-Findlow et al. 2019).
Making self-comparisons to nondisabled people may also elicit body dissatisfaction (Vinoski Thomas,
Warren-Findlow et al. 2019). As negative fat talk and body talk more broadly involves social
comparisons, it may be that disabled people and those with body differences engage in body talk that
involves components of comparative body norms, perceived difference and the need to belong,
internalised ableism and weight stigma, and attempts to conform with normative body ideals
(Kornhaber, Visentin et al. 2018, Vinoski Thomas, Warren-Findlow et al. 2019, Myhre, Råbu et al.
2021, Zelihić, Williamson et al. 2021). People with visible and invisible disabilities and body
differences may therefore experience different aspects of body image according to body functionality
in reference to societal (ableist) expectations of a ‘normative’ body, construction of, and valuation of
a ‘well’ and/or ‘disabled’ body, which intersect with weight stigma (i.e., constructions of the fat body
as the ‘ill/sick’ body).
Cisgender women’s fear of fat/weight gain has been shown to be related to their own body
dissatisfaction and restrained eating behaviour, and not significantly related to the body dissatisfaction
and restrained eating behaviour of female friends (Chow, Hart et al. 2019, Chow, Ruhl et al. 2019).
However, engagement in negative body talk has been found to be significantly related to both an
individual’s degree of fear of fat, and weight status (Chow, Hart et al. 2019, Chow, Ruhl et al. 2019).
Engaging in more negative body talk with a friend leading to increased engagement in restrained
eating (Chow, Ruhl et al. 2019). Cisgender women with less fear of fat engaged in less restrained
eating, however engaging in more negative body talk with a friend increased engagement in restrained
eating (Chow, Ruhl et al. 2019). Furthermore, individuals may be exposed to pervasive weight talk
that involves unhealthy weight control behaviour from a variety of sources (Simone, Hazzard et al.
2021) (i.e., peers, parents/caregivers, multi-source). Parental weight talk is particularly likely to
involve discussion of disordered eating as a form of weight control (Simone, Hazzard et al. 2021).
48
Greater exposure to weight talk that involves unhealthy weight control behaviours, particularly from
multiple sources, may be a risk factor for disordered eating behaviour (Simone, Hazzard et al. 2021).
Contrary to previous research findings that negative fat talk and positive body talk engagement
both increased disordered eating for women with higher weight status (Hart, Chow et al. 2017), a
study by Chow and colleagues found that engagement in negative fat talk had a minimal effect on
body dissatisfaction for women with higher weight status (Chow, Ruhl et al. 2019). By contrast,
negative fat talk was associated with greater body dissatisfaction for women with lower weight status
(Chow, Hart et al. 2019). It’s feasible that the greater effect of negative fat talk for women with lower
weight status may occur as a mechanism of the feared weight-based marginalisation through a
priming effect, and as a mechanism of a feared possible future larger/fat self. These findings have
important implications for the harmful role of negative body talk on fear of fat and disordered eating,
and negative body talk as a potential pathway in fostering or perpetuating eating disorder cognitions.
Further research is needed into these factors, including the impacts of minority stress,
intersectionality, marginalisation, feared weight-based marginalisation and their relationships to
negative fat talk, internalised weight bias, and disordered eating.
Critically, feminist identity and ideology do not necessarily appear to protect young cisgender
women from the tendency to engage in negative fat talk (Lafleur and Baudendistel 2015), although
further research is needed to examine feminist identity and body talk in diverse samples (i.e. diverse
genders, race/ethnicities, disability and neurodivergence; grounding in and experience with feminist
ideology). Feminism may help women critically evaluate and avoid internalisation of harmful thin
media ideals (Heinberg, Thompson et al. 1995, Myers and Crowther 2007), however feminist
cisgender women have also reported being unable to maintain complete resistance against the power
and pervasiveness of socio-culture pressures about thinness (Rubin, Nemeroff et al. 2004, Myers and
Crowther 2007). Literature on feminist ideology/identity on body image domains, however have
shown significant variability in effect size across studies (Murnen and Smolak 2009). When the
samples were not convenience samples, but involved groups who may have greater interest in or
deeper grounding in and experience with feminist ideology (e.g., women’s studies students, lesbian
women, older women), feminism may protect against extreme body dissatisfaction. It may be
therefore, that consolidated feminist identity/ideology is protective against internalisation of harmful
cultural ideals and body shame (Murnen and Smolak 2009).
A study examined feminist identity, race, and conformity to feminine norms as predictors of fat
talk (Lafleur and Baudendistel 2015). Consistent with the literature, negative fat talk was associated
with age and body dissatisfaction. There were no racial differences in body dissatisfaction or BMI,
however cisgender white women were more likely than Black women to engage in negative fat talk,
particularly regarding body comparison. Women who endorsed feminine norms to be thin and
physically attractive were also at greater likelihood of engaging in negative fat talk. Feminists and
49
non-feminists did not differ according to body dissatisfaction, BMI, or engagement in negative fat
talk, however women who endorsed a more radical feminist ideology exhibited greater levels of body
dissatisfaction and more negative fat talk engagement (Lafleur and Baudendistel 2015).
Being a feminist may result in stigmatisation in a patriarchal society positions feminism as un-
feminine and undesirable, and where diet culture equates thinness with hegemonic femininity and
promotes weight stigma and policing the bodies of women which contributes to gendered oppression.
This occurs in the broader context of socio-cultural and political power structures that objectify,
sexualise and degrade the bodies of women-identifying people and people perceived as women (Piran
2010, Fikkan and Rothblum 2012, Eeltink 2017, Jovanovski 2017). More radical feminist identity and
ideology may thereby increase the threat of stigma, threat to one’s femininity, and marginalisation as
a result. Cisgender women who identify as feminists may therefore endorse greater adoption of social
expectations associated with femininity (i.e., internalised weight bias, thin body ideals). It’s feasible
that for cisgender women with more radical feminist ideology/identity engage in more negative fat
talk as a mechanism of intersecting gender minority stress, the stigma associated with a feminist
identity and ideology, the pressures of hegemonic feminine ideals, normalisation of negative fat talk
and the gendered thin ideal among racial-ethnic groups, and fear of weight-based marginalisation.
Self-Discrepancy and Fear of the Fat Self
Eating disorder conceptualisations often centre motivation and drive for weight loss, thinness, and
muscularity, however an alternative explanation for is that motivation for disordered eating occurs
through the mechanisms of actual-ideal body image discrepancy and avoidance of a feared possible
self, or an interaction between self-discrepancies and feared selves. The actual-ideal body image
discrepancy model forms part of the Self-Discrepancy theory (SDT; Higgins 1987). The SDT theory
refers to an individual’s (dis)comfort in relationship to their concept of themselves in body image
perceptions, and the levels of conflicting beliefs they may experience between these self-concepts
(Higgins 1987). The SDT theory involves basic components of self-concept, including the actual self,
the ideal self, the ought self, the future self, and the potential self (Higgins 1987, Sawdon, Cooper et
al. 2007). The actual self refers to one’s personal psychological characteristics; the potential self
refers to the concept of who oneself has potential to become; the future self involves the self-
conceptualisation of who one may be in the future (Higgins 1987, Sawdon, Cooper et al. 2007). The
ideal self refers to the conceptual representation of attributes one wishes to possess or obtain; and the
ought self encompasses characteristics that oneself or others belief one ought to have, and is based on
different societal values (Higgins 1987, Sawdon, Cooper et al. 2007). The ideal self and ought self are
regarded as self-guide concepts of self, meaning that they do not represent the current self, but an
individual may desire to possess or obtain these characteristics, and to strive to narrow the
discrepancy between their actual (current) self and the ideal and ought selves (Higgins 1987, Sawdon,
50
Cooper et al. 2007). The degree of differences between how an individual perceives their current
appearance, their ideal appearance, and how they would like to be perceived be others is therefore
believed to lead to body satisfaction or dissatisfaction. The discrepancy between the two values of
perceived actual body image minus the ideal body image is commonly used to assess an individual’s
degree of body image dissatisfaction (e.g., Solomon-Krakus, Sabiston et al. 2017), known as the
actual-ideal body image discrepancy.
Specific types of self-discrepancies have been examined across diagnostic subgroups of eating
disorders (Strauman, Vookles et al. 1991, Mason, Lavender et al. 2016), as well as in the relationship
to muscle-oriented behaviours (Thomas, Tod et al. 2014). A study by Mason and colleagues examined
self-discrepancy constructs (actual-ideal and actual-ought) between ED diagnostic groups (low weight
anorexia nervosa; bulimia nervosa; and binge eating disorder), and ED behaviours transdiagnostically
(Mason, Lavender et al. 2016). Actual-ideal discrepancy was positively associated with low weight
AN, and actual-ought discrepancy was positively associated with BN and BED (Mason, Lavender et
al. 2016). Self-discrepancies did not differentiate between BN and BED (Mason, Lavender et al.
2016). Transdiagnostic comparison revealed actual-ought discrepancy to be positively correlated with
severity of binge-eating, purging, and global ED severity (Mason, Lavender et al. 2016). In addition,
significant relationships were found between diagnosis and actual-ideal discrepancy for binge-eating
and driven exercise. Significant associations were also found between diagnosis and actual-ought
discrepancy for global ED severity (Mason, Lavender et al. 2016). These findings indicate that self-
discrepancy may have a causal and maintaining role in disordered eating that differs among different
eating disorder diagnostic subgroups, behaviours, and severity (Mason, Lavender et al. 2016). The
differences in self-discrepancy types by diagnostic subgroups is interesting. It may be that greater
internalisation of societal values and messages of who one ‘ought’ to be or is expected to be is
associated specifically with binge and binge-purge behaviours, and greater internalisation, and
conceptual representations of the idealised self is associated with striving to diminish perceived
discrepancy through increased restrictive behaviours. This study did not differentiate the AN
diagnostic group into subgroups (i.e., AN-B/P subtype and AN-R subtype). Higher weight ‘atypical’
AN patients were also not included. This may lose some nuance between differences in self-
discrepancies between ED diagnostic subgroups, however these findings may indicate different socio-
cultural impacts and internalisations (e.g., internalisation of weight bias and thin body ideals).
Research has supported that media exposure activates self-discrepancies, which is associated with
negative affect (Harrison 2001). Exposure to thin-rewarded portrayal media has been found to activate
actual-ideal self-discrepancies, whereas exposure to a fat-punished portrayal activated actual-ought
self-discrepancies (Harrison 2001). Both types of media exposure were correlated with negative affect
(Harrison 2001). Given that chronic negative affect predicts disordered eating, these findings have
51
important implications for the harmful effects of thin-ideal media exposure and weight stigma
internalisation for self-concept and disordered eating risk (Harrison 2001). The relationship of body
image discrepancies to disordered eating may also be mediated by shame and self-compassion
(Mansourinik, Davoudi et al. 2019). Actual-ideal self-discrepancy has been found to mediate the
relationship between actual-ought discrepancy and shame (Bessenoff and Snow 2006), which
suggests that the internalisation of body ideals may be a precursor to negative emotional outcomes
from cultural norms regarding the body. Body shame has been implicated in body dissatisfaction,
disordered eating severity and fear of fat/weight gain (Jambekar, Masheb et al. 2003, Troop and
Redshaw 2012, Duarte, Pinto-Gouveia et al. 2014, Kelly and Tasca 2016, Woodward, McIlwain et al.
2019).
Shame resulting from internalisation of cultural body ideals (i.e., weight stigma and other body
marginalisations) is an important consideration in how an individual experiences their ‘ideal’ self, and
how they belief they ‘ought’ to be based on societal expectations, and their risk for disordered eating.
In a study of the body perceptions of racially/ethnically diverse cisgender women and men (Gillen and
Lefkowitz 2011), in comparison to Black/African American women, Latina American women and
white/European American women believed their peers’ ideal body size was thinner than their own
ideal body size. Cisgender men showed greater variability among racial/ethnic groups (Gillen and
Lefkowitz 2011). Body image and self-esteem was found to be best predicted by discrepancy between
perceptions of one’s own body size, and the size individuals believed those of another gender
perceived as ideal (Gillen and Lefkowitz 2011). These findings indicate that cisgender women’s
beliefs that they fall short of a thin ideal is related to body image and self-esteem.
Eating disorder patients tend to describe themselves with a diminished sense of ‘agency’, and
greater despair over defining or becoming the person they desire to be in comparison to non-patients
(Bers, Blatt et al. 2004). This may indicate that EDs involve self-discrepancies involving actual-ideal
and actual-ought dimensions, in addition to discrepancies between the actual-potential and actual-
future self. Critically, these characteristics differentiated ED patients from primarily depressed
patients, suggesting that these dimensions of self-concept may be distinctly related to disordered
eating over and above depression in ED patients (Bers, Blatt et al. 2004). Building on the findings by
Bers and colleagues, a study examined the relationship between self-discrepancies, disordered eating,
and depression (Sawdon, Cooper et al. 2007). Eating disorder and depressive scores were associated
with self-discrepancies (Sawdon, Cooper et al. 2007). The relationship between ED and actual-future
discrepancies, but not with actual-potential discrepancies was found to be mediated via appearance-
related stimuli (Sawdon, Cooper et al. 2007). When controlling for depression, only the relationship
between actual-potential self-discrepancies and ED remained significant, indicating that actual-
potential self-discrepancy may be specifically ED-related outside of depression (Sawdon, Cooper et
al. 2007). Actual-potential and actual-future selves may be important with regard to internalised
52
weight bias and fear of fat/weight gain in imagined feared selves for individuals with EDs. It may be
that those with EDs perceive a greater discrepancy between their actual-ideal and actual-ought selves
based on body ideals (e.g., the thin body, the muscular and/or lean body, the gender congruent body,
the hegemonic gender normative body, the able body etc), and perceive a that their potential selves as
having a greater likelihood for weight gain, and as a consequence, negative and threatening outcomes
(i.e., weight-based marginalisation). This is particularly important for considering the immediacy of
the threat of imagined weight gain, and may in part explain why those with EDs may associate food
and liquid consumption with rapid weight gain and engage in urgent and enduring behaviours to avoid
it.
The majority of research on body image dissatisfaction that compares actual, ideal and ought
physical selves, however, requires participants to choose and rate figures and silhouettes from pictoral
rating scales, which may be limiting (Stunkard 1983, Thompson and Gray 1995, Lombardo, Cerolini
et al. 2021). For example, these figures and silhouettes are often drawings, and lack realism and
diversity. Further, they often appear to represent white/Caucasian figures and silhouettes, and may
therefore already represent a major aspect of the idealised body in Western culture, thereby erasing
the impacts of racism and colorism, and the racialized body. The figures and silhouettes also represent
physically abled bodies, and also don’t show bodies with visible facial or skin differences, birth and
congenital differences, and other physical differences. This therefore also erases further aspects of the
idealised abled and assumed ‘healthy’ body; the normative body, and experiences of disabled and
chronically ill people, both invisible and visible. In addition, figures and silhouettes are often depicted
in a gender binary, which may erase the experiences of transgender and non-binary people. For
example, gender non-binary individuals may have an ideal self that is not represented in the gendered
representations of figures and silhouettes, and some may have body ideals that fluctuate between
gendered representations, and aspects that cannot be represented (e.g., discrepancies between actual,
ideal, and ought perceived voice femininity and masculinity).
Furthermore, the figures and silhouettes are lined up in a progressive weight spectrum; with
emaciated figures on the left side that progress in weight to larger and fat figures on the right side.
This can be argued as already ‘othering’ the figures on both outer ends of the scales. The figures and
silhouettes also, importantly, have the idealised normative ‘hourglass’ figures and weight distribution,
and research has shown that body composition and fat distribution is an important factor in body
dis/satisfaction (e.g., Dos Santos, Forte et al. 2020). The scales themselves are therefore already
reinforcing normative body ideals, and may therefore be cueing and maintaining internalised weight
bias and sizeism, gender norms, ableism, and body politics that position whiteness as the ideal
race/ethnicity, thereby increasing body dissatisfaction and othering. Some attempts have been made to
address issues of realism, for example, the Photographic Figure Rating Scale (PFRS) (Swami, Hadji-
Michael et al. 2008, Swami, Salem et al. 2008, Swami, Stieger et al. 2012) is a photographic version
53
of the Figure Rating Scale to enhance realism. These images however, may then become individual
rather than more generalised comparisons of more anonymous figures, and loses some universal
applicability. The current silhouette and figure rating scales are more widely used, however the
realism used in Photographic Figure Rating Scales is a promising beginning to furthering
development in this area. Further research should extend the diversity of figures and silhouettes within
silhouette and figure choice and rating scales for use in body image research. With these
considerations in mind, the following research examines body image from the self-discrepancy model.
Associations between transgender adolescents’ body image, therapy, body mass index (BMI),
disordered eating behaviours, and initiating gender affirming hormone therapy were explored
(Sequeira, Miller et al. 2017), with body dissatisfaction and disordered eating behaviours measured
using the Stunkard Figure Rating Scales and Eating Attitudes Tests. Transmen were found to have
greater overall body dissatisfaction compared to transwomen and cisgender controls, and both
transwomen and transmen had more severe disordered eating compared to cisgender controls
(Sequeira, Miller et al. 2017). Individuals that had initiated hormone therapy by 6 months
demonstrated lower levels of body dissatisfaction and disordered eating (Sequeira, Miller et al. 2017).
Transwomen had higher BMI trajectories and transmen had lower BMIs than cisgender controls
(Sequeira, Miller et al. 2017). The study findings suggested that transgender adolescents are at greater
risk for body dissatisfaction and disordered eating which may be partly based in self-discrepancies
such as gender incongruence of the actual/current physical self and the ideal and ought physical
selves. It’s important to acknowledge the impacts of social marginalisation and discrimination that
may also be factors for disordered eating for transgender youth. Importantly, initiating gender
affirming hormone therapy improved body satisfaction and disordered eating in this sample,
consistent with literature that gender affirmative care supports the wellbeing of transgender and non-
binary people (Chang and Singh 2018).
