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
“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
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
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).
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 is a form of bias that occurs automatically and unintentionally, that nevertheless affects judgments, decisions, and behaviors.”
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
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 can impact care for patients with eating disorders in several ways, including:
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:
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 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.
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.
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:
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.
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:
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:
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:
There are numerous strategies providers can employ to make eating disorder treatment more inclusive. Here are some examples:
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.