Working With The Client in Front of You – Social and Cultural Factors that Contribute to Body Image Concerns

By Blair Burnette, PhD, author of The Intuitive Eating Treatment Manual

Busting Stigma, Stereotypes, and Assumptions

Anyone can experience body image or eating concerns. For decades, the misconception that body image and eating concerns only affect thin, affluent, white girls and women pervaded mainstream discourse, treatment, and research. Scholars began contesting this assumption in the 1980s, providing compelling evidence that, not only do people across race, ethnicity, gender, and socioeconomic status experience eating concerns, but people not fitting the stereotype have unique and important risk factors (e.g., acculturation, discrimination) that can increase their susceptibility to disordered eating (Andersen & Hay, 1985; Iijima Hall, 1995; Root, 1990; Smolak & Striegel-Moore, 2004).

 One reason body image and eating disorders became so closely associated with white women is that case studies involving white women informed the development of the original diagnostic criteria for eating disorders. In turn, because interventions are designed to target key symptoms and risk factors (those diagnostic criteria), our earliest and most-researched treatments were developed with white women in mind. Another reason that these stereotypes are so entrenched is that there are pervasive and enduring disparities in research enrollment, limiting our understanding of how eating concerns present across other groups. Accordingly, people not fitting the stereotype of whom eating disorders affect have been presumed to be protected.

We now have abundant evidence that these stereotypes are not only inaccurate, but also extremely harmful. Body image and eating concerns affect people across gender, sexual orientation, race, ethnicity, age, socioeconomic status, and weight status. Indeed, many marginalized groups have heightened risk, but are the least likely to seek, be referred to, and receive help for their concerns. There is fairly consistent evidence that people who identify as gay, bisexual, lesbian, queer, gender nonbinary, gender expansive, and transgender have higher rates of body image concerns and disordered eating than straight and cisgender people (Calzo et al., 2017; 20 The Intuitive Eating Treatment Manual Diemer et al., 2018; Hartman-Munick et al., 2021; Kamody et al., 2020; Meneguzzo et al., 2018). Men also experience body image and eating concerns, but they’re less likely to recognize their own symptoms as disordered, seek treatment, or be identified by providers (Brown & Lavender, 2021; Strother et al., 2012). Accumulating research shows eating concerns are not limited to the affluent; rather, disordered eating appears to be increasing more rapidly in those at lower versus higher socioeconomic status, and food insecurity is a potent risk factor for eating disorders (Burnette, Burt, & Klump, 2023; Hazzard et al., 2020; Huryk et al., 2021).

We have limited data on eating concerns among middle-aged and older women and none on middle-aged and older men. However, there is evidence that women above age fifty are increasingly seeking treatment for new-onset, chronic, and recurrent eating disorders (Samuels et al., 2019). People at higher weights often have the highest rates of disordered eating (likely due in part to the pervasiveness of weight stigma and associated pressure to lose weight; Sonneville & Lipson, 2018), and are much more likely to be recommended weight loss treatment, which can cause serious harm (Hart et al., 2011). Finally, research looking at people with intersectional identities (e.g., LGBTQ+ people of color) is sorely lacking, but evidence suggests that individuals who occupy multiple marginalized social identities are at elevated risk for eating concerns (Burke et al., 2020; Panza et al., 2021).

Thus, it’s crucial that you consider that anyone who comes to you for help may be struggling with body image or eating. Equally crucial is not making any assumptions about what kind of concerns your client has before they tell you. Checking your biases in an ongoing manner helps you not inadvertently cause your clients harm or disrupt trust and safety in the therapeutic relationship. Biases and assumptions can creep in in many ways. Because we are saturated with messages associating weight to behaviors and to health, and because stereotypes about whom eating disorders affect are so prevalent and enduring, we must engage in a continued, reflexive process to ensure we’re not bringing our own implicit biases into the room in ways that will harm our clients.

Throughout The Intuitive Eating Treatment Manual, I’ll integrate cultural and identity considerations that could affect how you work with your clients on intuitive eating’s various principles. I’m bringing in my lived and clinical experience, and the wisdom of a diverse array of professionals and folks with lived experience. My hope is this manual will help you be inclusive and supportive of folks with diverse backgrounds, identities, and eating concerns. I urge you to continue your own work in understanding how interlocking systems of oppression affect your clients, and to practice within your competence areas. Education and consultation will be crucial when working with clients with unfamiliar backgrounds or presenting concerns.

