Culturally-sensitive care for patients with eating disorders

Presented by:

  • Malika Brown-Crosby, Primary Therapist at Within Health
  • Dr. Lesley Williams, Family Medicine Physician at Mayo Clinic

Cultural competency

Increasing diversity brings opportunities and challenges for healthcare providers and policymakers to create and deliver culturally competent healthcare systems. 

Specific ethnocultural or racialized groups suffer from health disparities and social disadvantages due to the meanings and consequences of their socially cultural identities.1

What is cultural competency?

“The ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs” - Betancourt et al., 2003

Cultural competence emerged as a framework for addressing diversity and inequality in the US in the 1980s. The concept has emerged from gathering information and making assumptions about patients based on their sociocultural background to developing skills to implement the principles of patient-centered care. 

Culturally competent healthcare services aim to deliver the highest quality of care to every patient regardless of race, cultural background, ethnicity, and language or literacy proficiency. Some commonly used strategies to provide culturally competent care include:2

  • Recruit and retain minority staff
  • Provide training to improve cultural awareness
  • Provide interpreter services
  • Coordinate with traditional healers and community health workers
  • Include culture-specific attitudes and values in health promotion information

A culturally competent healthcare system can help improve the quality of care and health outcomes and contribute to ending racial and ethnic health disparities.3 Cultural competence requires that organizations:3,4

  • Have defined values and principles and display behaviors, attitudes, and policies that allow them to work cross-culturally effectively.
  • Have the ability to value diversity, self-assess for cultural blind spots, acquire and institutionalize cultural knowledge, and adapt to the diversity of their communities.
  • Have the willingness to make clinical settings more accessible to patients

Cultural humility

When discussing cultural competency, we also have to address cultural humility. In simple terms, cultural humility is the practice of self-reflection on how your background and the background of others impact learning, research, teaching, and more. 

It involves a commitment to self-evaluation and self-critique, whereby you examine your own beliefs and cultural identity and learn about another’s culture. In doing so, you can recognize power dynamics and imbalances and fix these imbalances where they exist5 to help build honest and trustworthy relationships.

Cultural humility means one does not always know and is willing to learn from patients about their experiences while being aware of one’s embeddedness in culture(s).

Multicultural, social justice, and counseling competencies

Multicultural and social justice praxis
Source: Counseling Today

As the Multicultural and Social Justice Praxis diagram above shows, multiculturalism, and social justice should be at the center of all treatment. The quadrants reflect the complex identities and the privileged and marginalized statuses that practitioners and clients bring to the counseling relationship.

Clients and counselors/practitioners are both members of various racial, ethnic, gender, sexual orientation, economic, disability, and religious groups. These identities are categorized into privileged and marginalized statuses.

A client or counselor may hold either status or both statuses simultaneously. These statuses are prevalent depending on how each individual is experiencing the current interaction.6

Implicit bias

“Implicit bias is a form of bias that occurs automatically and unintentionally, that nevertheless affects judgments, decisions, and behaviors.”

What is implicit bias?

Implicit bias is an unconscious association, belief, or attitude toward any social group. Due to implicit biases, people may often attribute certain qualities or characteristics to all members of a particular group. This can lead to stereotyping, stigmatization, and/or marginalization.7

While no one is immune to implicit bias, this doesn’t mean you’re prejudiced or likely to discriminate against other groups. It just means that your brain is making associations and generalizations, possibly influenced by your environment and the society in which you were born.7

How can we assess implicit bias?

There are ways we can assess our own implicit bias on several different topics, including age, weight, sexuality, race, disability, gender identity, etc. One such way is by taking the Implicit Bias Test (IAT) at Project Implicit, which was founded to educate the public about bias and provide a “virtual laboratory” for collecting data.

The IAT uses a computer program to show participants a series of images and words and determines how long it takes for someone to choose between two options. Researchers suggest that people possess a stronger unconscious association when they select quickly. 

For example, if someone clicks quickly on a negative word every time they see someone in a larger body, they hold an implicit negative bias toward people in larger bodies.7

Implicit bias and care for patients with eating disorders

Implicit bias can impact care for patients with eating disorders in several ways, including:

  • Weight stigma
  • Assumptions about diagnoses based on body size
  • Non-diverse therapeutic group topics
  • Assuming all clients with the same eating disorder diagnosis struggle with the same body image concerns
  • Unwillingness to learn from clients


Also known as social marginalization or social inclusion, marginalization occurs when a person or groups of people are less able to do things or access basic services or opportunities. People can be marginalized based on their:

  • Race
  • Gender identity
  • Size
  • Race or ethnicity
  • Age
  • Socio-economic status

Marginalized groups often feel “othered,” i.e., they feel different or excluded, which can lead to poor self-esteem. This can result in a person feeling that it is them that needs to change and not society, which can increase their vulnerability to developing disordered eating behaviors.