In addition to the actual, ideal and ought selves specified within Higgins’s theory, it has been
proposed that individuals also possess an undesired or ‘feared’ self/selves: the self that one does not
wish to become or is afraid to become (Markus and Nurius 1986, Ogilvie 1987, Woodman and
Hemmings 2008, Woodman and Steer 2011). The feared body is therefore is meaningfully distinct
from the ideal body (Woodman and Hemmings 2008). The concept of a individuals with eating
disorders coping with fear of weight gain and a ‘possible fat self’ through disordered eating, however,
has some limitations. Many individuals with eating disorders have a higher body weight and size or
are fat. The ‘feared fat self’ should therefore be considered on a spectrum of the feared possible fat or
fatter self, within the concept of sizeism (Chrisler and Barney 2017, Pausé, Lupton et al. 2021)
Individuals with eating disorders may also have previously embodied a larger body size, and may be
attempting to avoid returning to a higher body weight or more accurately, the way they were treated
54
at a larger body size. It may be that disordered eating as an avoidant coping mechanism for the feared
possible larger or fat self represents avoidant coping for fear of the possibly rejected and
marginalised larger or fat self. Weight bias, weight discrimination, diet culture, harmful stereotyping
and negative fat talk are insidious and pervasive narratives regarding the fat body, endorsing fear of
fatness and distain for fat bodies, and therefore, fear of the fat(ter) self.
In a qualitative study of the ‘feared fat self’ in cisgender women in the U.S. (Fahs and Swank
2017), hypothetically gaining 100lbs (45kg) elicited subjective feelings consistent with dominant
weight stigmatising narratives regarding the fat body (Fahs and Swank 2017). Five central themes
emerged, including 1) Weight blame: anger and disgust toward the self; consistent with weight
stigmatising rhetoric of blame attribution. 2) Familiarity with gaining weight; consistent with diet
culture and the normalisation of dieting, weight cycling, disordered eating; 3) Fear of physical
limitations; consistent with weight stigma and the ableist rhetoric of the fat body as ‘sick’, ‘impaired’,
and the “obesity epidemic”; 4) Loss of “sexiness” and loss of male gaze; consistent with rhetoric of
the fat body as de-sexualised or a source of ridicule and disgust; and 5) Severely distressed feeling
that life is over; consistent with the rhetoric that weight gain and the fat body is tantamount with
moral and personal failure (Fahs and Swank 2017). This distress is also consistent with the very real
threat of weight discrimination leading to negative experiences, disparities and losses in multiple
domains including healthcare accessibility, occupation, economy, relationships, and material access.
The feared self is an understudied area, and how this may differ in diverse populations in important to
consider. It may be that the ‘feared fat self’ represents the feared marginalised self, as represented by
loss of status and domains in life associated with weight stigma.
The ideal and ought selves were proposed to be approach motivational (Higgins 1997); that is, one
is motivated to seek greater closeness to these selves (e.g., “I want to be thinner”). The feared self is
proposed to be avoidance motivational (Carver, Lawrence et al. 1999); one is motivated to avoid
greater closeness to the feared self (e.g., “I don’t want to become fat(ter)”). Ought and feared selves
may also interact, creating agitation (Carver, Lawrence et al. 1999). When an individual is close to
their feared self, other selves have little motivational effect, as they are primarily motivated to avoid
the feared self (Carver, Lawrence et al. 1999). As they gain distance from their perceived self, and
therefore, lowered avoidance motivation, approach to the ought self intensifies (Carver, Lawrence et
al. 1999). When individuals were close to their feared selves, actual-ought discrepancies were not
associated with anxiety (Carver, Lawrence et al. 1999). With greater distance from their feared selves,
however, ought discrepancies significantly predicted anxiety (Carver, Lawrence et al. 1999),
indicating the importance of the interaction between ought and feared self discrepancies.
Using the approach-avoidance framework, ought and feared body fat discrepancies were found to
interact as predictors of anxiety in cisgender women (Woodman and Hemmings 2008). When closer
to their feared fat(ter) self, ought body fat discrepancies were not associated with anxiety (Woodman
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and Hemmings 2008). Proximity to the ought body fat self strongly predicted anxiety only when
cisgender women were far from their feared fat self (Woodman and Hemmings 2008). This
interaction also held after controlling for ideal body fat discrepancies (Woodman and Hemmings
2008). Further, the feared fat self moderated the ought fat body fat discrepancy-anxiety relationship
for cisgender women but not cisgender men (Woodman and Hemmings 2008). The gender difference
in this interaction may indicate an internalisation of gendered weight discrimination that shapes the
formation of ought body fat and feared body fat self-concepts.
In an exploration of cisgender women’s actual, ideal, and ought body image, feared body image
(feared fat(ter) self) and social physique anxiety (Woodman and Steer 2011) the relationship between
ought body fat discrepancies and social physique anxiety was moderated by proximity to the feared
fat self. Specifically, when women were far from their feared body self, the positive relationship
between ought fat discrepancies and social physique anxiety was stronger (Woodman and Steer
2011). Greater anxiety with further distance from the feared fat(ter) body may also suggest greater
body disturbance (Gruber, Pope et al. 2001). A study found that compared to those who do not diet,
women who diet have a greater actual/ideal discrepancy, which was unrelated to thinness ideals, but
was driven by ‘distorted perceptions of their body weight’ (Gruber, Pope et al. 2001). It may be that
feared body weight and ought discrepancies also mediated the relationships in this study, however
were unmeasured.
Desire to avoid becoming the feared larger or fat self has been found to be a stronger motivator to
engage in dieting and to more strongly mediate body esteem than the desire to attain thinness and
hope for a thin self (Dalley and Buunk 2009, Dalley and Buunk 2011, Dalley, Toffanin et al. 2012,
Dalley, Pollet et al. 2013). By contrast, it has been suggested that drive for thinness may have greater
relevance than fear of fat/weight gain for eating disorder risk (Dondzilo, Rieger et al. 2019). Greater
approach bias toward thin-ideal bodies has been associated with eating disorder-related constructs,
and avoidance bias away from larger/fat bodies found not to be significantly correlated with these
constructs (Dondzilo, Rieger et al. 2019). It may be that the differences in these findings is an
individual’s proximity to their feared fat(ter) self, and their associated avoidance motivation or
approach motivation to their ought body self. Individuals internalise both an idealised thin self and a
feared or stigmatised larger/fat self. The salience of possible selves has been found to mediate
avoidance temperament on the dieting of cisgender women, with feared possible fat(ter) self a
stronger mediator than a hoped-for thin(ner) self (Dalley 2016). Perceived closeness to the feared self,
rather than objective closeness, is associated with the relationship between the feared fat(ter) self and
dieting, underscoring the key aspect of self-concept in disordered eating (Dalley and Buunk 2009,
Dalley and Buunk 2011).
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Considering this research collectively as applied to eating disorders: when perceiving themselves
as being close to their feared self (fat/unfit/not muscular/gender incongruent), an individual may be
motivated to avoid the feared self by engaging in dieting and disordered eating behaviour. As they
create distance from their feared self, they may increase in motivation to approach their internalised
ideal body (thin/fit/muscular/gender congruent), and the body they believe others think they ought to
have (thin/fit/muscular/congruent with gender binary or role expectations). This interaction may
partly explain persistent drive in eating disorder behaviour. It may also have implications for
differences in self-discrepancies and approach-avoidance for different groups, such as low-weight
AN, higher weight ‘atypical’ AN, muscle-oriented eating disorders, and transgender and non-binary
people. It may be that proximity to weight-based marginalisation or greater weight-based
marginalization (sizeism) is related to the level of threat experienced and motivation to avoid the
feared fat(ter) self (i.e., engaging in disordered eating behaviour). If gradual distancing from the
feared fat(ter) self occurs, and with it, greater distance from the threat of weight-based marginalisation
and sizeism, an individual may be motivated to approach the ‘ought’ thin self (i.e., engaging in
disordered eating behaviour). It may also be that this effect is particularly strong for those who
already experience social and identity-based devaluation through body and identity politics, or
mediated by proximity to other social marginalisations.
Approach and avoidance are known to be important mechanisms in eating disorders, for example,
drive for thinness has been found to be predicted by fear of food (Levinson, Brosof et al. 2017). The
emergence of feared possible selves among self-discrepancies is an important facet of avoidance
motivation in eating disorders. Proximity to feared selves may interact or predict indicators of
approach motivation. In accordance with the relationship of approach and avoidance motivation, fear
of food and fear of fat/weight gain may be indicative of a higher order fear of the larger or fat self. In
addition, greater vulnerability to investment in a feared possible self may also develop through
sensitivity to punishment, and therefore, greater sensitivity to social marginalisation, leading to
greater sensitivity to the threat of weight-based discrimination. Individuals with a vulnerability to
eating disorder development may develop greater punishment sensitivity through early developmental
adversity and traumas, and insecure attachment (Cardi, Matteo et al. 2013).
Weight Stigma and Suicidality
Weight-stigma, internalised weight-stigma, and self-perception of higher body weight are risk
factors for disordered eating, eating disorders, and suicidality (Minor, Ali et al. 2016, Brochu 2020,
Brochu, Veillette et al. 2020, Daly, Robinson et al. 2020, Hunger, Dodd et al. 2020, Douglas, Kwan et
al. 2021). Self-perception of being at a higher/fat body weight (‘over’weight) is linked with
disordered eating and greater likelihood of suicidal ideation and suicidal planning in adolescents in
comparison to those who self-perceive as being at a low weight (‘under’weight) (Kim and Seo 2020).
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This emphasises the significant harms of weight stigma for suicidal risk. Pervasive messages from
public health campaigns and diet culture position higher weight and fat bodies as a public health
epidemic. Fat bodies are positioned as diseased, dangerous, and the source of shame, ridicule, and
moral inferiority, and an overall burden on society; discrimination and ostracism are therefore
regarded as justifiable. Experiences of weight stigma and internalisation of these socio-cultural and
political messages may then result in greater disordered eating and suicidality through bi-directional
pathways of greater perceived burdensomeness, and thwarted belongingness. It’s feasible that
experience of marginalisation and intersectional marginalisation (i.e., experience of perceived
burdensomeness of a having marginalisalised social identity/identities) may create greater fear of
additional marginalisation and its impacts (e.g., thwarted belongingness), such as weight
discrimination. Experience of or awareness of the stigma and marginalisation of the fat body may be
met with met with internalisation of perceived burdensomeness of the fat body, and need for continual
attempts to resist it and the anticipated marginalisation, and therefore, being in a larger body. It may
be that internalisation of weight stigma and messages of the burdensomeness of the fat(ter) body and
threat of thwarted belongingness effect due to being in a fat(ter) body (i.e., weight-based
marginalisation) lead to fear of weight gain and ‘feeling fat’ (e.g., displacement of negative feelings
onto the body).
Disgust Sensitivity, Weight Stigma, Eating Disorders and Suicidality
Negative self-conscious emotions have been associated with body image disturbance and suicidal
ideation (Allen and Ypsilanti 2019). Self-disgust and suicidal ideation were found to be independently
associated with body image distortions, including: body image disturbance, appearance fixing, body
image avoidance, and reduced positive rational acceptance (Allen and Ypsilanti 2019). Furthermore,
self-disgust was associated with suicidal ideation over and above the effects of body image
disturbance (Allen and Ypsilanti 2019). Self-disgust dimensions were found to mediate all
associations between body image disturbance measures and suicidal ideation (Allen and Ypsilanti
2019). These findings emphasise the importance of self-disgust in body image disturbance and
suicidality. Given that self-disgust has been found to be an important factor of EDs in both body
image disturbance (Moncrieff-Boyd, Byrne et al. 2014, Stasik-O’Brien and Schmidt 2018) and
suicidality (Chu, Bodell et al. 2015), self-disgust may have important implications in internalised
weight stigma and suicidality in EDs. It may be that greater self-disgust, body image disturbances,
and suicidal ideation in EDs are related to weight stigma experiences, internalised weight stigma, self-
perception of higher body weight. It’s feasible that these feelings may then lead to a fear of weight-
based marginalisation, disgust with others and the world, and a sense of hopelessness, thereby
increasing suicidality.
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Disgust has been associated as a factor that maintains and exacerbates eating disorder cognitions
and behaviours, and may be a risk factor for suicidality (Chu, Bodell et al. 2015). Self-disgust is
associated with body image disturbance in anorexia nervosa (Moncrieff-Boyd, Byrne et al. 2014,
Stasik-O’Brien and Schmidt 2018), and uniquely mediates the relationship between shame and
compensatory behaviours such as purging and compulsions (Olatunji, Cox et al. 2015). Trauma and
suicide risk are also connected via self-disgust (Brake, Rojas et al. 2017), which may have
implications for eating disorder-related suicide, given the high rates of trauma experienced in this
population. Furthermore, the relationship of insomnia on suicidality may be mediated by disgust with
life and self-disgust (Chu, Buchman-Schmitt et al. 2013, Akram, Ypsilanti et al. 2019, Hom, Stanley
et al. 2019). Body dissatisfaction and eating disorder cognitions and behaviours have been found to be
linked with increased suicidal ideation; however, this is correlated with high but not low levels of self-
disgust and disgust with the world (Chu, Bodell et al. 2015). Furthermore, disgust sensitivity may be a
specific risk factor for binge-type eating disorders (Hamilton 2019, Brassard, Laliberte et al. 2021).
A comparison of individuals with binge-eating disorder (BED) with control participants (HC)
(Brassard, Laliberte et al. 2021) found that although BED participants did not differ from HC
participants on overall disgust sensitivity or its subscales, eating disorder cognitions and behaviours,
and overvaluation of shape and weight were significantly associated with global disgust sensitivity, as
well as core disgust and contamination-based disgust subscales (Brassard, Laliberte et al. 2021).
Greater core disgust has been found to predict increased likelihood of tentative diagnoses of bulimia
nervosa and binge-eating disorder, and increased contamination disgust predicted a decreased
likelihood of a tentative diagnosis of BED (Hamilton 2019). Dimensions of disgust sensitivity may
therefore be linked to disordered eating and suicidality.
A study by Lieberman and colleagues (Lieberman, Tybur et al. 2012) investigated disgust
sensitivity, weight stigma, and gender had findings consistent with the above literature. In study 1,
greater body size (measured through BMI) was found to elicit different domains of disgust, including
pathogen (contamination) disgust, sexual disgust, and moral disgust. In study 2, the relationships of
these forms of disgust sensitivity and relationships to weight stigma were explored. For cisgender
women but not men, increased pathogen/contamination disgust sensitivity predicted greater negative
attitudes toward fat-bodied individuals. For cisgender women only, there was also a significant
relationship between sexual disgust and weight stigma, but in the opposite direction. The greater a
cisgender woman’s sensitivity to sexual disgust, the less bias exhibited toward fat-bodied individuals
overall, the greater attraction, and inclination to interact socially with fat-bodied individuals
(Lieberman, Tybur et al. 2012).
Cisgender women reported greater fear of becoming fat, and men reported greater general negative
anti-fat attitudes, and a greater likelihood to make blame attributions, by attributing fatness to a lack
of willpower. There was also a significant finding of body size and gender in relationship to the
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subtypes of weight stigma. For cisgender men, but not women, the higher one’s body weight
(measured by BMI), the more negative one’s anti-fat attitudes overall. This effect occurred mainly via
cisgender men’s heightened bias on the Fear of Becoming Fat Subscale. That is, for cisgender men
but not women, the higher their BMI, the greater their fear of becoming fat(ter). Cisgender women
demonstrated the opposite effect. The greater cisgender women’s BMI, the more favourable attitudes
were reported, as measured by the dislike subscale. For cisgender women but not men, higher BMI
predicted less overall anti-fat bias, less negative attitudes regarding the attractiveness of fat-bodied
individuals, and less negative attitudes about socialising with fat individuals (Lieberman, Tybur et al.
2012). Cisgender women with a BMI greater than ≥25 reported less weight bias than cisgender
women with a BMI <25, but only on subscales measuring social interaction, attractiveness, and social
closeness. There was no relationship between moral disgust and any of the subscales for cisgender
women nor cisgender men. The interaction of race/ethnicity data as a variable on these factors was not
investigated (Lieberman, Tybur et al. 2012).
The findings by Lieberman and colleagues have important implications for the role of disgust in
weight stigma and fear of fat, particularly for cisgender women. The finding of less weight stigma for
women with greater sexual disgust may indicate internalised weight stigma that both over-sexualises
fat bodies and erases the sexuality and sexual availability of fat people. Further research is needed to
deepen understanding of disgust, weight bias, and gender interactions to understand these effects. The
finding of pathogen/contamination disgust is particularly important in the current context of the
SARS-CoV-2 COVID-19 pandemic, weight stigma, and the rise of eating disorders (Fernández-
Aranda, Casas et al. 2020, Pearl 2020, Phillipou, Meyer et al. 2020, Puhl, Lessard et al. 2020).
It stands to reason that pathogen/contamination disgust may be a driver of fear-of-fatness, weight
stigma, thinness drive, and increased vulnerability to disordered eating during the COVID-19
pandemic. Self-disgust and drive for thinness in eating disorders has been found to be moderated by
self-compassion, when adjusting for external shame (Marques, Simão et al. 2021). Medium and lower
levels of self-compassion buffered the association between self-disgust and drive for thinness,
indicating that self-compassionate interventions may be an effective way of diminishing drive for
thinness for individuals with eating disorders with high levels of self-disgust (Marques, Simão et al.
2021).
The prospect and experience of eating has been found to elicit feelings of disgust in individuals
with low-weight AN (Glashouwer and de Jong 2021). Disgust is elicited by the expected impact of
food on one’s own body; the fear of becoming fat, resulting in body-related self-disgust (Glashouwer
and de Jong 2021). This indicates internalised weight stigma, and may indicate a fear of weight-based
marginalisation, as a consequence of the meanings that would accompany embodiment of the feared
fat(ter) self; the profound weight stigma faced by those in larger bodies. The authors suggested that
60
disgust in AN may explain the persistence of food restriction in states of starvation, and that
restrictive eating may function as a means of avoiding self-disgust (Glashouwer and de Jong 2021). It
stands to reason that heightened focus on body cues in eating disorders, interoceptive differences, and
fears of health consequences may be vulnerability factors that link internalised weight bias and
disgust sensitivity to disordered eating. To extend this theory, in line with the conceptual model
proposed in this paper, these findings may indicate that restrictive eating in AN serves as a means of
avoiding self-disgust and the expected impact of food on the own body (the fear of gaining
weight/‘becoming fat(ter)’) within a greater fear of the threat of weight stigma, negative evaluation,
and social marginalisation.
Weight Discrimination, Disordered Eating, and Suicidality
According to the Interpersonal Theory of Suicide (IPTS) (Van Orden, Witte et al. 2010), the two
interpersonal constructs of thwarted belongingness and perceived burdensomeness predict the desire
to engage in suicidal behaviour. Thwarted belongingness encompasses the extent to which one feels
socially isolated, lonely, rejected, or as though they are lacking reciprocally caring relationships (Van
Orden, Witte et al. 2010). Belongingness is a fundamental human need, important for survival from
our first moments of attachment to caregivers, to connection to groups, and understanding of identity
(Van Orden, Witte et al. 2010). Perceived burdensomeness involves the extent one feels as though
they are so flawed that they are a liability or drain to close others, including that they are expendable
(Van Orden, Witte et al. 2010).