Body Image Concerns

Body image concerns are pervasive. In our culture almost no one can “win.” Almost none of us live in bodies that meet all the various cultural standards of attractiveness. The very few who do then likely learn their appearance is central to their worth and may experience lifelong pressure to continue meeting these (impossible) standards. It is therefore challenging for anyone to experience peace with and in their body. Nevertheless, some experience disproportionate barriers to body respect. People at higher weights receive ongoing messaging from myriad sources that their bodies are wrong and need changing. These messages come not just from media, but from family, friends, and medical professionals. Encouraging your fat¹ clients to respect and honor their bodies is a much different ask than for clients in thin bodies. Working with clients in higher-weight bodies will take additional consideration and care due to the weight stigma–saturated cultures in which we live.

For decades, body image research has focused on the thin ideal as the origin of discontent. However, the thin ideal is just one beauty ideal (and is most salient to white women). A curvy body ideal, with slim waist but larger breasts and hips, is more relevant to many Black and Latina women (Capodilupo, 2015; Hunter et al., 2020; Schooler & Daniels, 2014). Skin color, hair, and self-presentation are also often salient to body image among women of color. Women of color also experience pressure to look “put together,” which generally translates to Eurocentric norms of professional hair, dress, and conduct. This pressure to conform to both Eurocentric beauty ideals and those from another culture (ideals often at odds) can generate conflict and distress.

Male-identifying individuals may experience pressure to obtain a muscular physique. Research shows that men who have high drive for muscularity are more likely to engage in disordered muscle-building behaviors like anabolic steroid use (Dryer et al., 2016; Lavender et al., 2017). Trans and gender-nonbinary individuals may experience gender dysphoria, which is often accompanied by body image–related distress.

Those who have experienced body-related changes as the result of medical conditions and treatments (e.g., chemotherapy, surgery) may also experience body image–related distress. Women with breast cancer, for instance, may struggle to reconnect with their feelings of femininity and desirability after appearance-altering surgery. Medical conditions that involve losing physical strength or sexual function may challenge men’s conceptualizations of their own masculinity.

Ability status can have a profound impact on body image, especially within ableist societies where physical ability is assumed and bodily health is seen as a reflection of personal choices. Aging can cause body image–related distress as one’s body diverges from societal appearance ideals.

Finally, working with someone who has experienced trauma, especially physical or sexual trauma, requires expertise and sensitivity. Trauma can disrupt a person’s experience with and connection to their body.

It’s important to consider that many folks live at various intersections of these identities. Those who carry multiple socially marginalized identities will likely experience disproportionate barriers to body respect, which requires recognition and consideration in treatment.

Intuitive eating can absolutely help folks who are navigating body image–related distress. All your clients will have differing relationships with their bodies, so how you approach body respect will differ based on their experiences and identities. For clients who have distress related to their shape or size, you should have education on anti-fat bias, including its consequences and its racist origins.² For many clients, embracing intuitive eating and relinquishing the endless pursuit of weight loss will mean they remain in or recover into a higher weight (and thus a stigmatized) body. Glossing over or ignoring that fact won’t be therapeutic for your client. If body image concerns are primary for your client, you may want to move the session on body image earlier or cover the content in two sessions so your client has more time to process and practice. This is especially true if the hesitation to relinquish dieting stems from a fear of weight gain or the desire for weight loss.

PP. 19-22, Excerpt taken from The Intuitive Eating Treatment Manual

Footnotes:

1.  I’ll occasionally use “fat” to describe people in larger bodies. “Fat” is a neutral descriptor, not a pejorative. Some people prefer to be called fat rather than other terms (e.g., people “of size”). Let your client guide the terminology used in session

2. For reading about the racist origins of anti-fat bias, I highly recommend Fearing the Black Body by Sabrina Strings and Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness by Da’Shaun L. Harrison.

Blair Burnette, PhD, is assistant professor in the psychology department at Michigan State University. She serves on the editorial board of the journal Body Image, and is an active committee member of the Academy for Eating Disorders.