Eating disorder treatment aims to move from exclusion to inclusion for all marginalized groups, and there is still some way to go. Integration is different from inclusion. With inclusion, everyone has an equal voice, and everyone is an equal member of the community.

Racial discrimination and maladaptive eating behaviors

Racial discrimination is a stressor for young black women that can lead to poor health outcomes, including developing maladaptive eating behaviors.8

In a recent study of young black women, 81.5% of the participants reported experiencing racial discrimination. Plus, those exposed to racial discrimination were more likely to experience overeating and lack of control eating. 

The researchers concluded that young black women might use disordered eating behaviors to cope with exposure to racial discrimination.8 This is particularly significant as young black women face racial discrimination daily. 

Why understanding implicit bias matters for all eating disorder professionals

It’s important to remember that stigma is not isolated to our obvious differences. Eating disorder professionals must critically reflect on the role of stigma - particularly weight bias - in their lives.

Studies have shown that many eating disorder professionals feel discomfort caring for patients from marginalized backgrounds. For example, a 2014 study found negative weight stereotypes among some eating disorder professionals, with 29% of participants reporting that their colleagues demonstrated negative attitudes toward larger-bodied patients.9

The same study revealed that eating disorder professionals with stronger weight bias were more likely to blame larger bodies to behavioral causes.9 Weight bias such as this is sure not only to be a source of misdiagnosis but also to serve as a barrier to treatment.

Therefore, understanding stigma is vital to providing competent eating disorder care, regardless of the patient’s size or current diagnosis.

Research on eating disorder patients

There is a misconception that eating disorders primarily affect white females from a specific socioeconomic background. However, it’s well documented that eating disorders affect people of diverse ethnic and racial backgrounds.

Due to the misconception of the “typical” eating disorder patient, most treatment and assessment protocols have been developed primarily for white women. Therefore, they may not be valid for other ethnic groups and genders. 

There is a lack of literature on culturally-sensitive treatments for eating disorders in the United States, even though marginalized groups show similar, if not higher, prevalence of eating disorders. Some notable research studies include:

  • A large-scale study found that the prevalence of anorexia nervosa and binge eating disorder was similar across Latinos, African Americans, Asian Americans, and Whites.10
  • In a population-based study of 2793 adolescents, girls of Asian background reported the highest rates of disordered eating across all eating disorder behaviors compared to their White counterparts.11
  • Additional research found that despite higher average BMI than White or Asian American Men, Black men report higher body satisfaction, lower prevalence of negative feelings about binge eating, and lower incidence of being fearful of weight gain due to binge eating.11
  • In another study, Black boys reported the second-highest prevalence rates of unhealthy weight control behaviors (UWCB) and overeating, with 38.5% of Black boys endorsing UWCB and 10.1% engaging in dieting.11
  • Rodgers et al. discovered that the prevalence of diet behaviors was lowest in black girls compared to Latino, White, and Asian peers. Furthermore, Black girls endorsed the lowest prevalence of UWCB among these groups, although it was still considerable at 43.1%.11

However, there is still a misrepresentation of marginalized and minority groups in eating disorder research, particularly regarding Native Americans and those of two or more racial/ethnic identities.

Research on providing culturally sensitive care for patients with eating disorders

A 2021 study by Reyes-Rodriquez et al. concluded that being comfortable discussing race and ethnicity with clients may promote better treatment outcomes.10 Practitioners should:

  • Suspend their preconceptions about race and ethnicity
  • Recognize individual differences and consider the potential effects of therapy
  • Acknowledge the ways that power, privilege, and racism might affect therapist-client work
  • Be willing to take risks with clients
  • Stay open to learning and up to date on research about what is important in culturally-sensitive care
  • Admit their lack of knowledge and ability to understand what it’s like to be in a client's shoes with a different race or ethnicity than their own

Providing culturally sensitive practices and being well-informed about culture, race, ethnicity, national origin, and language is an ethical issue and essential for effectively implementing services and research.12

If eating disorder providers are not providing culturally-sensitive practices for marginalized groups, the therapeutic environment can feel toxic, returning to the feeling of being “othered” we mentioned earlier. Feelings of shame and exclusion can recreate the same stigmatizing experience that first led to eating disorder development.