Cultural norms of weight stigma lead to heightened weight-based-discrimination, and perceived
weight-based discrimination is associated with suicidal ideation (Hunger, Dodd et al. 2020). The
experience of weight stigma is threatening to one’s identity, and avoidant coping and psychosocial
stress as a result may predict disordered eating (Hand, Robinson et al. 2017). Weight discrimination in
adolescents is associated with increased risk of thoughts of self-harm, self-harming behaviour,
suicidal ideation and planning, and suicide attempts, controlling for sociodemographic factors, BMI,
and depression (Sutin, Robinson et al. 2018).
Using the IPTS to investigate the effects of weight stigma on suicidality, a recent study (Douglas,
Kwan et al. 2021) found a direct, positive linear relationship between weight stigmatisation and
suicide risk. An indirect effect of weight stigmatisation on risk occurred through perceived
burdensomeness but not thwarted belongingness (Douglas, Kwan et al. 2021). Higher stigmatisation
was associated with greater perceived burdensomeness, which predicted greater risk for suicide
(Douglas, Kwan et al. 2021). An indirect effect of weight stigmatisation on suicide risk was found
through emotional dysregulation. Higher weight stigmatisation was associated with higher emotional
dysregulation, which was associated with greater suicide risk (Douglas, Kwan et al. 2021). When all
61
regression models were combined, only an indirect effect of suicidality via perceived burdensomeness
remained (Douglas, Kwan et al. 2021). A study by Brochu and colleagues (Brochu, Veillette et al.
2020) used the IPTS to investigate the effects of internalised weight bias on suicidality. Weight bias
internalisation was positively associated with suicidality indirectly through both perceived
burdensomeness, thwarted belongingness (Brochu, Veillette et al. 2020). Furthermore, the indirect
associations of perceived burdensomeness and thwarted belongingness were of equivalent strength.
When the covariates of participant BMI, self-perceived weight status, gender, age, and race were
included, this parallel mediation model remained significant (Brochu, Veillette et al. 2020). These
findings have important implications for the impacts of weight stigma on suicidality, and suicidality in
eating disorders (i.e. felt and internalised weight stigma), and emphasise the need for longitudinal and
intervention studies to examine the relationships between weight bias experiences and internalisation
and suicidality. Future research should also examine these effects using an intersectional approach for
marginalised groups who may be at higher risk of suicidality, due to experiencing multiple sources of
perceived burdensomeness and thwarted belongingness (i.e., weight stigma, eating disorder stigma,
racism, homophobia, biphobia, transphobia, intersex discrimination, ableism).
The relationships among perceived burdensomeness, thwarted belongingness, eating disorders, and
suicidal ideation have been examined in multiple studies. In a sample of individuals with eating
disorders, Smith and colleagues (Smith, Dodd et al. 2016) found that compared to a healthy control
sample, individuals with eating disorders had greater perceived burdensomeness and thwarted
belongingness, and that perceived burdensomeness was associated with suicidal ideation. Similarly, in
another sample of individuals with EDs, Pisetsky and colleagues (Pisetsky, Crow et al. 2017) also
found perceived burdensomeness and thwarted belongingness to be positively correlated with suicidal
ideation. A cross-sectional study in an ED sample (Forrest, Bodell et al. 2016) demonstrated that both
current and lifetime ED cognitions and behaviours were linked with both perceived burdensomeness
and thwarted belongingness, which in turn, predicted suicidal ideation. In a cross-sectional study in a
nonclinical population (Kwan, Gordon et al. 2017), perceived burdensomeness and thwarted
belongingness were found to mediate the relationships between ED cognitions and behaviours (e.g.,
global ED, drive for thinness), and suicidal ideation. In a nonclinical sample, dietary restraint was
found to longitudinally predict increases in perceived burdensomeness and thwarted belonginess via
negative life events (Dodd, Smith et al. 2014). A more recent longitudinal study (Trujillo, Forrest et
al. 2019) examined the bidirectional, longitudinal relationship between disordered eating at two
timepoints, using thwarted belongingness and perceived burdensomeness as determinants of suicidal
ideation. Overall, perceived burdensomeness predicted greater ED cognitions and behaviours
longitudinally, and among those with anorexia nervosa and sub-threshold AN, both thwarted
belongingness and perceived burdensomeness predicted greater ED cognitions and behaviours over
time (Trujillo, Forrest et al. 2019).
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These collective results of these studies suggest that perceived burdensomeness and thwarted
belongingness are factors related to disordered eating in nonclinical populations, and clinical eating
disorder diagnoses. Due to the cross-sectional designs of a number of these studies, however, the
direction of the associations between disordered eating/diagnosed EDs, perceived burdensomeness,
and thwarted belongingness is undetermined. Evidence was found for a longitudinal relationship
between disordered eating behaviour, perceived burdensomeness, and thwarted belongingness (Dodd,
Smith et al. 2014, Trujillo, Forrest et al. 2019). The longitudinal relationship between initial dietary
restraint and later perceived burdensomeness and thwarted belongingness was indirect, however,
mediated through increased negative life events. The study also did not examine a bi-directional
relationship, and used a nonclinical population (Dodd, Smith et al. 2014). The findings by Trujillo and
colleagues provide support for the relationship between perceived burdensomeness and thwarted
belongingness on suicidal ideation in disordered eating/eating disorders (Trujillo, Forrest et al. 2019)
demonstrating a bi-directional relationship that both higher perceived burdensomeness and thwarted
belongingness led to greater disordered eating, and greater disordered eating led to both higher
perceived burdensomeness and thwarted belongingness in those with AN and sub-clinical AN, and
that higher perceived burdensomeness is bi-directionally linked to disordered eating in controls
(Trujillo, Forrest et al. 2019).
The contributing factors of minority stress and discrimination on disordered eating and eating
disorder-related suicide have been under-researched. These may be important factors in the higher
risk and rates of disordered eating and suicide for certain populations, such as individuals with non-
binary and diverse genders and sexualities (LGBTQIA+). Sexual identity minority stress has been
found to relate to relate to each the Interpersonal Theory of Suicide (IPTS) (Hicks 2017). All four
measured domains of sexual minority stress (sexual identity victimisation, rejection sensitivity,
visibility management, and internalised homophobia), combined to predict the degree of each
thwarted belongingness, perceived burdensomeness, and suicidal ideation constructs of the IPTS
(Hicks 2017). Conducting research into eating disorder-related suicide using a minority stress and
intersectional approach, and investigation the impacts of minority stress, discrimination, and
intersectionality on eating disorders may help in advancing understanding of the experiences of eating
disorders in particular populations, eating disorder-related suicidality, and related domains such as
perceived burdensomeness and thwarted belongingness. Re-framing the constructs of ‘fear of
fat/weight gain’ and ‘feeling fat’ as ‘fear of weight-based marginalisation’ or ‘feeling de-valued’ and
‘feeling negative about body fat’ and may reflect how thwarted belongingness and perceived
burdensomeness link to these constructs in eating disorder suicide risk.
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Attachment in Eating Disorders
A systematic review and meta-analysis of ‘systems for social processes’ in eating disorders
(Caglar-Nazali, Corfield et al. 2014) revealed that individuals with EDs had difficulties in the
majority of constructs of social processing. Individuals with EDs had attachment insecurity, perceived
low parental care, appraised high parental overprotection, showed difficulty in facial emotion
recognition and facial communication, increased facial avoidance, reduced agency, negative self-
evaluation, alexithymia, difficulty in understanding mental states, and sensitivity to social dominance
(Caglar-Nazali, Corfield et al. 2014). These sensitivities and difficulties with social processes have
important implications regarding internalisation of weight stigma, fear of fat/weight gain, and fear of
weight-based marginalisation. It’s feasible that greater attachment insecurity, difficulty interpreting
and communicating emotions, and sensitivity to social dominance increases sensitivity to the threat of
marginalisation, such as weight stigma. Fear of fat/weight gain and disordered eating in an attempt to
avoid weight gain and weight-based marginalisation or greater weight-based marginalisation (i.e.,
sizeism) may then occur.
Adolescents experience insecure attachment in relationships to both parents/caregivers and peers.
U.S. adolescents perceived higher weight status as a primary reason that peers were the victims of
bullying at school (Puhl, Luedicke et al. 2011). Higher weight/fat students were observed to be at
greater risk of victimisation which included being ignored, avoided, excluded from social activities,
being teased, having negative rumours spread about them, being verbally threatened, and physically
harassed (Puhl, Luedicke et al. 2011). The body fat of cisgender adolescent girls is collectively more
closely monitored and criticised in comparison to cisgender boys, however cisgender boys and girls of
all sizes and different social groups including those of higher body weights are critical of those with
more fat (Taylor 2010), indicating early internalised weight stigma, gendered effects, and negotiations
and constructions of social rank and distancing based on weight stigma. In addition, youth with
multiple minority/marginalised identities may be at greater vulnerability to bullying and peer
victimisation, and risk of disordered eating as a consequence.
Sexual minority cisgender youth report higher rates of bullying and peer victimisation in
comparison to heterosexual peers, and cisgender sexual minority youth who are of a racial/ethnic
minority may also be at a higher risk for bullying and peer victimisation compared to heterosexual
cisgender peers of the same race/ethnicity (Jackman, Kreuze et al. 2020). A study investigated the
intersection of minority sexual identity, gender identity, and Hispanic/Latinx identity and their
interaction with peer victimisation in predicting disordered eating among U.S. youth (Thapa and
Kelvin 2017). Sexual minority youths, youth who were victims of dating violence, and youth who
were bullied at school were at significantly higher odds of disordered eating than their peers (Thapa
and Kelvin 2017). Furthermore, a significant three-way interaction was found between gender, sexual
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identity, and dating violence victimisation; and gender, sexual identity, and electronic bullying (Thapa
and Kelvin 2017). The effect of dating violence victimisation on disordered eating was strongest
among sexual minority adolescent boys, and the effect of electronic bulling on disordered eating was
strongest among heterosexual adolescent boys (Thapa and Kelvin 2017). A later study echoed these
results, finding a significant tree-way interaction between gender, sexual identity, and bullying
victimisation, demonstrating that bullying was associated with high levels of disordered eating among
sexual minority young men (Pistella, Ioverno et al. 2019). Adolescents with diverse sexual and gender
identities (i.e., transgender, lesbian, gay, bisexual, pansexual, asexual) have also reported significantly
high rates of weight-based teasing from family members and peers, prevalent across weight
categories, and particularly highest for those at higher body weights (fat bodies) and lower body
weights (very lower weight bodies) (Puhl, Himmelstein et al. 2019). In addition, prevalence of peer
and family weight-related teasing may be similarly problematic for adolescents across a number of
diverse racial/ethnic groups, and especially so for higher weight/fat adolescents (van den Berg,
Neumark-Sztainer et al. 2008). It’s important to note, however, that differing socio-political climates
since this study was conducted may intersect with weight stigma, and impact the levels to which
adolescents are victimised and effected by weight-based victimisation (e.g., anti-Black racism in the
U.S., anti-Asian racism in the wake of the COVID-19 pandemic) (Hardy 2020, Williams and Cooper
2020, Abraham, Williams et al. 2021).
Childhood and adolescent experiences of bullying, teasing, and weight-based teasing by peers
(Puhl and Luedicke 2012) and family members (Keery, Boutelle et al. 2005, Pearlman, Schvey et al.
2020, Dahill, Touyz et al. 2021) have been consistently found to be found to be related to risk for
body dissatisfaction and eating disorder development (Menzel, Schaefer et al. 2010, Day, Bussey et
al. 2021) well into adulthood (Puhl, Wall et al. 2017). Children and adolescents with attachment
injuries, insecure attachment styles, and survival of adverse and traumatic experiences may be even
more vulnerable to the impact of internalising weight-based teasing and early weight-based
marginalisation, as a support network is critical to survival. An absent, insecure, or underdeveloped
support network can exacerbate the child’s sense of threat and vulnerability abandonment
(Monteleone, Patriciello et al. 2018). A child perceiving threat may then seek to re-join and gain in-
group acceptance by attempting to reduce body weight in accordance with cultural body capital and
gendered binary, colonialist-racial, abelist expectations and aesthetic preferences and expectations,
without necessarily understanding the layered meanings of why their body was rejected. For those
with higher predisposing risk factors for eating disorder development, the energy deficit caused
through restrictive eating may then trigger a neurobiological and metabolic bind (Kaye 2008, Scolnick
and Mostofsky 2014), leading to the progression of disordered eating and eating disorders, which may
become chronic and enduring. Higher levels of attachment insecurity across eating disorder subtypes
are related to greater severity of disordered eating (Tasca 2019). Low parental care and early trauma
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may lead to attachment insecurity, creating a predisposition to disordered eating, the formation of
early maladaptive schemas, and a sensitivity to the threat of perceived rejection (Damiano, Reece et
al. 2015, Pugh 2015, Forsén Mantilla, Clinton et al. 2019, Tasca 2019, Meneguzzo, Collantoni et al.
2020, Amianto, Martini et al. 2021, Meneguzzo, Cazzola et al. 2021).
Among those with eating disorders, attachment insecurity has been shown to be directly negatively
related to body esteem, mediated by alexithymia (Keating, Tasca et al. 2013). Attachment anxiety
may also contribute to both depression and disordered eating through emotional reactivity and
difficulties with impulse regulation (Tasca, Szadkowski et al. 2009). For those with eating disorders,
higher attachment avoidance is related to lower identity differentiation, indirectly through poorer self-
concept (Demidenko, Tasca et al. 2010). Higher attachment anxiety in those with eating disorders is
also directly related to lower differentiation of self, and higher attachment anxiety is indirectly linked
to lower identity differentiation through poorer self-concept (Demidenko, Tasca et al. 2010). These
results are consistent with developmental theories that early attachment experiences influence the
development of one’s concept of self, which then impacts on the development of self-identity. With
regard to discrimination, minority stress, weight stigma, and disordered eating; attachment insecurity
may lead to lower differentiation of self and power self-concept, thereby heightening the vulnerability
of an individual to the threats of discrimination and stigma. Disordered eating may then be used to
cope with the threats of discrimination and stigma to one’s identity (i.e., Mason, Smith et al. 2019,
Mason, Mozdzierz et al. 2021).
Adverse childhood experiences, such as childhood maltreatment and trauma may have a direct
effect on eating disorder cognitions and behaviours (Tasca, Ritchie et al. 2013). Attachment anxiety
and avoidance have been shown to equally mediate the childhood maltreatment eating disorder
relationship (Tasca, Ritchie et al. 2013).
Critically, cases of child abuse involving a caregiver starving a child have been reported, in
relation to parental/caregiver eating disorders (Cuzzolaro and Donini 2016, Túry, Szalai et al. 2020)
or possibly factitious disorder imposed on another/Munchausen by proxy abuse. A parent/caregiver’s
eating disorder can become superimposed on the child, with or without necessarily having purposeful
intent of abuse (Honjo 1996, Moszkowicz and Bjørnholm 1998, Russell, Treasure et al. 1998, Zamora
and de Ugarte Postigo 2007, Sadock, Sadock et al. 2009, Andreis 2016, Túry, Szalai et al. 2020).
Whether or not this abuse involves greater degrees of internalised weight stigma, healthism, ableism,
and other socio-cultural and political messages (i.e., body politics) is an important consideration for
research in this area. However, it is important to acknowledge that irrespective of the intent of the
starvation of the child (i.e., parental/caregiver eating disorder features subconsciously superimposed,
or conscious, purposeful abuse), that harm to the child is still severe.
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Cisgender women mothers with histories of eating disorders may restrict their children’s food
intake out of their own desire to skip the meal, and stress over food preparation, in addition to,
critically, fear that their children will gain weight and become fat (Mazzeo, Zucker et al. 2005). Child
feeding practices involving covert control are also associated to higher restriction by cisgender
women mother’s in their own eating, and greater concern about their child’s weight status (Gonçalves,
Lima et al. 2017). Cisgender women mothers with histories of eating disorders may also report
different approaches to feeding their child, such as limiting processed foods (Hoffman, Bentley et al.
2014), consistent with following their own dietary rules in order to influence and control weight and
shape (Bardone-Cone, Harney et al. 2010) and concern with restricting foods to those perceived as
‘healthy’ or ‘good’ within a good/bad and healthy/unhealthy dichotomy (Dellava, Hamer et al. 2011).
Furthermore, parent’s binge-eating and restrictive child feeding practices has been found to correlate
both directly and indirectly with restriction for weight control mediated via distress responses, and
indirectly via restriction for health (Saltzman, Liechty et al. 2016).
A study comparing feeding and child eating in cisgender women mothers with different ED
subtypes and no ED in Norway (Reba-Harrelson, Von Holle et al. 2010) found that mothers with
bulimia nervosa and binge-eating disorder were more likely than mothers without eating disorders to
restrictive feeding styles and child eating problems than mothers without eating disorders. The small
AN sample size may have limited the detection of significant differences between groups. However,
although not significant, the adjusted mean score of mothers with AN was found to be .30 lower than
the No-ED group, indicating that they were less likely to restrict the feeding of their child than
mothers without eating disorders. Overall, binge-type eating disorders was associated with greater
reports of child eating problems, and greater likelihood than other subgroups to endorse restrictive
feeding styles (Reba-Harrelson, Von Holle et al. 2010). As the majority of data were collected from
self-report measures, the accuracy of report must be considered, such as the influence of demand
characteristics (e.g., socially desirable responding). It may also be that denial, minimisation of, or lack
of awareness of eating disturbances in AN played a role in differences of report between groups. By
contrast, cisgender women mothers with AN who were well enough to have children and participate
in the study may have significant concerns about transgenerational eating disorders in their children,
and may strive hard to ensure that their children’s nutritional needs are met (Reba-Harrelson, Von
Holle et al. 2010).
