Developing a Measure of Non-Binary Gender (Genderqueer) Assessment
by: Lisa Michelson, B.A.
Classifications of gender identity, gender expression, and biological sex have become prevalent topics within contemporary healthcare conversations. These topics were once understood as a binary of options (i.e. male/female, masculine/feminine), but now these topics are viewed as a part of a spectrum (i.e. an individual can vary in how much they identify as “male” and “female”/”masculine” and “feminine”). However, the healthcare system has not yet been able to adapt its treatment plans, insurance plans, and other types of documentation within healthcare to this new ideology of gender and sex. This causes individuals who do not associate or perform as the stereotypical “male” or “female” (at the very least) to be misunderstood, and (at most) to receive inadequate healthcare.
Before we move on, let’s define some terms. Performing gender is “performing” one’s gender in alignment with societal expectations of that gender (i.e. a woman would be performing gender if she were to wear a dress). Non-performing gender is deviating from what culture depicts as an individual’s “authentic self,” or the individual’s identity that society is most comfortable with. Examples of non-performing gender are cross-dressing or identifying as transgendered. Heteronormativitiy are policies, beliefs, norms, and disciplinary mechanisms that reinforce the sex/gender system; for example, heteronormative culture endorses “female” and “male” sex designations on birth certificates. Cisnormativity is the expectation that all people are cissexual, that those assigned male at birth always grow up to be men and those assigned female at birth always grow up to be women. Not performing gender (i.e. cross-dressing or being transgendered) can cause a variety of negative outcomes, such as bullying and teasing, to be elicited. It is this performativity of being a “man” and being a “woman,” that has affected how individuals are treated within the healthcare system.
There are issues if an individual does not perform his/her/their gender identity. For example, Trans* individuals are poorly understood and medicated by healthcare professionals, who mostly lack training in Trans* healthcare. Because physicians are not trained in the treatment of Trans* individuals and because important healthcare documents force individuals to designate their sex as “male” or “female,” Trans* individuals experience systematic violence by the healthcare system; for example, they do not have the option of identifying as two genders on medical documents, if they feel their identity is a blend of male and female. If one does not follow the gender binary system, then one’s identity undergoes erasure and is not viewed as legitimate. There are serious ethical issues with forcing Trans*, inter-sexed, or non-binary individuals to associate with one of two genders if they view their identity as either a mixture of male and female, or one outside of the binary scale.
Because there are currently no assessments that attempt to understand gender separate from performativity, I, along with the EAT lab, have developed the Non-Binary Gender Assessment (NBGA). This assessment asks individuals questions about how they view themselves rather than through performativity questions. Traditional performativity questions assess items such as “I like guns.” In scoring, this individual would be described as “masculine.” However, this is based off of stereotypical analysis of gender performativity within a heteronromative, cisnormative culture. In other words, it is unfair to attach masculinity to the “I like guns” statement. In fact, a female who considers herself feminine may like guns as well.
Instead, we are trying to develop a measure that does not rely on these stereotypes. In the Non-binary Gender Assessment (NBGA) individuals are asked questions regarding how they view their identity. For example, individuals have the opportunity to quantify their gender identity on a scale from 1 to 10 in three categories “Female,” “Male,” and “Other.” Allowing individuals to quantify their own gender rather than assigning them a gender based off performativity aids in the individual’s agency, which is defined as one’s ability to make an autonomous decision for himself/herself. Through this 62-item survey, individuals answer a series of questions regarding ones’ gender identity, gender expression, and biological sex; for example “I am afraid to not wear clothes in public because people will look at my body (i.e. at a swimming pool or sauna).” The individual is not marginalized by a series of “yes” or “no” questions, but rather have the opportunity to scale one’s answer and provide clarification for answers if desired.