Approaching patients with a marginalized experience requires the following:

  • Validation that a client’s experience is valid and believed.
  • Humility and the understanding that we don’t know it all when it comes to another person’s culture.
  • Openness by learning from different people’s perspectives and experiences.
  • Authentic connection building genuine and trustworthy relationships with clients.
  • Comfort with discomfort having the ability to have difficult conversations.

What can allies do?

Allies can help marginalized patients move towards active empowerment and help them embrace connection and belonging, which are crucial tools in healing and recovery. You can do this by:

  • Reflecting on recent events around the world and the unyielding discrimination that affects members of minority groups
  • Acknowledging inequalities and poor mental health
  • Showing compassion for all your clients in their time of vulnerability
  • Believing when a client shares their experience with you. It takes great courage to speak up about struggles with an eating disorder, and sharing doubts based on bias could make them reluctant to do so.
  • Working towards healthcare systems that are trauma-informed, culturally responsive, and the intersectionality of people’s lives.

There are numerous strategies providers can employ to make eating disorder treatment more inclusive. Here are some examples:

  • Create an inclusive work culture.
  • Hire a diverse staff and create opportunities for promotion into leadership roles.
  • Audit your policies and practices to reflect diverse backgrounds and perspectives.
  • Create a diversity and inclusion committee and invent in implementing the recommendations for change.
  • Require all staff members to participate in ongoing training in cultural humility and competency.
  • Regularly evaluate the organization's cultural competency on behalf of clients and staff.
  • Provide wider opening hours and virtual treatment
  • Find ways to provide affordable care to clients from marginalized groups
  • Audit marketing materials
  • Ensure a physical environment that is accessible for all patients, including those with larger bodies and disabilities.
  • Understand how your background affects your responses to people from other diverse backgrounds.
  • Don’t buy into stereotypes and assume that all members of cultural groups share the same beliefs and practices.
  • Actively examining, acknowledging, and eliminating prejudice and bias practices
  • Openly address stigma, shame, and privilege
  • Collaborate to create diverse community networks.

Final thoughts

Attention to diversity and cultural competency has become significant in eating disorder treatment in recent years as our society continues to become increasingly diverse. 

For eating disorder treatment to be successful, there needs to be a systemic modification of interventions to integrate clients’ relevant cultural factors, e.g., language and values.


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  2. Brach, C. & Fraser, I. (2000). Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review, 57 (Supplement 1), 181-217. 
  3. Cultural competence in health care: Is it important for people with chronic conditions? (2019, February 13). Health Policy Institute. Retrieved March 10, 2023. 
  4. Centers for Disease Control and Prevention. (n.d.). Cultural competence in health and human services. Centers for Disease Control and Prevention. Retrieved March 10, 2023.
  5. What is cultural humility? The basics. (n.d.). Equity and Inclusion. Retrieved March 13, 2023.
  6. Ratts, M. J., Singh, A. A., Nassar‐McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Multicultural and Social Justice Counseling Competencies: Guidelines for the counseling profession. Journal of Multicultural Counseling and Development, 44(1), 28–48. 
  7. Cherry, K. (2020, September 18). Is it possible to overcome implicit bias? Verywell Mind. Retrieved March 13, 2023.
  8. Brown, K. L., Graham, A. K., Perera, R. A., & LaRose, J. G. (2022). Eating to cope: Advancing our understanding of the effects of exposure to racial discrimination on maladaptive eating behaviors. The International journal of eating disorders, 55(12), 1744–1752. 
  9. Puhl, R. M., Latner, J. D., King, K. M., & Luedicke, J. (2014). Weight bias among professionals treating eating disorders: attitudes about treatment and perceived patient outcomes. The International Journal of Eating Disorders, 47(1), 65–75. 
  10. Reyes-Rodríguez, M. L., Watson, H. J., Smith, T. W., Baucom, D. H., & Bulik, C. M. (2021). Promoviendo una Alimentación Saludable (PAS) results: Engaging Latino families in eating disorder treatment. Eating Behaviors, 42, 101534. 
  11. Rodgers, R. F., Berry, R., & Franko, D. L. (2018). Eating Disorders in Ethnic Minorities: an Update. Current Psychiatry Reports, 20(10), 90. 
  12. Barnett, J. E. (n.d.). Culturally sensitive treatment and ethical practice - APA divisions. Culturally Sensitive Treatment and Ethical Practice. Retrieved March 14, 2023.