The overall mean differences suggested that cisgender women with AN may have different feeding
styles for their children, often in the opposite direction to cisgender women mothers with BN and
BED (Reba-Harrelson, Von Holle et al. 2010), consistent with literature findings (e.g., Hoffman,
Bentley et al. 2014); although the unbalanced sample size may limit the power of detection of these
differences. In addition, the average body weight (measured by BMI) of mothers with BN, BED, AN
and No-ED groups were found to be different (Reba-Harrelson, Von Holle et al. 2010). Cisgender
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women mothers with BN and BED had a higher body weight (categorised by the BMI group of
‘over’weight) in comparison to cisgender women mothers with AN or in the No-ED group, who were,
on average of a lower body weight (categorised by the ‘normal’ BMI group). ED subgroup appeared
to influence feeding style of children independent of cisgender women mother’s BMI. However, the
study did not include internalised weight stigma or experiences of enacted stigma as covariates. It
may be that internalisation of weight stigma, greater experiences of weight stigma, and fear of the
consequences of weight stigma for their child (i.e., weight-based marginalisation) correlated with their
own higher weight status are related to higher conscious or subconscious restrictive feeding practices.
Parental/caregiver concern for weight gain in children and health beliefs conflated with body size may
be a driver for starvation in child abuse and restrictive feeding practices. Future research should
examine internalised weight stigma, experiences of enacted weight stigma, healthism, fear of negative
evaluation related to parenting (e.g., belief of a child’s higher weight/fat body as a reflection of ‘poor
child-rearing’ and/or shame related to poverty/classism) fear of weight-based marginalisation,
healthism, and related factors. These factors may be important considerations in attachment insecurity
pathways to disordered eating, and disordered eating in families. Collectively, the research supports
that ‘fear of fat/weight gain’ is pervasive across a multitude of domains, and may be expressed
through weight-based discrimination and attitudes, weight biased messages in culture, politics and
media, food selection, dieting, emotional eating, disordered eating, weight gain, and
parental/caregiver child feeding practices.
Crucially, for cisgender women of a higher body weights, averse childhood experiences have been
found to be positively associated with greater internalisation of weight stigma (Keirns, Tsotsoros et al.
2021). Adverse childhood experiences may be an early life factor that increases vulnerability to adult
weight stigma through biological (e.g., stress response), social (e.g., attachment insecurity, fear of
negative evaluation, social anxiety), cognitive (e.g., self-criticism/depreciation, early maladaptive
schemas, poor concept of self), and/or emotional (e.g., shame, lack of self-compassion, emotional
dysregulation) mechanisms. As a consequence of childhood maltreatment, attachment insecurity that
encompasses affect dysregulation and interpersonal sensitivity for individuals who have experienced
it may then lead to greater vulnerability to the impacts of stigma, marginalisation and minority stress,
including weight stigma, and disordered eating as a result. Fear of fat/weight gain and ‘feeling fat’ as
known eating disorder constructs may occur through these mechanisms. Collectively, these literature
findings emphasise the role of attachment insecurity as a risk factor for disordered eating. Early
maltreatment, discrimination, bullying, and weight-based discrimination may increase vulnerability to
the development of and exacerbation of disordered eating, and attempts to avoid further maltreatment
by seeking acceptance, such as conforming to thin ideals, or attempts at concealing or changing one’s
stigmatised identity (e.g., concealing sexual identity, gender identity, neurodivergence, chronic
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pain/disability status, disordered eating in attempts to conform to gender binary norms, disordered
eating in attempt to lose weight).
Social and Appearance Anxiety in Eating Disorders
Eating disorders, fear of negative evaluation, and social anxiety can be understood as connected
through weight bias in Western cultures, where appearance and thinness are highly valued, and higher
and fat bodies are de-valued and pathologized. Social anxiety and eating disorders have a very high
co-occurrence (Godart, Flament et al. 2003, Swinbourne and Touyz 2007, Pallister and Waller 2008,
Swinbourne, Hunt et al. 2012, Kerr-Gaffney, Harrison et al. 2018).
Social appearance anxiety is defined as the fear that one will be evaluated negatively based on one’s
physical characteristics (Hart, Flora et al. 2008). Fear of negative evaluation is defined as the
apprehension that one feels at the prospect of being negatively appraised by others (Leary 1983).
Social appearance anxiety and fear of negative evaluation have been found to be vulnerabilities for
both social anxiety and eating disorders (Levinson and Rodebaugh 2012), which may partially explain
the common co-occurrence, in addition to high prevalence of attachment anxiety among those who
have developed eating disorders. It is possible that treating negative appearance evaluation fears (i.e.,
social appearance anxiety and fear of negative evaluation) may reduce the severity of both eating
disorders and social anxiety (Levinson, Rodebaugh et al. 2013).
The ‘thin ideal’ is the internalisation of societal body politics, body hierarchy and expectations,
which affect emotions and behaviours (Thompson and Stice 2001). The relationship between social
anxiety and eating disorders, to some extent, may reflect wider socio-cultural and political contexts,
such as high valuation on appearance and thinness (Diedrichs 2017).
Social anxiety in eating disorders may also be connected to perceptions of low social rank, low
belongingness, or de-valued identity or standing. Social anxiety and self-perception of inferiority may
lead to shame (Grabhorn, Stenner et al. 2006). Internalised shame has also been associated with social
comparison and submissive behaviour (Cardi, Mallorqui-Bague et al. 2018), both risk factors in low-
weight AN. In this context, disordered eating may then be used in an attempt to increase social rank
(Troop, Allan et al. 2003). Social anxiety in ED patients may therefore relate to socio-cultural
contextual factors such as weight stigma, and perceptions of low social rank. Social exclusion is a key
risk factor for eating disorders (Fung, Xu et al. 2016, Cardi, Mallorqui-Bague et al. 2018). Individuals
with low-weight anorexia have been found to have smaller social networks, to spend less time
socialising and more time engaged in solitary activities (Tiller, Sloane et al. 1997, Krug, Penelo et al.
2013, Doris, Westwood et al. 2014). They also report more loneliness (Cardi, Mallorqui-Bague et al.
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2018). Bullying and friendship difficulties have been found to predict eating disorder cognitions and
behaviours (Copeland, Bulik et al. 2015).
Social anxiety occurs prior to, during, and as a consequence of eating disorders (Westwood,
Lawrence et al. 2016). Prior to onset, low-weight anorexia patients perceive themselves as inferior to
peers, shy, and anxious about fitting in (Cardi, Tchanturia et al. 2018). Interpersonal difficulties may
therefore predispose disordered eating through negative affect, and serve as an attempt to increase
belongingness and reduce the distress of social isolation (Baker 2020). Further, fear of negative
evaluation and perceiving oneself as inferior to others predict eating disorder thoughts and behaviours
(Cardi, Mallorqui-Bague et al. 2018). This relationship has been found to be mediated by perceived
lack of social competence (Cardi, Mallorqui-Bague et al. 2018). Social difficulties may be which may
a particularly important risk factor disordered eating for autistic women and non-binary people who
engage in high levels of social camouflaging (Baker 2020, Brede, Babb et al. 2020). Individuals with
autism may be acutely aware of and sensitive to social difficulties and rejection, including weight-
based discrimination and abelism, and may use disordered eating to cope with social difficulties
(Baker 2020, Brede, Babb et al. 2020). Self-perception of inferiority, interpersonal difficulties and
sensitivity to rejection, may mean that individuals with eating disorders are more acutely attuned to
the impacts of discrimination and marginalisation, such as weight-based discrimination and rejection.
It may be that disordered eating becomes a method of attempting to avoid weight-based
discrimination and rejection through attempts at weight control, and a method of coping with weight-
based discrimination and rejection through emotional regulation.
Higher levels of fear of negative evaluation are reported among clinical samples of cisgender
women with eating disorders compared to controls (Hinrichsen, Wright et al. 2003). Fear of negative
evaluation is predictive of restrictive eating and drive for thinness (Gilbert and Meyer 2005, Levinson
and Rodebaugh 2012), increased binge-purge behaviour (Hamann, Wonderlich-Tierney et al. 2009),
and changes in binge-purge behaviour longitudinally (Gilbert and Meyer 2005). Fear of negative
evaluation has been linked with weight/shape concerns and the development of eating disorders
and/or muscle dysmorphia in adolescents (Trompeter, Bussey et al. 2019). For adolescent cisgender
girls, and adolescents with a higher body weight (measured with BMI), this relationship is stronger in
comparison to adolescent cisgender boys (Trompeter, Bussey et al. 2018), suggesting that those who
face greater scrutiny (i.e., based on gender and greater weight status) are more vulnerable to
developing disordered eating as a manifestation of fear of negative evaluation, and social pressures of
body ideals. This may indicate a sensitivity to weight stigma in a known developmental risk period for
eating disorders, and potentially, sensitivity to the impacts of weight-based marginalisation. Similarly,
fear of negative evaluation has been found to predict subsequent thin ideal internalisation among
those with high but not low BMIs (DeBoer, Medina et al. 2013). It has been speculated that fear of
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negative evaluation may have an a priori relationship to disordered eating with fear of negative
evaluation increasing risk for internalisation of the thin ideal (DeBoer, Medina et al. 2013). It may be
that fear of negative evaluation is closely related to fear of marginalisation. Awareness and sensitivity
to weight stigma and weight-based marginalisation may therefore then increase risk for internalisation
of the thin ideal.
Conflicting findings on drive for thinness have been found, however, with fear of negative
evaluation found to predict body dissatisfaction and disordered eating but not dietary restraint or
negative affect (DeBoer, Medina et al. 2013). A qualitative review found that levels of social anxiety
are comparable across ED diagnostic groups, and are correlated with greater ED severity, but not
associated with BMI (Kerr-Gaffney, Harrison et al. 2018). However, BMI was positively correlated
with social appearance anxiety, drive for thinness, and body dissatisfaction in cisgender women
diagnosed with an eating disorder (Claes, Hart et al. 2012). BMI was also positively correlated to
social appearance anxiety but not general social anxiety in an undergraduate sample, mediated by
body image dissatisfaction (Titchener and Wong 2015). It may be that irrespective of body weight,
individuals with eating disorders and social anxiety experience body shame and appearance-based
rejection-sensitivity, which heightens risk for disordered eating. It’s plausible that self-discrepancies
are also a mechanism in social appearance anxiety specifically. Both social anxiety and shame are
regarded as important factors in eating disorders, and eating disorder patients have been found to have
higher scores in internalised shame in comparison to those with anxiety and depression, with shame a
significant contributor to social anxiety (Grabhorn, Stenner et al. 2006). Appearance-based rejection-
sensitivity also appears to be an important mechanism in the greater vulnerability for socially anxious
individuals to develop elevated levels of disordered eating (Linardon, Braithwaite et al. 2017). It may
be that perceived rejection based on one’s appearance and shame may therefore lead to disordered
eating in an attempt to cope.
It may be that the link between social appearance anxiety, but not social anxiety, to BMI is related
to factors including body shame (associated with weight stigma), appearance-based rejection-
sensitivity (based on anticipated and enacted weight discrimination), and fear of weight-based
discrimination and marginalisation. The findings by Hart and colleagues (Hart, Rotondi et al. 2015)
provides some support for this concept, with discrimination found to be associated with social
appearance anxiety above and beyond correlations of social appearance anxiety with anxiety and body
image dissatisfaction. Their study examined social appearance anxiety in gay and bisexual men of
Colour from Canada. Social appearance anxiety was highly correlated with anxiety and body image
dissatisfaction. Experiences of racism were uniquely associated with social appearance anxiety (Hart,
Rotondi et al. 2015). These findings also have implications for social appearance anxiety,
discrimination, and the intersectional discrimination of multi-marginalised groups, such as this cohort.
Although this study did not examine other experiences of discrimination (e.g., individuals who
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experience racism, LGBTIQ+ discrimination, weight discrimination, ableism), it may be that these
experiences heighten social appearance anxiety, and therefore, disordered eating disk for minority and
marginalised groups.
Among self-identified lesbian women (Mason and Lewis 2016), discrimination and proximal
sexual minority stress are associated with increased social anxiety. Social anxiety in turn is associated
with greater body shame, and body shame is linked to binge-eating. These results indicate that lesbian
women’s social anxiety, body satisfaction and disordered eating is impacted by oppressive social
environments created through minority stress and discrimination. Tentative evidence also suggests
that among sexual minority people, those who are bisexual may be more vulnerable to social anxiety,
potentially as a mechanism of minority and intra-minority stress (Mahon, Lombard-Vance et al.
2021). Transgender and gender-diverse youth who experience bullying and discrimination also
experience greater anxiety (Witcomb, Claes et al. 2019). Among transgender and gender non-binary
people, lower social anxiety is reported for those who have undergone gender-affirming medical
interventions in comparison to those considering it (Butler, Horenstein et al. 2019). Gender-affirming
medical interventions may result in greater conformity to societal expectations of gender binary
norms, thereby reducing anticipation or experiences of discrimination, victimisation, and
nonaffirmation of one’s gender identity (Butler, Horenstein et al. 2019), leading to decreased social
anxiety and social appearance anxiety.
Weight-based discrimination has also been shown to strongly predict social anxiety, body
dissatisfaction, and loneliness (Juvonen, Lessard et al. 2016). The relationship between weight-based
discrimination and disordered eating is also moderated by anticipated weight stigma (Hunger, Dodd et
al. 2020). Processing information about appearance stereotyping and discrimination can adversely
affect immediate body image experiences (Lavin and Cash 2001), possibly as a mechanism of self-
evaluative thought processes. For example, if an individual perceives weight bias (e.g., negative fat
talk, weight discrimination in the media) or intersecting discrimination (e.g., weight discrimination,
healthism and ableism, racism and weight discrimination, weight and LGBTIQ+ discrimination), they
may quickly infer and expect that they will be perceived or treated similarly. These inferences and
expectations may then lead to negative self-appraisals of one’s appearance (Lavin and Cash 2001).
Furthermore, discrimination is a risk factor for anxiety and negative affect even after accounting for
genetic susceptibility as a potential confound (Cuevas, Mann et al. 2021), highlighting the importance
of discrimination as a unique environmental risk factor for anxiety.
In addition to social anxiety, social appearance anxiety is a specific underlying vulnerability that
prospectively predicts eating disorder behaviour (Koskina, Van den Eynde et al. 2011, Levinson and
Rodebaugh 2016). over and above other measures of social anxiety, and is a shared risk factor for
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both disordered eating and social anxiety (Levinson and Rodebaugh 2012). Social appearance anxiety
is positively associated with social anxiety and negative body image (Claes, Hart et al. 2012), and
explains unique variability in social anxiety beyond personality, affect, depression, and negative body
image affect (Hart, Flora et al. 2008, Levinson and Rodebaugh 2011). It has been argued that for those
with high levels of emphasis, investment or overvaluation of appearance, social evaluation of
appearance leads to disordered eating (Rieger, Van Buren et al. 2010).
For individuals in marginalised groups, it may be that experiencing discrimination increases the
salience of appearance-based concerns as a means of trying to cope with and reduce the threat of
discrimination, increase social safety, and manage one’s identity in different contexts. It is likely that
social anxiety and social appearance anxiety are related to fears of discrimination, and these factors
should be considered in risk for disordered eating, particularly regarding minority stress, and
intersectional marginalisation.
Weight Bias in the Eating Disorder Diagnostic System
BMI, Biases and Weight Stigma
Terms in the literature and clinical practice that distinguish between weight categories as
‘underweight’, ‘normal weight’, ‘overweight’ and ‘obese’ (as opposed to ‘low weight’, ‘medium
weight’, ‘high weight’, ‘very high weight’) imply a weight ideal, and position bodies on a spectrum of
normative and deviant (Rodgers 2016). This language and discourse perpetuates weight bias and body
politic hierarchies in research and healthcare, such as internalisation of anti-fat attitudes, beliefs in the
controllability of weight through diet and exercise, and the need to control weight; which shapes
understanding of and research into eating disorder experiences. Furthermore, the language and
discourse of ‘healthy’ and ‘normal’ weight ranges as an ideal, and positioning of diverse body types
outside of this category fosters the beliefs of the body/weight ideal for eating disorder patients, that
may lead to or perpetuate self-objectification, self-surveillance, body preoccupation, body shame, and
disordered eating.
The formula of body mass index (BMI) was developed in the 19th Century by Adolphe Quetelet
(Quetelet 1869). Quetelet was a mathematician, astrologer, and statistician, but not a health
practitioner. He was interested in studying human characteristics in relation to crime and mortality,
and many of his beliefs with regard to crime were racially based (i.e., the debunked field of
phrenology). Quetelet wanted to determine what the ‘average [cisgender] man’ (l’homme moyen)
looked like, and his concept of this was grounded in problematic values of normal/abnormal,
superiority/inferiority, and an ideal body, which became the basis of the BMI calculation. Quetelet
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created the Quetelet Index (later re-branded as the BMI) in order to determine the ‘ideal man’. In his
book ‘A Treatise on Man and the Development of His Faculties’, Quetelet wrote: “If the average man
were completely determined, we might consider him as the type of perfection; and everything
differing from his proportions or condition, would constitute deformity and disease; everything found
dissimilar… would constitute a monstrosity” (Quetelet 1842, p. 99). In order to determine his ‘perfect,
average ideal’, Quetelet collected data primarily from white European cisgender men. Therefore the
mean of this data had a racial and ethnocentric bias. Furthermore, Quetelet had not intended for the
index to be a tool of measurement for a person’s health and wellness – it was intended for use to
categorise people in relation to population distributions. Population averages cannot be used as a
determinate of individual wellness, particularly those that have been based on a limited racial/ethnic
sample.
The Quetelet Index was adopted by health and life insurance companies in the late 20th century as a
replacement for their own height-weight tables (which were also based on statistic samples drawn
from predominantly white cisgender men and some white cisgender women). Health insurance
companies in the early 1900s began to conflate fatness with increased risk of heart disease (Strings
2019), a belief that persists, despite the greater complexity of the relationship (e.g., social determinate
factors that lead to higher weight [poverty, cortisol dysfunction due to chronic stress of weight stigma,
disordered eating]) (Kahan and Puhl 2017, Pearl, Wadden et al. 2017, McCleary-Gaddy, Miller et al.
2018, Medvedyuk, Ali et al. 2018, Vartanian, Pinkus et al. 2018). Insurance companies, however,
could then use the index to assign or refuse insurance coverage based on weight as a proxy for heart
disease risk (Strings 2019), thereby compounding social determinant risk factors and treatment gaps,
particularly for underserved and marginalised individuals. In 1972, Ancel Keys and colleagues (Keys,
Fidanza et al. 1972) conducted a study on fatness, also using a sample of predominantly white
European American men. Based on studying this sample, they determined that the Quetelet Index was
a more accurate measure of body fat than height and weight tables, and rebranded it as the Body Mass
Index. The BMI then became a widely used and standard measure utilised by health practitioners to
distinguish between weight categories that are determined by a standardised weight to height ratio.
According to the BMI categories, a person with a BMI below 18.5 is considered underweight; a
person with a BMI between 18.5 and 24.9 is considered to be within a healthy weight range; a
person with a BMI ranging from 25.0 to 29.9 is considered overweight; and a person with a BMI of
30 or higher is medicalised as obese (CDC 2011). The BMI system has a number of critical
problems, however.
Foremost in its initial development, the BMI was also developed using populations of white men,
and therefore lacked generalisability to other racial, ethnic, and gender groups, in addition to
individuals with diverse body structures, to which it is now widely applied. Quetelet had also not
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intended the BMI to assess adiposity at an individual level. The BMI has been found to have poor
sensitivity and specificity. It does not, for example, take into consideration differences in body fat and
muscle mass distribution according to sex, race/ethnicity, age, age changes, bone structure and
density, and a person’s body fat versus lean tissue content (Wellens, Roche et al. 1996, Dudeja, Misra
et al. 2001, Rothman 2008, CDC 2011). The BMI height2/weight calculation also divides the weight
by too much in short people and too little in tall people, leading to an exaggeration of thinness in short
people and fatness in tall people, resulting in inaccuracies and weight misclassification (Burton 2007,
Heo, Faith et al. 2012, Shah and Braverman 2012). The Benn parameter (kg/mB) has been proposed as
one alternative to improve the height limitation of the BMI, where B is the power that minimises the
correlation with height (Johnson, Norris et al. 2020).
BMI is used as a measure of attained unhealthiness, rather than a probabilistic indicator of risk
(that is closely related to other factors that influence health, such as social determinants i.e.,
oppression, poverty, discrimination) (Gutin 2021). Public health messaging on COVID-19 has used
BMI to conflate the perceived riskiness and unhealthiness of body weight/size with as a surrogate
for COVID-19 severity (Gutin 2021). Greater body fat and associated BMI status has been used as a
proxy for COVID-19 illness severity and susceptibility to infection (Gutin 2021). This rhetoric
equates body size with health, thereby shaping beliefs about vulnerability and personal responsibility
during the ongoing COVID-19 pandemic (Gutin 2021). Weight biased public health messaging
further perpetuates and deepens weight discrimination and fears of fat contagion, where weight is then
presumed to increase risk for COVID-19 infection (Flint 2020, Hardy 2020, Puhl, Lessard et al. 2020,
Pearl and Schulte 2021). Weight stigmatising public messaging has dangerous implications for the
development and exacerbation of disordered eating and eating disorders during a time of anxiety,
upheaval, isolation, grief and loss.
While the BMI correlates with the amount of body fat a person has on their body, it is not a direct
measure of body fat, and is an uncertain diagnostic index of higher weight status (Wellens, Roche et
al. 1996). In lower BMI tertiles, correlations between BMI and fat-free mass (FFM) have been found
to be approximately twice as large as those between BMI and percent body fat (Wellens, Roche et al.
1996). When assigning if cisgender women and men were in the “obese” BMI weight category, the
BMI was only able to correctly identify 44% of fat-bodied cisgender men, and 52% of cisgender
women, based on percentage from body fat (Wellens, Roche et al. 1996). Furthermore, studies have
found that body adiposity index (BAI) is a more accurate index of anthropometric measures for body
adiposity than the BMI for Black/African American and Hispanic/Mexican American adults
(Bergman, Stefanovski et al. 2011), although findings have been inconsistent (Barreira, Harrington et
al. 2011). Body composition in Chinese individuals has been shown to differ to those of age and sex
matched white peers, with a lower BMI and higher body fat percentage in Chinese adults compared to
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white adults (Wang, Thornton et al. 1994). In studies of Chinese populations, however, weight
circumference and BMI were suggested to be more accurate tools than BAI for estimating whole body
fat and central body fat (Lam, Lim et al. 2013, Yu, Wang et al. 2015). These findings provide further
support for the literature that the BMI differs in its sensitivity according to morphology based on
race/ethnicity.
Everyday racial discrimination has been shown to increase risk for cardiovascular disease (Beatty
Moody, Matthews et al. 2014), lead to decreased metabolic function and increased weight
circumference (Beatty Moody, Chang et al. 2018), and greater weight status and BMI (Gee, Ro et al.
2008). Greater weight status is often correlated or conflated with cardiovascular disease and the
metabolic disease, however these research findings indicate that the chronic harms and stress of
discrimination may be significant factors in these relationships.
In addition, BMI percentiles based on female and male sexes further complicate the diagnoses of
eating disorders for intersex, transgender and non-binary youth, as choosing appropriate growth charts
is challenging and based on a binary system. Growth chart and BMI data measures are needed for
intersex, transgender and non-binary youth, however no current guidelines are known on how to
collect and report these data. It has been suggested that researchers and clinicians consider using both
female and male growth charts for these populations (Kidd, Sequeira et al. 2019). It’s important to
consider how best to approach growth charts for that provides gender-affirming, optimal medical care
to support to the safety and wellbeing of intersex, transgender and non-binary youth.
Multiple methods have been developed to estimate body fat percentage (Bfat%), such as dual-
energy X-ray absorption (DXA) scans, and underwater weighing, which are generally regarded as
gold-standard methods (Plank 2005). These methods however, are expensive, complex, time-
consuming, and may be too impractical to be routinely conducted in clinical settings or population
studies. Alternative methods such as skin-fold thickness and impedance analysis are also not widely
used in research or clinical practice due to inaccuracy in evaluating Bfat% (Goran, Driscoll et al.
1996, Piers, Soares et al. 2000), making BMI the most commonly used measure. Waist circumference
(WC) is also a commonly accepted index used as a measure of central adiposity (McCarthy 2006),
however there is no standard way to do waist measurements, and they can therefore be prone to error.
Waist circumference (WC) and waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), new BMI,
Body Adiposity Index (BAI), Clinica Universidad de Navarra-Body Adiposity Estimator (CUN-
BAE), and A Body Shape Index (ABSI) are other proxy indices of adiposity (Amirabdollahian and
Haghighatdoost 2018), however are not as commonly used in eating disorder research as BMI. These
measures also have sensitivity and specificity limitations, such as different cut-off points according to
sex, and variation in weight category thresholds between ethnic groups (Amirabdollahian and
Haghighatdoost 2018).
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The index conceptualisation of an ‘ideal’ in and of itself is problematic, and is aligned with
harmful ideology that may endorse and maintain body politic hierarchies, diet culture, and eating
disorder cognitions. The continued use of the BMI in the diagnostic system for eating disorders,
therefore, serves to reinforce eating disorder risk. Furthermore, BMI is used in both research and
clinical settings as an indicator of eating disorder diagnosis and clinical severity, in addition to being a
clinical tool for patient triage. This is critically important when considering the limited beds and
resources available to patients, the barriers eating disorder patients face to accessing care (i.e., weight
discrimination, minority stressors, intersectional marginalisations), and the inaccuracies inherent in
the BMI system.
The BMI is a limited proxy for adiposity, however has and continues to be used as a means of
classifying weight statuses or ‘classes’ into presumed health/disease, diagnosing eating disorders and
eating disorder subtypes. BMI is also often used as one measure of determining eating disorder
severity, need for referral to eating disorder treatment, and prioritising individuals with eating disorder
diagnoses to limited treatment spaces through BMI-based triage. This system has been argued as
being grounded in weight stigma and sizeism. More accurate alternatives to determine the level of risk
associated with body weight in eating disorders have been suggested for use, such as calculating the
severity of weight suppression through weight discrepancy calculations and use of growth charts, and
asking an individual about their history of weight cycling, in addition to evaluating the level of
chronicity of disordered eating. However, BMI remains the dominant criterion for differentiating
between eating disorder diagnoses by weight, and a significant criterion in treatment referrals. It has
been suggested that rather than eliminating the use of BMI altogether, that its continued use in
research, clinical practice, and treatment should be in keeping with a weight-neutral approach that
BMI is ‘just a number’ rather than a characteristic of disease, measure of attained ‘unhealthiness’, or a
probabilistic indicator of risk (Gutin 2021).
Weight Stigma and Eating Disorder Subtypes
Higher Weight/ ‘Atypical’ Anorexia Nervosa
Weight stigma has been argued to be ingrained in the eating disorder diagnostic system, in its use
in discriminating between eating disorder subtypes, and the historical use the BMI in distinguishing
between diagnoses and determining clinical severity and medical risk. The diagnosis of ‘atypical’
anorexia nervosa is a subtype of Other Specified Feeding and Eating Disorders (OSFED), in which all
symptoms for AN are met with the exception of a low body mass index ([APA]; 2013, p. 353). For
the criteria of AN to be met, it was formerly included that an individual must have a BMI under 18.5.
Criteria now include the presence of significant weight loss([APA]; 2013). ‘Atypical’ AN therefore,
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is defined by the symptoms of anorexia nervosa in the presence of significant weight loss in
individuals who are not at a low body weight. Significant problems with this diagnosis exist,
including the fact that “significant weight loss” has not been defined, and the distinction is not made
between having ‘atypical’ anorexia versus having weight suppression. Forney and colleagues (Forney,
Brown et al. 2017) aimed to define “significant weight loss” in ‘atypical’ anorexia. It was determined
that even a 5% weight loss combined with cognitive concerns may produce a group with a clinically
significant eating disorder. ‘Atypical’ anorexia was observed in adults with weight categories of
medium weight (medicalized as ‘healthy weight’), higher weight (medicalized as ‘overweight’), and
much higher weight (medicalized as obesity), highlighting that restrictive eating, of course, occurs
irrespective to weight category and eating disorders should be screened at all weights (Forney, Brown
et al. 2017).
Atypical AN is highly prevalent, with reports of 2.8% lifetime prevalence compared to 0.8%
prevalence of low weight anorexia (Stice, Marti et al. 2013, Whitelaw, Gilbertson et al. 2014). In a
systematic review of the prevalence and consecutive admission literature of higher weight ‘atypical’
AN (Harrop, Mensinger et al. 2021), in epidemiological designs, higher weight ‘atypical’ AN was
typically as common or more common than low weight AN, and rates varied significantly based on
the population studied and operational definitions (e.g., OSFED, ‘subthreshold’ AN). Higher weight
‘atypical’ AN was frequently less represented in consecutive clinical samples, which likely
represented the weight bias in treatment referrals, under-diagnosis, and additional treatment barriers
for this population (Harrop, Mensinger et al. 2021).
Research has shown that compared to other eating disorder diagnoses, ‘atypical’ AN is associated
with equal or higher medical impairment and mortality rates (Sawyer, Whitelaw et al. 2016). With
regard to co-occurring psychiatric diagnoses, research has found little clear distinctions between low-
weight anorexia and ‘atypical’ or higher weight AN (Sawyer, Whitelaw et al. 2016). The literature
suggests that more similarities than differences are shared between low weight AN and ‘atypical’
higher weight AN, including eating disorder cognitions and restriction behaviours, medical
complications, and rates of co-occurring psychiatric diagnoses and suicidal ideation (Whitelaw,
Gilbertson et al. 2014, Sawyer, Whitelaw et al. 2016, Coniglio, Becker et al. 2017, Moskowitz and
Weiselberg 2017). The only characteristic that differentiates the diagnoses may actually be the
starting weight (middle or lower vs higher weights) prior to the eating disorder development, or the
body’s resilience to weight loss in the state of caloric deprivation and starvation (Sawyer, Whitelaw et
al. 2016). Compared with low-weight AN, adolescents with higher-weight anorexia and an ‘atypical’
AN diagnosis have been found to have been at a much higher weight prior to illness (71% vs 12%)
(Sawyer, Whitelaw et al. 2016). Sawyer and colleagues (Sawyer, Whitelaw et al. 2016) found
adolescents with atypical anorexia to have lost more weight (17.6 kg vs 11.0 kg) over a longer time
period (13.3 vs 10.2 months), indicating more severe weight suppression. Adolescents with higher-
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weight AN and an ‘atypical AN’ diagnosis, however, showed more severe eating and body image-
related distress (Sawyer, Whitelaw et al. 2016). In addition to experiencing body image dissatisfaction
and disturbances like those with low weight AN, by having larger bodies, individuals with ‘atypical’
higher weight AN are also more likely to experience weight stigma (Harrop 2020). A systematic
review of 42 articles comparing the weight history and medical complications of low and ‘atypical’
higher weight AN (Harrop 2020) revealed that ‘atypical’ AN patients experienced commensurate
rates of life-threatening medical complications (electrolyte imbalance, bradycardia, orthostasis,
hypothermia) to low weight AN patients, despite having higher body weights. ‘Atypical’ AN patients
however, experienced lower rates of bone density loss and amenorrhea in comparison to low weight
AN patients (Harrop 2020).
The accessibility and experiences of individuals according to these diagnoses varies significantly,
however. ‘Atypical’ AN patients were reported a treatment delay of 11.6 years from the time patients
believed they had an ED until receiving treatment, with lower minimum BMI associated with less
delay in receiving treatment, and higher maximum BMI associated with lower levels of care received
(Harrop 2020), indicating a significant effect of weight bias on treatment accessibility. For those at
higher weights and a diagnosis of ‘atypical’ AN, psychological and medical risk may be exacerbated
by receiving prescribed weight loss by treatment providers who perpetuate weight stigma,
underrecognition and failure to recognize AN in higher weight patients, delayed access to treatment
and denial of treatment based on BMI status, and longer periods of living with undiagnosed, untreated
EDs, and healthcare providers triggering and re-triggering disordered eating (Dios 2019, Harrop 2019,
Harrop 2020).
Collectively, these findings support literature that individuals with AN at a higher body weight
experience equal emotional and medical risk to those with low weight AN, and may in fact experience
more distress related to food and eating, possibly reflective of more severe weight bias internalisation
or drive for thinness, in addition to greater delays in treatment access, and barriers to treatment (e.g.,
provider weight bias and failure to recognise the presence of AN). Diagnostic criteria that
differentiates ‘atypical’ higher weight AN from low weight AN based on weight status therefore may
perpetuate weight stigma, reinforce eating disorder cognitions, lead to diagnostic overshadowing,
misunderstanding, and perceived justification for providers prescribing weight loss in the presence of
ED cognitions and behaviours that further perpetuate the eating disorder and associated health risks
(Dios 2019, Harrop 2019, Harrop 2020, Harrop, Mensinger et al. 2021). Furthermore, the weight-
based differentiation between low weight AN and higher weight ‘atypical’ AN may create barriers to
help-seeking, and treatment inaccessibility to treatment based on BMI cut-offs and bed shortages
(Harrop 2019, Harrop 2020, Harrop, Mensinger et al. 2021). Based on BMI alone, an individual with
an ED at a lower body weight may be presumed to be at a higher medical and emotional care need,
and triaged earlier than an individual at a higher body weight, leading to significant treatment delays
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as an individual with a higher body weight may remain on a weight list for a prolonged period of time
despite severe medical and emotional need. Weight bias is therefore a critical concern for the
differences in recognition and treatment accessibility for individuals with AN at a higher body weight.
Further research is needed in diverse populations, and consensus in needed on diagnostic terms
(Harrop, Mensinger et al. 2021).
Anorexia Nervosa Binge-Purge Subtype
The differentiation between anorexia nervosa binge-purge subtype (AN-B/P) and bulimia nervosa
(BN) based largely on weight criteria is also argued to represent weight bias. The characteristics of
individuals with AN and BN are argued to differ at numerous levels, including genetics, brain-based
characteristics, temperament, gut microbiome composition, cognition, emotional regulation, and
emotional eating (Hübel, Abdulkadir et al. 2021, Reichenberger, Schnepper et al. 2021). Many of
these studies, however, have not differentiated AN groups into AN-R and AN-B/P subtypes, and/or
have not included ‘atypical’ AN (e.g., Hübel, Abdulkadir et al. 2021) which may limit findings.
Diagnostic crossover between anorexia nervosa restrictive subtype (AN-R) to binge-purge subtype
(AN-B/P) however, is common, as is diagnostic crossover from AN to BN (Fichter and Quadflieg
2007, Eddy, Dorer et al. 2008), and diagnostic crossover from BED to BN (Fichter and Quadflieg
2007). Research has also grouped eating disorders according to behaviourally-based criterion (e.g.,
restrictive and binge/purge eating disorders), rather than weight-based criteria (Mond, Hay et al. 2006,
Leclerc, Turrini et al. 2013, Wu, Hartmann et al. 2014, Simon, Skunde et al. 2016, Kim, von Ranson
et al. 2018, Weinbach, Sher et al. 2018, Low, Ho et al. 2021), which if applied in clinical contexts,
may be a method that could reduce weight stigma harms faced by patients in larger bodies.
Importantly, internalised weight stigma and the weight bias associated with ED diagnoses is
evident in how individuals may feel shame when experiencing diagnostic crossover (Mortimer 2019).
Different EDs may be perceived as existing on a ‘hierarchy’ associated with moral standards,
judgements of character traits, and beliefs about how these morals, values, and traits may be read on
the body, consistent with weight stigma in broader society (Arroyo and Andersen 2017). For some, a
diagnosis of AN may be associated with traits such as determination, higher moral standards,
diligence, and control (Mortimer 2019). Other ED diagnoses (i.e. BN, BED) may associated with
‘failure’ in ‘resisting’ food and ‘achieving’ weight loss, which may then be linked negatively with
value and moral judgements, chaos, impulsivity and greed (Mortimer 2019). Movement from one ED
to another (e.g., AN-b/p to BN; by increase in weight; AN-R to BN; AN to BED; BN to BED) may be
experienced as an “identity crisis” and a self-perceived shameful moral failing (Mortimer 2019). Due
to changes in their diagnosis and weight status, an individual may fears that others with believe they
are lazy, greedy, or have lower moral standards that may be ‘read’ in their higher weight body
(Mortimer 2019).
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Avoidant Restrictive Food Intake Disorder
Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder subtype characterised by
selective eating that may involve restriction to very narrow groups of foods, sensory-based eating, and
widespread food aversion (Zickgraf, Lane-Loney et al. 2019). ARFID frequently co-occurs with other
conditions, such as autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD)
(Kambanis, Kuhnle et al. 2020), social and attention difficulties, and learning and cognitive
differences (Nicely, Lane-Loney et al. 2014). Restrictive eating among those with ARFID is
reportedly not driven by weight or shape concerns (Zimmerman and Fisher 2017), and includes four
major subtypes. The four major ARFID subtypes include: 1) low appetite and lack of interest type; 2)
sensory sensitive eating type; 3) fear of aversive consequences eating type; and 4) co-primary poor
appetite and selective eating (‘co-primary’) (Zickgraf, Lane-Loney et al. 2019). These subtypes may
also interconnect (Reilly, Brown et al. 2019).
The fear of aversive consequences subtype of ARFID can involve fear and avoidance of ‘bad’ food
and fear of ‘disease’. The fear of aversive consequences subtype is particularly linked to co-occurring
anxiety, obsessive-compulsive conditions, and trauma (Kambanis, Kuhnle et al. 2020). When
considering how diet culture and the food industry pathologies foods within and related to its
pathologisation of fat bodies, it must be questioned whether or not ARFID is truly divested from
weight bias. In addition, given the social difficulties that commonly co-occur for individuals with
ARFID (Nicely, Lane-Loney et al. 2014), fear of weight-based marginalisation may also be present as
a motivation for upholding a ‘healthy’ eating pattern in order to conform to social values that conflate
‘healthy’ eating practices with personal morals and maintaining a lower weight in order avoidance of
disease (pathologisation of fat bodies) (Henderson, Ward et al. 2009, Pausé, Lupton et al. 2021).
As an individual with personal experience of ARFID, have understood my own ARFID eating
patterns as being grounded in sensory-based eating and avoidance of sensations, textures, and pursuit
of food characteristics other than taste, such as wanting to categorise and sort food in line with my
autistic behaviour. However, internalised messages of ‘bad’ foods and health and ‘disease’ are evident
in my personal experience of fear of aversive consequences of food, as well as the food choices, and
anticipated sensations of eating within my personal experience of ARFID eating patterns.
It’s important that when considering the fear and avoidance of ‘bad’ foods in ARFID, it is
acknowledged that individuals with ARFID still exist within social structures. They are still receiving
messages of what makes a food ‘bad’, ‘good’, ‘healthy’, ‘unhealthy’ or ‘dangerous’ for their body
within social, cultural, family, body politics, and other socio-political and cultural environmental
messages (e.g., diet culture and social media messaging). The anxiety of and obsessions in ARFID
relates closely to how an individual anticipates eating and experiences interoception. These factors
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may be less strongly connected to a pursuit of weight loss in comparison to other eating disorders,
however diet culture messages, weight bias and healthist beliefs which foods are ‘bad’ and lead to
disease risks may still play a role in ARFID food choices and eating behaviour.
Orthorexia Nervosa
The term Orthorexia Nervosa (ON) was first coined by Bratman and Knight in the late 1990s
(Bratman 1997, Bratman 2017), and is defined as an obsession with healthy, pure and virtuous
eating choices, or the thought that eating certain foods will have harmful effects. ON is not currently
recognized as an eating disorder in the DSM-5, and research suggests that ON may be a facet of
eating disorders, a phenotype, an emerging other specified eating disorder associated with changing
socio-cultural-political climate, or a cultural pathology (e.g., internalised healthism) (Segura-Garcia,
Ramacciotti et al. 2015, Hanganu-Bresch 2020, Meule and Voderholzer 2021, White, Berry et al.
2021). The dietary restriction and health-driven aspects of ON has been argued to be distinct from
ARFID (Dunn and Bratman 2016, Zickgraf, Ellis et al. 2019), although more research is needed. It
has also been suggested that ON by proxy may occur as another subset of ON (Cuzzolaro and Donini
2016), or perhaps related to factitious disorder imposed on another/Munchausen by proxy abuse
(Túry, Szalai et al. 2020, Bursch, Emerson et al. 2021).
ON involves concern about the quality of the food and its associated heath its source, processing,
and packaging (Brytek-Matera, Rogoza et al. 2015, Bratman 2017). Food choices are rigid, restricted,
and can lead to malnutrition (Brytek-Matera, Rogoza et al. 2015, Bratman 2017). Violation of these
restrictions leads to anxiety and distress over fear of disease and other negative impacts to health
(Brytek-Matera, Rogoza et al. 2015, Bratman 2017). Dietary restrictions also increase over time
(Bratman 2017). Body image concerns and self-worth are dependent on meeting “healthy” eating
pattern, and this significantly impacts quality of life and functioning (Bratman 2017). ON is typically
described as an eating disorder (or eating disorder subset) without a drive for weight loss or over-
valuation of weight and shape, where health is the primary concern (Bratman 2017). Due to the
recency of its conceptualization and the scarcity of literature, however, significant gaps exist in
understanding the mechanisms of ON, and its underlying causes and drivers remain unclear (Varga,
Dukay-Szabó et al. 2013). More research is needed to re-evaluate current measurement tools,
establish a consensus for the conceptualization of ON, and establish a measure with strong
psychometric properties (Meule, Holzapfel et al. 2020, Opitz, Newman et al. 2020). Research has
indicated that ON is associated with both disturbances in eating and elevated weight and shape
concerns (Tremelling, Sandon et al. 2017). Furthermore, for individuals who have self-diagnosed ON,
a majority identified weight loss as a motivator during for ON eating behaviour, but indicated that
their rationale was to lose weight for health rather than appearance-related factors (Valente, Brenner
et al. 2020).
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Individuals may also perceive ON as a ‘salvation’ from chronic diseases (Valente, Brenner et al.
2020). This may indicate that individuals with ON may be particularly high on internalisation of
weight bias in relation to healthism. During semi-quarantine, increased exposure to social media
recommendations to adhere to ‘healthy eating’ in order to lower risk of COVID-19 infection is linked
to greater anxiety, use of nutritional supplements, and greater problems with orthorexia nervosa
(Devrim-Lanpir, Güzeldere et al. 2021). This indicates internalisation of health anxiety, healthist
public messaging and changes in eating and health behaviour according to media influence
surrounding COVID-19.
Critically, current constructs of ON may need to be altered, as studies have suggested that the
overvaluation of weight and shape in ON may in fact involve the pursuit of weight loss, like the
majority of other eating disorder subtypes. ON tendencies and behaviours have also been significantly
correlated with starving to lose weight (Haddad, Obeid et al. 2019), and ON has been associated with
selecting food for weight control over health reasons (Bartel, Sherry et al. 2020). These findings
indicate that weight loss is a main priority in ON. It may be that ON involves a spectrum of
internalised weight stigma, healthism, and associated health-oriented behaviours and drive for weight
loss (Hanganu-Bresch 2020). It may be that a spectrum of weight stigma and healthism internalization
and associated drive for weight loss and health-oriented behaviours occurs in ON. Similar to fat-
phobic AN (FP-AN) and nonfat-phobic AN (NFP-AN), some individuals with ON may report no
drive for weight loss as a motivation in their eating and exercise behaviour, low drive for weight loss,
and/or minimise these concerns. It may also be that pursuit of weight loss and weight stigma
contradicts with the values held by individuals with ON, such as pursuit of health and wellness,
leading to a denial of or minimisation of dieting to pursue weight loss.
A cross-sectional study of correlates of ON among a representative sample of the Lebanese
population, however (Haddad, Obeid et al. 2019) found that higher levels of ON tendencies and
behaviours were associated with identifying as a cisgender woman, and critically, starving to lose
weight. ON tendencies and behaviours were also associated with convincing others to follow a diet,
thinking that eating out is unhealthy, and increased scores on the eating attitudes test (EAT) (Haddad,
Obeid et al. 2019). A more recent study found that ON is more closely related to eating disorders than
to obsessive compulsivity (Bartel, Sherry et al. 2020), providing further support that eating concerns
may be a central factor in ON. A study of ON and other features of disordered eating in cisgender
men (White, Berry et al. 2020) found that higher levels of ON behaviours were positively associated
with eating disorder behaviours, and with muscularity-oriented attitudes (i.e., thin and athletic
internalisation) and muscularity-related behaviours (i.e., drive for muscularity, harmful exercise
behaviour) (White, Berry et al. 2020). These results extend the current understanding of tendencies of
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ON and their association with disordered eating and body ideals. It may be that these men have
internalised health narratives that conflate between health with weight, and muscular appearance
within the hegemonic masculine body ideal, which they then express through health-related concerns
and this particular form of disordered eating.
Body politics involving healthism and ableism, sizeism, classism (e.g., food sovereignty, poverty,
and food insecurity), and what constitutes a ‘healthy’ and ‘able’ body, which is then ascribed value or
de-valued. The ON disordered eating pattern of concern with virtue echoes fasting for virtue and
purity, as detailed by early literature on eating disorders, and historical literature that looks at
disordered eating in different socio-political and time contexts such as the holy anorectics and
fasting Saints (Bell 2014). While research on ON is still emerging, it is this author’s suggestion that
ON is not truly divested from weight stigma through the pursuit of ‘health and wellness’. The health
and wellness industry is grounded in weight stigma and the pathology of fat bodies. Individuals with
ON may be deeply invested in messages of health and wellness within the greater context of diet
culture, and the internalisation of healthism, weight stigma, ableism, sizeism, and the stratification of
the moralized body within body politics. The devaluation and pathologisation of fat bodies and the
‘sick’ body, therefore, is important to consider in relation to ON.
Cultural differences are also an important factor in the conceptualisation of ON as an eating
disorder. For example, in older Chinese people (He, Zhao et al. 2021) higher scores of ON were
positively associated with greater physical activity, fruit and vegetable consumption, greater body
appreciation, body functionality appreciation, and life satisfaction, but negatively related to body
dissatisfaction. Therefore, for older Chinese people, the characterization of ON as a disordered eating
variant may not be culturally or generationally appropriate (He, Zhao et al. 2021). These findings do
not support ON as an eating disorder, at least in this population. Selection bias in participant
recruitment is suggested to have played a part in these findings (Hay 2021), however this study has
interesting implications for the diagnosis of ON more broadly, particularly with regard to cultural
sensitivity.
Redescription of the way people see, think and behave (such as eating and health behaviours) can
become new ways of knowing, transforming, legitimizing, normalizing, and shaping interpretation
of experiences, which has implications for ON as a diagnosis (Ross Arguedas 2020), including the
fact that ON is regarded as an eating disorder without fear of fat/weight gain. It’s important to
consider how weight stigma and news media narratives of eating disorders contribute to an
individual’s self-concept about disordered eating and different eating disorder subtypes (Ross
Arguedas 2020), such as internalised stigma and shame, and how these narratives may relate to
development of the ‘eating disorder self’. In addition to how weight stigma and diet culture may
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impact the development of disordered eating in ON and other specified feeding and eating disorders
and eating disorders more broadly.
Eating Disorders Without Fear of Fat/Weight Gain
Individuals with AN who do not report fear gaining weight or becoming fat have been reported in
both non-western and western populations, and have been identified as subgroup of AN, known as
non-fat phobic AN (NFP-AN) (Dalle Grave, Calugi et al. 2008, Becker, Thomas et al. 2009, Lee, Ng
et al. 2012, Wildes, Forbush et al. 2013). Changes to the AN diagnostic criterion within the fifth
edition of the DSM ([APA]; 2013) led to the removal of fear of fat/weight gain as a prerequisite for
AN diagnosis. AN without fear of fat/weight gain, therefore, can be classified as a variant of AN.
Individuals with NFP-AN may exhibit lower ED cognitions and behaviours (Forbush and Wildes
2017, Murray, Coniglio et al. 2017), and different rationales for food restriction, which may be an
explanation for denying or reporting minimal fear of fat/weight gain and shape/weight concerns
(Becker, Thomas et al. 2009, Lee, Ng et al. 2012, Murray, Coniglio et al. 2017, Izquierdo, Plessow et
al. 2019). They may also, however, demonstrate lower insight into their condition, lower remission,
and higher treatment drop-outs (Crow, Swanson et al. 2008, Santonastaso, Bosello et al. 2009, Carter
and Bewell‐Weiss 2011). Attitudes toward dieting has been reported to differ among adolescents with
ARFID in comparison to those with fat-phobic AN (FP-AN) and NFP-AN (Izquierdo, Plessow et al.
2019). Individuals with FP-AN and NFP-AN demonstrated a stronger association between pro-dieting
and true statements on implicit association tests, in comparison to those with ARFID and control
participants, who demonstrated a stronger association between pro-dieting and false statements
(Izquierdo, Plessow et al. 2019). All groups demonstrated a negative implicit association with
underweight models, however control participants demonstrated a significantly stronger negative
association than individuals with FP-AN and NFP-AN (Izquierdo, Plessow et al. 2019). Individuals
with NFP-AN exhibited a mixed pattern in which some of their implicit associations were consistent
with their explicit endorsements, whereas others were not, which may indicate a minimising response
style on explicit measures. In contrast, individuals with ARFID showed implicit associations
consistent with explicit endorsements (Izquierdo, Plessow et al. 2019). This study, however, did not
distinguish between the subtypes of ARFID (low appetite and lack of interest type; sensory sensitive
eating type; fear of aversive consequences eating type; co-primary poor appetite and selective eating).
For example, the ARFID sample may have included individuals who were all or mostly of the sensory
sensitive eating subtype, and/or low appetite and lack of interest subtype. It’s important that research
examine differences in internalised weight stigma and fear of weight-based marginalisation for
ARFID subtypes in comparison to FP-AN and NFP-AN.
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It is possible that the ARFID fear of aversive consequences subtype may have differences in
internalised weight stigma, and that the fear of aversive consequences of eating may also include
internalised ‘good/bad’ food dichotomy messages that are related to weight stigmatising messages, in
addition to fear of the aversive consequences of weight gain such as weight-based marginalisation.
It’s also possible that the mixed pattern exhibited by the NFP-AN participants indicates attempts to
suppress or un-learn internalised weight stigma, or that weight stigma values are inconsistent with the
values held by the individual. Further research may be needed into the values endorsed by individuals
with NFP-AN, including conflicts between eating disorder behaviour, shame, and fears of weight-
based marginalisation. It may be that individuals with NFP-AN believe they should not fear weight
gain in and of itself, but continue to fear the harms and outcomes associated with weight stigma and
fatphobia. Individuals with NFP-AN may therefore report that they do not experience a fear of weight
gain and fat phobia, but may still exhibit implicit associations with internalised weight bias. These
individuals may experience shame for eating disorder behaviour that is driven by internalised weight
stigma inconsistent with their values.
Similarly to the study by Izquierdo and colleagues, a study was conducted comparing fear of
fat/weight in in FP-AN, NFP-AN, and control participants (Korn, Vocks et al. 2020). All individuals
with AN were found to show a marked preference for weight maintenance as opposed to weight gain,
suggesting that individuals with NFP-AN may also experience some degree of fear of fat/weight gain
whether subconscious, or conscious, despite denial or minimisation of it (Korn, Vocks et al. 2020). It
may also be, however, that other aspects of weight gain are feared, such as weight-based
marginalisation or the anticipated somatic experience of weight gain itself, which may be in-line with
other reported motivations for food restriction (i.e. food aversion, sensory aspects) (Lee, Lee et al.
2001). Diagnostic criteria for avoidant/restrictive food intake disorder (ARFID) specifically exclude
fear of weight gain. Difficulty differentiating between ARFID and NFP-AN and other ED diagnostic
categories has been reported, based on the fact that an individual may not endorse fear of fat/weight
gain and weight/shape concerns, and endorsements may not necessarily match internal beliefs (Norris,
Santos et al. 2020). Difficulty differentiating between diagnostic categories (i.e., ARFID or NFP-AN)
has been reported as a consequence of these related and transdiagnostic constructs, in addition to high
diagnostic cross-over (Norris, Santos et al. 2020). These issues have let to eating disorder patients
being initially diagnosed with ARFID, and subsequently re-diagnosed as meeting AN criteria with a
non-fat phobic profile (Norris, Santos et al. 2020). Re-diagnosed eating disorder patients presented
with restriction, denied fear of weight gain, and endorsed nutrition and feeding-focused worries
related to health (e.g. food harm, poisoning) as opposed to weight and shape concerns/fears (Norris,
Santos et al. 2020), highlighting the complexity of these characteristics. Measuring fear of fat/weight
gain in AN through implicit association tests (Borgers, Krüger et al. 2021) has been used to argue that
fear of fat/weight gain in AN is a continuous construct, which is suggested to be a potential alternative
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measure to overcome the limitations of self-report. Fear of fat/weight gain and drive for thinness,
however, may be related, but distinct constructs (Rodgers, Fischer et al. 2021). Increased attentional
bias in eye-tracking fat bodies may also be an alternative measure of fat phobia and fear of fat/weight
gain in AN (Hartmann, Borgers et al. 2020).
Weight Stigma, Food Insecurity, COVID-19, and Disordered Eating
Food Insecurity, Race, COVID-19 and Disordered Eating
Within weight stigma and the fear of fat, it is critically important to acknowledge and address
disparities in individuals who occupy multiple marginalised identities. These combined identity and
statuses may be impacted by weight stigma, eating disorder risk, diagnosis, treatment access, and
research (Burke, Schaefer et al. 2020, Burke, Hazzard et al. 2021). This includes considering the ways
that these identities and statuses may be dimensional and fluid, and how intersectional marginalisation
may compound risks and vulnerabilities to disordered eating, such as poverty.
An important aspect of intersectional marginalisation in eating disorders includes food insecurity,
food sovereignty, poverty, marginalisation, and food deserts or ‘food apartheid’ (a term coined by
Karen Washington, a Black food justice activist) (Brones 2018, Reese 2019), with Black households
having a significantly higher probability of food insecurity across the majority of main sources of
household income in comparison to other racial/ethnic groups in Canada and the U.S. (Coleman-
Jensen, Rabbitt et al. 2018, Dhunna and Tarasuk 2021). Furthermore, a one-unit increase in the
frequency of lifetime anti-Black racism has been demonstrated to increase the odds of very low food
security at an increase of 5% (Burke, Jones et al. 2018). Increased odds of very low food security
were linked with more reports of discrimination that was devaluing or stigmatising, took place at a
workplace or school, or was threatening or aggressive (Burke, Jones et al. 2018). Anti-Black racism
and uneven capitalist urban development in the U.S. created conditions of food apartheid and inter-
generational food insecurity, which in turn, leads to cycles of ongoing poverty, job insecurity,
homelessness, and health disparities (Reese 2019), including disordered eating. Black residents in the
U.S. created their own geographies and investment in community in order to survive and provide
food, creating critical food culture and connectedness (Reese 2019).
When considering food insecurity in the current socio-political climate, therefore, such as the
impacts of food insecurity during the COVID 19 pandemic on disordered eating, it’s important to
consider the social, cultural, and historical impacts of food insecurity, its effects on different
populations, and its historical socio-political intersections such as racism (Williams and Cooper
2020). Political ideologies and political climate dominate and influence perceptions of viral risk,
contagion, and aid responses to vulnerable groups (Williams and Cooper 2020, Hardy, Rieger et al.
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2021). During a global crisis such as the COVID 19 pandemic therefore, food insecurity and
disordered eating risk may impact individuals differently according to race/ethnicity, such as through
structural inequality, oppression, racism, and trauma effects.
Food insecurity increases risk for negative body image, internalised weight stigma, disordered
eating and eating disorders (Becker, Middlemass et al. 2017, Lydecker and Grilo 2019, Rasmusson,
Lydecker et al. 2019, Hazzard, Loth et al. 2020, Paslakis, Dimitropoulos et al. 2020, Barry, Sonneville
et al. 2021, Becker, Middlemas et al. 2021, Shankar-Krishnan, Fornieles Deu et al. 2021), and suicide
(Davison, Marshall-Fabien et al. 2015, Koyanagi, Stubbs et al. 2019, Men, Elgar et al. 2021).
Individuals who face social marginalisations, discrimination, and oppressions (such as racism,
poverty) are at increased risk of food insecurity, and may therefore be at increased vulnerability for
eating disorder development and exacerbation (Burke, Jones et al. 2018, Hazzard, Loth et al. 2020,
Hernandez 2021). Furthermore, in a low-income marginalised population, higher traumatic event
exposure (directly experiencing or witnessing) was found to positively increase the likelihood for food
insecurity, worsened disordered eating, weight stigma, and anxiety (Becker, Middlemass et al. 2018).
These findings have implications for trauma during the COVID-19 pandemic, in addition to
implications for specific risk factors for marginalised and minority groups who may face compounded
risk during the pandemic (i.e., multiple traumas, intergenerational traumas, minority stress, structural
oppressions).
Greater severity of food insecurity is also correlated with higher weight status (i.e., through
social/political structural oppressions that disadvantage certain groups socially, economically, and in
healthcare, disordered eating, and limited access to nutrition) (Barletta-Sherwin and Stone 2018,
Pourmotabbed, Moosavian et al. 2020). Research on the effect of the COVID-19 pandemic on food
insecurity, weight stigma, disordered eating and eating disorders among different populations is
needed, however it is likely that marginalised populations experienced a greater impact for these
issues, through widening health and economic disparities, compounded structural oppressions, and
increased minority stress factors in the political climate (Lachance, Sean Martin et al. 2014, Brooke,
Peitzmeier et al. 2020, Hardy 2020, Paslakis, Dimitropoulos et al. 2020, Wang, Gee et al. 2020,
Williams and Cooper 2020, Tabler, Schmitz et al. 2021).
COVID-19, Weight Stigma, and Disordered Eating
Weight stigma, public discourse and health messaging, and food insecurity is particularly relevant
in the context of the COVID-19 pandemic. During the COVID-19 pandemic, quarantine and physical
social distancing have led to increased social isolation, increasing the vulnerability and isolation of
marginalised individuals. This may be further compounded by increased racism and xenophobia
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during the COVID-19 pandemic (Wang, Gee et al. 2020, Abraham, Williams et al. 2021), thereby
increasing the harmful impact of minority stress, discrimination, marginalisation, and health
disparities. During the stress, anxiety, fear, uncertainty, and grief of the COVID-19 pandemic, weight
stigma and diet culture have had significant impacts on body image and disordered eating (Phillipou,
Meyer et al. 2020, Termorshuizen, Watson et al. 2020, Buckley, Hall et al. 2021, Czepczor-Bernat,
Swami et al. 2021, Robertson, Duffy et al. 2021). COVID-19-related stress is significantly linked to
greater body image disturbance, mediated by self-compassion (Swami, Todd et al. 2021). By contrast,
self-compassion did not significantly moderate the effects of stress on body image disturbance
(Swami, Todd et al. 2021), suggesting that greater self-compassion may have a protective role for
body image problems during the COVID-19 pandemic, but to a limited extent. Quarantine and
physical social distancing led to virtual interactions largely replacing face-to-face interaction for
significant proportions of time, and socialisations through virtual self-body image (such as through
social media and videocalls) may have changed responses to social pressure and body-ideal
internalisation (Pearl 2020, Rodgers, Lombardo et al. 2020, Pearl and Schulte 2021, Speranza,
Abrevaya et al. 2021).
Internalised weight stigma may also have increased through the impacts of quarantine and physical
social distancing leading to limited social support, changes in routine, and greater exposure to and
impact from weight stigmatising messages in media. Public health messaging that greater body fat
increases vulnerability to COVID-19 infection may have led to increases in internalised weight stigma
and fostered heightened health concerns and fears of contagion, leading to disordered eating as an
attempt to reduce risk for infection, cope with health anxiety, and as a response to internalised weight
stigma (Flint 2020, Pearl 2020, Puhl, Lessard et al. 2020, Rodgers, Lombardo et al. 2020, Scharmer,
Martinez et al. 2020, Devrim-Lanpir, Güzeldere et al. 2021, Pearl and Schulte 2021).
During semi-quarantine, increased exposure to social media recommendations to adhere to
‘healthy eating’ in order to lower risk of COVID-19 infection is linked to greater anxiety, use of
nutritional supplements, and greater problems with orthorexia nervosa (Devrim-Lanpir, Güzeldere et
al. 2021). This indicates internalisation of health anxiety and changes in eating and health behaviour
according to media influence surrounding COVID-19. During COVID-19 lockdown, individuals were
found to experience a significant increase in media pressures and the internalisation of thin/low body
fat beauty ideals (Baceviciene and Jankauskiene 2021). Cisgender women were also found to increase
in body appearance evaluation, and decrease in general and psychological quality of life, with no
changes in these domains shown for cisgender men (Baceviciene and Jankauskiene 2021). There was
also an increase in ‘healthy’ eating behaviour (Baceviciene and Jankauskiene 2021), which may
indicate internalisation of healthism and weight biased messages from the media, and associated drive
for thinness.
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A study found that during the pandemic, the most significant predictors of body dissatisfaction
among Indian cisgender women were negative fat talk and societal influences via the media (Ahuja,
Khandelwal et al. 2021). Negative fat talk conversations tended to focus on two dominant themes:
acknowledging weight gain in the context of the pandemic and normalising it, and focus on diet and
exercise (Ahuja, Khandelwal et al. 2021). The most discussed body parts during lockdown were
‘tummy fat’ and ‘hair quality’ (Ahuja, Khandelwal et al. 2021), which may indicate both internalised
weight stigma and healthism, and gendered and racial/ethic effects (i.e., gendered and racial/ethnic
beauty ideals). Importantly, exercise and diet advice given by peers led to increased body
dissatisfaction (Ahuja, Khandelwal et al. 2021), which underscores the harms of conversations that
may lead to increased cues and internalisation of healthism and weight stigma.
Media pressure during the COVID-19 pandemic has been found to affect body image satisfaction
significantly more than other kinds of social pressure across genders and generations (Speranza,
Abrevaya et al. 2021). Adolescents have reported increased exposure to weight stigmatising content
during the COVID-19 pandemic, with pandemic-related increases in body dissatisfaction for a
significant proportion, particularly among adolescent cisgender girls with higher BMI (Lessard and
Puhl 2021). Media during the COVID-19 pandemic has also been linked to cisgender women
experiencing greater pressure to be thin, and cisgender men more pressure to be muscular, especially
for the younger generation (Speranza, Abrevaya et al. 2021). This may indicate that the pressure of
hegemonic feminine/masculine body ideals may have intensified during this period, and/or that with
the stress and pressures of uncertainty, fear of viral contagion, lockdowns and quarantines, and weight
stigma during the COVID-19 pandemic, individuals are experiencing greater susceptibility to
internalisation of hegemonic feminine/masculine body ideals. The impact of COVID-19 lockdowns
and public health messages have also been found to have led to changes in individuals’ health
behaviours, including changes in weight-gain-related online search behaviours, such as increases in
search intensity for weight loss and workouts, with decreases in search intensity for fitness, nutrition,
and fast food (Hasanzadeh and Alishahi 2020).
Young adults who have experienced weight stigma have faced increased vulnerability to distress
and disordered eating during the COVID-19 pandemic, which is likely exacerbated through weight
stigmatising public health messaging risk for COVID-19 infection, and weight stigmatising media
messages regarding weight gain during quarantine and isolation (Flint 2020, Puhl, Lessard et al. 2020,
Lucibello, Vani et al. 2021, Pearl and Schulte 2021). These weight stigmatising media messages have
included COVID-specific terms that incite fear and shame regarding weight gain during the pandemic
and COVID-19 related quarantine and semi-quarantine, such as ‘covidbesity’ (a combination of
‘COVID’ and ‘obesity’, implying weight gain that occurs during the pandemic) and ‘quarantine 15’
(implying the weight gain of 15 lbs of body weight during the quarantine; an adaption to ‘freshman
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15’, the implication of gaining 15 lbs of body weight while adjusting to the transition of university)
(Khan and Moverley Smith 2020, Pearl 2020). Media content that stigmatised fat bodies, romanticises
the thin ideal, and involves high levels of food-related content (i.e., good/bad healthist food
dichotomy) may trigger or exacerbate disordered eating (Khosravi 2020). In one study, after the
implementation of public health prevention and lockdown measures, following increased exposure to
food and exercise-related social media content, more than half of study participants reported a
worsening of eating disorder behaviours (Branley-Bell and Talbot 2020).
Among young adults, pre-pandemic weight stigma experiences were found to predict higher levels
of depression, stress, eating as a coping strategy, and disordered eating during the COVID-19
pandemic (Puhl, Lessard et al. 2020), a finding that remained after accounting for demographic
characteristics and BMI (Puhl, Lessard et al. 2020). Among cisgender women in Poland (Czepczor-
Bernat, Swami et al. 2021), during the COVID-19 pandemic, those with a higher body weight had
significantly greater body dissatisfaction, lower evaluation of their appearance, and lower satisfaction
with body areas at both high and low levels of COVID-related stress and anxiety in comparison to
women with lower body weights (Czepczor-Bernat, Swami et al. 2021). Cisgender women with
higher body weight and higher COVID-related stress and anxiety also had significantly higher levels
of thinness drive, overweight preoccupation, and bulimia nervosa in comparison to women with lower
body weights (Czepczor-Bernat, Swami et al. 2021). These findings suggest that COVID-19
pandemic stress is exacerbating negative body image and disordered eating particularly for cisgender
women at higher body weights, which may indicate effects of internalised weight stigma related to the
pandemic.
Fear of weight-based marginalisation may have increased through effects such as isolation and
changes in social connectedness that magnify belongingness as a human need and social support as a
means of increasing emotional safety and material resources in times of hardship. These factors may
have amplified the social capital of thin body ideals in order to avoid weight-based marginalisation
during the COVID-19 pandemic. In addition, weight stigmatising messages of the perceived dangers
of fatness and COVID-19 infection risk and perceived shame associated with gaining weight in
lockdown may have increased internalised weight bias, conflation of weight with health and disease,
and internalisation of beliefs of weight and eating as moralistic (i.e., contributing to COVID-19
contagion, wastefulness and greed in times of scarcity). These factors may have increased fear of
fat/weight gain in order to avoid fear of weight-based marginalisation based on judgements of
personal character and morals associated with the COVID-19 pandemic. Weight-based stigmatisation
and food insecurity during the COVID-19 pandemic may increase and exacerbate risk for disordered
eating, and should be considered particularly for marginalised populations who may face heightened
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levels of food insecurity and weight discrimination that intersections with other forms of identity-
based discrimination.
Eating Disorders in Specific Populations
Racial/Ethnic Minorities
Eating Disorders in Racial/Ethnic Minorities
The nature of pervasive identity-based oppression (e.g., racial objectification) is historical,
transgenerational, accumulative, and recurring; it is not limited to a single traumatic occurrence
(Bryant-Davis 2007, Cheng and Youngju Kim 2018). The systemic oppression of minority groups
constitutes a collectively carried, transgenerational societal trauma (e.g., colonisation, enslavement,
sexism) (Root 1992, Felipe 2016). Prolonged discrimination may produce more posttraumatic stress
responses than victimisation from a singular hate crime (Bandermann and Szymanski 2014). Micro
forms of objectification and discrimination experienced throughout an individual’s lifespan create a
psychological stress amounting to an ‘insidious trauma’ (e.g., microaggressions, racial objectification,
sexual objectification, weight discrimination) (Sue, Bucceri et al. 2009, Szymanski and Balsam 2011).
Insidious trauma may also occur through exposure to multiple forms of prolonged, intersecting
objectification (Cheng and Youngju Kim 2018). Negative perceptions of one’s body and facial
features may be internalised from experiencing racial discrimination and racial/ethnic teasing
(Cummins and Lehman 2007, Kawamura 2011). Body image problems and disordered eating may
develop as traumatic stress responses to ongoing experiences of oppressive racial and sexual
objectification (Gil-Kashiwabara 2002, Sahi Iyer and Haslam 2003, Tolaymat and Moradi 2011,
Watson, Robinson et al. 2012, Watson, Ancis et al. 2013, Cheng 2014, Velez, Campos et al. 2015,
Cheng, Tran et al. 2017). Women of Colour may attribute the onset of disordered eating and body
image problems to traumatic experiences, including racial and sexual oppression (Thompson 1994,
Thompson 1996).
Although research is limited, literature has suggested that First Nation Indigenous peoples are at
equal or higher risk of disordered eating in comparison to non-indigenous populations, with high
prevalence of overvaluation of weight and shape (Striegel‐Moore, Rosselli et al. 2011, Hay and
Carriage 2012, Gomez-Restrepo, Rincón et al. 2017, Burt, Mannan et al. 2020, Lacey, Cunningham et
al. 2020). First nation peoples with eating disorders may also be younger, have a higher body weight,
and have poorer mental health-related quality of life (Burt, Mannan et al. 2020).
A review of 14 studies of eating disorders in Black/African and Indigenous peoples was conducted
amid the COVID-19 pandemic (Mikhail and Klump 2021). Four articles were included that examined
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how environmental stressors, including discrimination and acculturative stress, were associated with
disordered eating in Black and Indigenous people (Perez, Voelz et al. 2002, Gerbasi, Richards et al.
2014, Munn‐Chernoff, Grant et al. 2015, Kelly, Smith et al. 2018). Perceived every day
discrimination, racial discrimination, weight discrimination, stigma, and acculturative stress are
associated with disordered eating in Indigenous, Black, Brown, and Other People of Colour (Perez,
Voelz et al. 2002, Gerbasi, Richards et al. 2014, Lacey, Parnell et al. 2015, Munn‐Chernoff, Grant et
al. 2015, Himmelstein, Puhl et al. 2017, Kelly, Smith et al. 2018, Beccia, Jesdale et al. 2020).
First Nation peoples may be at greater risk for body dissatisfaction and internalised weight stigma
through the impacts of colonialist violences and minority stress, racism; colonialist values and media
that idealise and privilege white, thin bodies and gendered body norms. An Australian study into
media influences on body image and disordered eating among First-Australian adolescents (McCabe,
Ricciardelli et al. 2005) found that First Nation adolescents were more dissatisfied with their weight
and engaged in greater disordered eating to change their weight and shape compared to non-
indigenous adolescents. First Nation adolescents were also more sensitive to media messaging to lose
weight, despite receiving fewer media messages (McCabe, Ricciardelli et al. 2005), suggesting
minority stress impacts may lead to internalised weight stigma and disordered eating for young First
Nation Indigenous peoples. It’s important to note that this study was undertaken in the early 2000s.
Widespread use of personalised and multimedia exposure may increase the vulnerability faced by
First Nation Australian adolescents, particularly through new media platforms, and further research is
needed.
Eating disorder risk may also increase as a dose effect according to intersectional minority factors,
such as multiracial and gender identity (Burke, Hazzard et al. 2021). A study investigated eating
disorder prevalence among multiracial U.S. undergraduate and undergraduate students (Burke,
Hazzard et al. 2021). Higher prevalence of elevated disordered eating was exhibited by multiracial
individuals identifying as Alaskan Native/American Indian and Hispanic/Latinx (Burke, Hazzard et
al. 2021). Higher prevalence of elevated disordered eating was also found amongst other multiracial
marginalised groups, including Black/African American and Hispanic/Latinx; Black/African
American and Asian American/Asian individuals, at greater than expected prevalence than expected
based on observed prevalence estimates in their corresponding monoracial groups (Burke, Hazzard et
al. 2021). Across gender identities, higher than expected estimates of elevated disordered eating were
found among individuals identifying as Black/African American and White, and lower than expected
prevalence estimates were found among multiracial individuals identifying as Middle
Eastern/Arab/Arab American and White (Burke, Hazzard et al. 2021).
A study investigated the relationships of internalised racism, internalised biphobia, and body
surveillance on the body satisfaction in Black/African American and Asian/Asian American women
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who identified as plurisexual (non-monosexual; including bisexual, pansexual, omnisexual,
polysexual, queer and other non-heterosexual sexual identities) (Paul 2021). Both internalised racism
and internalised biphobia significantly positively predicted body dissatisfaction for both groups of
plurisexual Women of Colour (Paul 2021). Further, the mean score for internalised racism for
Black/African American women was significantly different from the mean score of the Asian/Asian
American women (Paul 2021). Those with high levels of internalised racism/biphobia were more
likely to be dissatisfied with their bodies (Paul 2021), indicating the importance of intersectional
minority stressors. Further research is needed into how intersecting minority stressors and
discrimination impact body image and eating disorder risk for minority and marginalised groups, and
how these factors may be addressed in culturally appropriate ways that draw on the strengths of these
individuals and communities in order to counteract these systematic and social violences.
Intimate Partner Violence and Disordered Eating
In the United states, intimate partner violence (IPV) against women disproportionately affects
those of ethnic minorities (i.e., Black/African American, Latina/Hispanic, Alaska Native/Native
American, Asian American cisgender women), including immigrant ethnic minority women
(Stockman, Hayashi et al. 2014). IPV is also associated with disordered eating (Bundock, Howard et
al. 2013, Stockman, Hayashi et al. 2014, Kothari, Easter et al. 2015, Lacey, Parnell et al. 2015, Schirk,
Lehman et al. 2015). Women have described altered eating behaviour connected to survival of IPV as
being related to multiple aspects of coping, including: (a) somatisation (survivours experience
significant somatic experiences as a consequence of abuse); (b) avoiding abuse (survivours alter their
eating behaviours to avoid abuse); (c) coping (survivours use food to manage with the psychological
effects of abuse); (d) self-harm (survivours use food to hurt themselves as reaction to abusive
experiences); and (e) challenging abusive partners (survivours use their eating behaviours to retaliate
against their abusers) (Wong and Chang 2015). IPV can therefore lead to changes in eating behaviour
for survivours (Wong and Chang 2015). These changes may indicate different forms of coping,
including means of avoiding further abuse, coping with the psychological and somatic experiences of
surviving abuse, and different patterns in eating as a source of comfort, strength, and agency in
abusive relationships (Wong and Chang 2015).
The majority of studies of IPV and health outcomes have had insufficient sample sizes of ethnic
minority women or have not used sufficiently sophisticated statistical techniques to distinguish the
differences between racial/ethnic groups (Stockman, Hayashi et al. 2014). Intra-ethnic group studies
have confounded race/ethnicity social determinants of health (i.e., income) by using samples of
primarily poor ethnic minority women due to easier accessibility to clinical populations (Stockman,
Hayashi et al. 2014). Significant gaps may therefore exist in knowledge of IPV and health outcomes
for racial/ethnic groups, including the relationship of IPV to disordered eating.
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Research has investigated the association between IPV and disordered eating in racial/ethnic
minority women. The role of IPV and perfection in predicting disordered eating was explored for
Turkish cisgender women (Muyan, Chang et al. 2015). IPV was found to be an important predictor of
both dieting and bulimia (Muyan, Chang et al. 2015). Beyond IPV, perfectionism was found to predict
additional variance in disordered eating (Muyan, Chang et al. 2015). Specifically, significant
perfectionistic predictors of dieting included parental expectations, and significant predictors of
bulimia included parental criticism, doubts about actions, and personal standards (Muyan, Chang et al.
2015). The impact of IPV, depression, and post-traumatic stress response (PTSR) on disordered eating
patterns was studied in cisgender women of Black/African American and African Caribbean Women
(Lucea, Francis et al. 2012). IPV, depression, and PTSR were found to be independent risk factors in
the full sample (Lucea, Francis et al. 2012). Depression partially mediated the relationship between
IPV and disordered eating (Lucea, Francis et al. 2012). The influence of risk for lethality from
violence was fully mediated by depression (Lucea, Francis et al. 2012). These findings indicate that
research into disordered eating should also consider IPV, and that IPV, disordered eating, and
depression should be assessed when either of the others are detected (Lucea, Francis et al. 2012). The
roles of social context and severe IPV were also studied in Black/African American and
Black/African Caribbean cisgender women (Lacey, Parnell et al. 2015). Relative to Caribbean Black
women, among Black African American women, noticeably higher rates were found of any anxiety
disorder, post-traumatic stress response, any substance disorder, alcohol abuse, suicide ideation and
attempts, and any overall psychiatric diagnosis, with the most consistent associations found for severe
intimate partner violence. Among both groups, everyday discrimination was significantly associated
with anxiety disorders, eating disorders, and any psychiatric diagnosis, and to a lesser extent,
neighbourhood drug problems were found to be associated to a diagnosis of a mood disorder,
substance disorders, and any psychiatric diagnosis (Lacey, Parnell et al. 2015).
Compared to white women, Black and Latina women with experiences of IPV are less likely to
seek medical attention for injuries resulting from IPV and access mental health services for support
for IPV (Ahmed and McCaw 2010, Flicker, Cerulli et al. 2011, Lucea, Stockman et al. 2013). Due to
experiences of medical mistrust and discrimination, ethnic minority women who have been abused
often seek IPV-related help from informal support systems (e.g., friends, family) rather than seeking
help from formal support systems (e.g., health providers, mental health professionals) (Bauer,
Rodriguez et al. 2000, Campbell, Sharps et al. 2002, Bent-Goodley 2007, Lucea, Stockman et al.
2013). In addition, harmful racial stereotypes may increase vulnerability for risk and exposure to IPV,
victim-blaming, shaming, and barriers to help seeking (Brice-Baker 1994, Bell and Mattis 2000).
There is a crucial need to acknowledge the role of sociopolitical factors and social determinants of
health in IPV prevention and treatment accessibility and efforts, including structural and historical
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racism, multiple intersecting oppressions, intergenerational traumas, colonialist violence, genocide,
enslavement, cultural erasure, immigration, and acculturation (Campbell, Sharps et al. 2002,
Hampton, Oliver et al. 2003, West 2004, Waltermaurer, Watson et al. 2006). Sociopolical, structural
and historical factors of racism and colonialist violence must be considered in the higher levels of
mutual violence in cisgender heterosexual monoracial/ethnic Black couples and interracial/ethic
couples compared to monoracial/ethnic white couples (Martin, Cui et al. 2013), as well as higher
levels of violence in interracial/ethnic couples (Martin, Cui et al. 2013, Brownridge, Taillieu et al.
2018). These sociopolical, structural and historical factors are critical in their relationship to how the
bodies of Black, Indigenous, and People of Colour are perceived and positioned in society, and the
violences against them, which includes racism in the fear of fat and internalised weight stigma
(Strings 2019), and how this relates to disordered eating. Further research and understanding is
needed to identify culturally relevant aspects of seeking care for IPV that utilises a strength-based
focus, such as the power and activism of ethnic minority women (West 2004), and the importance of
community support. Further research is needed to understand how IPV relates to disordered eating for
racial/ethnic minority groups, experiences of coping with abuse and discussing abuse with healthcare
practitioners, and to develop culturally appropriate treatments (Stockman, Hayashi et al. 2014).
Intersecting Discrimination and Disordered Eating
The impact of weight-based discrimination on psychological wellbeing is also highly affected by
other influences on social status, such as socio-economic status (Ciciurkaite and Perry 2018). The
psychological harm of weight discrimination on Latina/Hispanic cisgender women and women in the
lowest household income group have been found to be significantly greater relative to white women
and women with higher household income, indicating higher social status (white privilege, class
privilege) has a buffering effect on the harms of weight stigma on psychological well-being
(Ciciurkaite and Perry 2018).
Weight stigma has been found to be prevalent at comparative rates across racial/ethnic groups,
however differences have been found in the internalisation of and coping with weight stigma
according to race/ethnicity and gender (Himmelstein, Puhl et al. 2017). Black/African American
cisgender women and men reported less weight bias internalisation compared to white cisgender
women and men (Himmelstein, Puhl et al. 2017). In comparison to white cisgender women,
Black/African American women were less likely to cope with stigma using disordered eating, whereas
Latina/Hispanic women were more likely to cope with stigma using disordered eating (Himmelstein,
Puhl et al. 2017). Black men were more likely than white men to cope with stigma via eating
(Himmelstein, Puhl et al. 2017).
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Weight-related teasing has been found to be associated with body concerns, disordered eating, and
health diagnoses in racially and ethnically diverse young men, irrespective of body mass (Williamson,
Osa et al. 2021). Furthermore, race and ethnicity did not moderate these relationships (Williamson,
Osa et al. 2021), indicating that weight-related teasing and distress is linked with body concerns,
disordered eating, and poorer health in racially and ethnically diverse young men regardless of body
size. It may that the relationships between weight-related teasing and distress to body concerns,
disordered eating, and poorer health is linked to a fear of weight-based marginalisation, which would
explain these findings, given the pervasiveness of weight stigma, and the harms associated with it.
The relationship of weight stigma, race/ethnicity, and disordered eating may be more nuanced in its
variance among racially and ethnically diverse groups, however, such as intersectional relationships
between body ideals and racism, gendered racism, and gendered norms.
A study investigated the intersectional relationships between racism, gendered racism, and
conformity to masculine norms to muscularity-oriented disordered eating for Asian American men
(Le, Bradshaw et al. 2021). Muscularity-oriented disordered eating was found to be positively
associated with gendered racism, heterosexual presentation, self-reliance, and conformity to the
masculine norms of Playboy (Le, Bradshaw et al. 2021). Conformity to power over women was
negatively associated with muscularity-oriented disordered eating for Asian American men (Le,
Bradshaw et al. 2021). Racism and other masculine norms were not associated with muscularity-
associated disordered eating, and ethnic identity did not moderate the association between either
racism or gendered racism and muscularity-oriented disordered eating (Le, Bradshaw et al. 2021).
These findings highlight the importance of conducting research from an intersectional minority
approach, and to examine the relationships of gender expectations and gendered racism in disordered
eating.
Research into the body image of Black women may also have been conducted with a limited
understanding of body image and culturally inappropriate measures for Black women (Overstreet,
Quinn et al. 2010, Wilfred 2020), thereby underestimating body image dissatisfaction and disordered
eating risk and rates (Perez and Joiner Jr 2003). Black women experience pressure to adhere to ideals
of a ‘slim thick’ body (i.e., small waist, larger buttocks), a lighter skin tone, and straighter hair
(Wilfred 2020). The Appearance Satisfaction Questionnaire (ASQ) developed by Wilfred (2020) was
developed as a culturally appropriate measure for body image in Black women to assess body image
concerns specific to Black women, and associated effects of poor body image (i.e., acculturative
stress, sexual risk-taking behaviour). The ASQ demonstrated good internal consistency, and positive
correlations with current body image and disordered eating measures, and with acculturative stress,
but not sexual risk taking behaviours (Wilfred 2020). The Double Consciousness Body Image Scale
(DCBIS) by Wilfred and Lundgren (Wilfred and Lundgren 2021) is an additional newly developed
culturally relevant body image assessment for Black women. The DCBIS centres the experiences of
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Black women, including pressures to adhere to cultural body ideals not currently captured in common
body image measures, and behavioural manifestations of these pressures (Wilfred and Lundgren
2021). Together, these findings provide further support for the impact of acculturative stress for the
body image of Black women, and risk for disordered eating. Together, these findings indicate the
importance of gendered body ideals and body image factors in racially and ethnically diverse studies
of disordered eating. Current measures of body image in Black women may be limited by culturally
inappropriate measures, and further research is needed using newly developed and emerging
culturally appropriate measurement tools of body image for Black women in order to gain a more
accurate understanding of body image and eating disorder risk and experiences in these populations.
Collectively, these findings indicate that racism, gendered racism, weight discrimination, and IPV
are important intersectional and minority considerations in the disordered eating of First Nation
Indigenous peoples, Black, Brown, Asian, migrant, and other people from diverse racial, ethnic and
cultural backgrounds. Disordered eating may be used to cope with experiences of intersecting
discrimination and violence. The socio-political, historical, and structural factors in the oppression
and margination of racial/ethnic minority people must be considered in body image, disordered eating,
and coping with discrimination, trauma, violence and abuse. These research findings also have
implications on the experiences of fear of weight/gain and ‘feeling fat’ in the disordered eating
experiences of racial/ethnic minority people. Multiple marginalisation (e.g., LGBTIQ+ discrimination
and racial discrimination), and seeking to avoid the harms of intersectional social marginalisation (i.e.,
weight stigma) may be a factor in the disordered eating experiences of racial/ethnic minority people.
The power and strengths of racial/ethnic minority people are key factors in supporting well-being,
such as community and family networks, including othermothers, chosen and constructed families, as
sources of support in coping with the effects of discrimination, oppression, and trauma (Abreu and
Gonzalez 2020). Positive, strength-based culturally-sensitive approaches that involve drawing on
these supports and understanding of historical and culturally contextual factors in body image may be
important in advancing eating disorder treatments for racial/ethnic minority people.
Gender and Sexually Diverse People (LGBTQIA+)
Eating Disorders in Cisgender Sexual Minority People
Cisgender sexual minority adolescents (e.g., Ackard, et al., 2008; French, et al., 1996; (Shearer,
Russon et al. 2015, Zullig, Matthews-Ewald et al. 2019) and adults (e.g., Peplau, et al., 2009; Wrench,
& Knapp, 2008) reportedly experience disproportionate body dissatisfaction, body distortion,
unhealthy weight control behaviours, and eating disorders. Unhealthy weight control behaviours (e.g.,
fasting, diet pill use, vomiting, and laxative misuse) have been found to be significantly more
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predominant for cisgender sexual minority young women (34.7%) and young men (32.5%) in
comparison with exclusively cisgender heterosexual young women (18.8%) and young men (9.7%)
(Hadland, Austin, Goodenow, & Calzo, 2014). Cisgender, sexual minority women and unsure women
and men have also been found to have increased rates of self-reported eating disorder diagnosis
compared with cisgender heterosexual women, with highest rates reported for transgender individuals
(e.g., Diemer, et al., 2015; Witcomb et al., 2015). These findings indicate that transgender and
cisgender sexual minority young adults are at elevated risk for self-reported eating disorder diagnosis
and compensatory behaviours (Diemer, et al., 2015). Crucially, among sexual minority people, reports
of perceived discrimination has been found to be associated with a significantly higher percentage of
anorexia nervosa compared to those without reports of perceived discrimination (Kamody, Grilo et al.
2020). Irrespective of gender and race/ethnicity, cisgender sexual minority people report significantly
higher occurrences of eating disorders, body dysmorphia, and appearance and performance
enhancement drug use (Gonzales and Blashill 2021).
Having a Gay-Straight Alliance at a school has been found to reduce multiple forms of bias-based
bullying (i.e., bullying based on race/ethnicity, body weight, disability, gender identity, gender
expression, sexual identity, and religion) and to increase perceived school safety for youth who
experience bias-based bullying in comparison to schools without a Gay-Straight Alliance (Lessard,
Watson et al. 2020). Importantly, each type of bias-based bullying (i.e., bullying based on
race/ethnicity, body weight, disability, gender identity, gender expression, sexual identity, and
religion) uniquely contributed to feelings of unsafety (Lessard, Watson et al. 2020). However, only
weight-based bullying and sexuality-based bullying made independent negative contributions to
academic grades and school suspensions (Lessard, Watson et al. 2020), indicating the insidiousness of
these forms of biased-based bullying on the sense of safety and education for youth at school. These
findings have implications for the development of eating disorders in LGBTIQ+ youth, as
adolescence is a key risk period in eating disorder development. Gay-Straight Alliances may be an
important protective factor against discrimination pathways to disordered eating for LGBTIQ+ youth
and youth who experience multiple marginalisation at school.
Eating Disorders in Gender Minority People
Transgender and non-binary adolescents and young adults report a high prevalence of body
dissatisfaction, body incongruence, disordered eating, self-injury and suicidal behaviours, (Jones,
Pierre Bouman, Haycraft, & Arcelus, 2019; Peterson, Matthews, Copps-Smith, & Conard, 2017;
Romito et al., 2021; (Donaldson, Hall et al. 2018, Duffy, Henkel et al. 2019, Liu, Sheehan et al. 2019,
Morris, Galupo et al. 2019, Duffy, Calzo et al. 2021) which may be related to victimisation
experiences (Williams, Jones et al. 2021). Importantly, transgender and non-binary youth with a
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desire for weight change report a higher frequency of suicide attempts (Peterson et al., 2017).
Transgender and non-binary people may also experience significant food insecurity (Linsenmeyer,
Katz et al. 2021), which is an important consideration in negative body image, internalised weight
stigma, and eating disorders (Becker, Middlemass et al. 2017, Lydecker and Grilo 2019, Rasmusson,
Lydecker et al. 2019, Hazzard, Loth et al. 2020, Paslakis, Dimitropoulos et al. 2020, Barry, Sonneville
et al. 2021, Becker, Middlemas et al. 2021, Shankar-Krishnan, Fornieles Deu et al. 2021), and
suicidality (Davison, Marshall-Fabien et al. 2015, Koyanagi, Stubbs et al. 2019, Men, Elgar et al.
2021).
Compared with cisgender adolescents, transgender and non-binary adolescents have a higher risk
of engaging in disordered eating and weight control behaviours, including fasting, using diet pills,
taking laxatives, and lifetime non-prescription steroid use (Guss, Williams, Reisner, Austin, & Katz-
Wise, 2017). One study found 63% of transgender and non-binary youth (Avila, Golden, & Aye,
2019) engaged in intentional weight manipulation for the purpose of affirming their gender, while
15% showed elevated eating disorder behaviour scores (EDE-Q global scores); a rate higher than
expected (Avila et al., 2019), highlighting key differences and vulnerabilities for this subpopulation.
Transgender and non-binary people face significant barriers to eating disorder screening and treatment
(Duffy, Calzo et al. 2021, Hartman-Munick, Silverstein et al. 2021). Furthermore, eating disorder
treatments can also be problematic for transgender and non-binary people, with recovery orientation
that focuses on body acceptance which may exacerbate gender dysphoria, or erase, invalidate, or
otherwise fail to acknowledge the complexity of transgender and non-binary identities and
experiences (Hartman-Munick, Silverstein et al. 2021). For transgender and non-binary people,
androgynous and non-stereotypical body ideals are perceived as affirming to their gender
identity/identities, and serve several functions (Galupo, Cusack et al. 2021). The androgynous body
ideal conceptualised by transgender and non-binary people involves; 1) attaining neutrality and de-
categorising gender; 2) disaggregating gender expression; 3) managing gender dysphoria; and 4)
achieving authenticity. In order to approach or maintain an androgynous or non-stereotypical body
ideal, transgender and non-binary people may engage in different behaviours or actions, involving:
gender expression (clothes, hair, make-up, body modifications), body shape (weight, muscularity,
eating/dietary behaviour), and sex characteristics (hormone therapy, body hair, vocal, chest, genitals)
(Galupo, Cusack et al. 2021).
Transgender and non-binary people may engage in body-checking actions associated with
disordered eating and weight concerns (i.e., checking waist size, checking for bones, checking
muscles, taking selfies to compare weight/size between photos), however may also engage in body-
checking actions for reasons not currently measured by body-checking tools, such as maintaining
gender congruence and avoiding minority stress (Cusack and Galupo 2020). Body-checking
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behaviour by transgender and non-binary people may therefore include motivation driven by gender-
related factors (i.e., checking gender congruence of bodily characteristics) and expression (i.e.,
checking external modifications and androgynous aesthetic) (Cusack and Galupo 2020). Gender-
affirming care should be incorporated into eating disorder treatment to address these factors, increase
accessibility, and meet the needs of transgender and non-binary people (Calzo, Lopez et al. 2020,
Hartman-Munick, Silverstein et al. 2021, Knutson and Koch 2021). Consistent with body-checking
behaviour, body dissatisfaction and disordered eating for transgender and non-binary people may be
partly based in self-discrepancies such as gender incongruence of the actual/current physical self and
the ideal and ought physical selves (Sequeira, Miller et al. 2017). High ED prevalence in transgender
and non-binary people may result from the dual pathways of sociocultural pressures to conform to