The hope in creating this scale is to better understand an individual’s gender and sex identity. Additionally, the goal is to see if the NBGA illuminates any relationships between both gender and sex identity and eating disorders. Previous research suggests that there is a higher prevalence of eating disorders in non-binary populations when compared to the same demographic in binary populations (Feldman & Meyer, 2007; McClain & Peebles, 2016). If the NBGA is able to detect the parts of an individual’s gender and sex identity that can cause an increase prevalence in eating disorder symptoms, then this may help in better understanding why non-binary individuals engage in disordered eating behaviors in the first place. Stay tuned as the EAT lab continues to develop and validate this measure!
Culture and Eating Disorders
by: Benjamin J. Calebs, B.A.
Eating disorders have traditionally been viewed as impacting the lives of non-Hispanic White women in Western countries. Relatedly, there have been debates about the degree to which eating disorders may be culture-bound syndromes (Keel & Klump, 2003). The DSM-5 defines a cultural syndrome as “a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context” (American Psychiatric Association, 2013, p. 14). As you can imagine cultural and ethnic differences in eating disorders are a very complex topic!
Some researchers have argued that eating disorder diagnoses such as anorexia nervosa and bulimia nervosa are culture-bound syndromes motivated by Western ideals of thinness, while others have emphasized the substantial biological and genetic components to eating disorders. After a review of the evidence on eating disorders across cultures and time periods, Keel and Klump (2003) concluded that bulimia nervosa is heavily influenced by culture, while anorexia nervosa is experienced similarly across cultures. The authors suggest that bulimia nervosa may be so influenced by culture because binge eating is reliant upon an individual having access to enough available food to have a binge episode. Relatedly, purging seems to predominately occur in cultures where thinness is highly valued (Keel & Klump, 2003).
In spite of the traditional view of eating disorders outlined before (i.e., that eating disorders are predominately seen in non-Hispanic White, Western women), it is now clear that disordered eating behaviors occur across different ethnicities and cultures. Lifetime prevalence rates of eating disorders vary among ethnic groups in the United States, yet disordered eating has been found among European Americans, African Americans, Hispanic Americans, and Asian Americans (for a recent review see: Levinson & Brosof, 2016).
Our lab recently completed a review on disordered eating across ethnic groups. I will discuss a bit about what this review found. African American women tend to show lower levels of disordered eating behaviors than European American women, which may be related to the lower levels of both body dissatisfaction and thin-ideal internalization reported by African American women as compared with European American women. Hispanic American women may have higher levels of binge eating than either European American women or African American women. Asian American women show lower levels of many disordered eating behaviors than European American women. Ethnic minority groups in the United States are less likely than European Americans to seek treatment for eating disorders, suggesting a further need to examine how cultural and ethnic differences relate to differences in eating disorder symptomatology and treatment.
Both similarities and differences in disordered eating symptoms have been found across cultures as well. Researchers have found that Japanese women may have levels of body dissatisfaction that are similar to women in the United States; yet there may be different motivations behind body dissatisfaction among Japanese women. For example, body dissatisfaction is largely motivated by the thin-ideal in American culture, while body dissatisfaction may be driven more by a desire for delayed maturation in Japanese culture. In Chinese culture, fear of fatness may play a role in body dissatisfaction similar to American culture.
However, such generalizations may be limited by common definitions of cultural and ethnic groups. For example, China is inhabited by 56 different ethnic groups. As was seen when looking at the differences in disordered eating between ethnic groups in the United States, it’s likely that variability exists in levels of disordered eating across ethnic groups in China (and everywhere!). Imprecise definitions of culture or ethnicity can contribute to difficulties in examining similarities and differences across cultures.
Eating disorders are the outcome of a complex interaction between a variety of factors, including culture, environmental risk factors, individual differences in personality, and genetic factors. In order to understand how to reduce the distress and impairment that eating disorders cause, it’s important to examine the unique contribution of each of these factors. In so doing, researchers and clinicians can create interventions that best meet the needs of diverse populations.
Eating Disorder Treatment: Where to Start and What to Expect
by Laura Fewell, B.A.
Choosing an eating disorder treatment program can be overwhelming, especially when you are not sure exactly which treatment (if any) you need. Outpatient? Intensive treatment? A therapist, dietitian, or other specialist? And how exactly do you know if you have an eating disorder or disordered eating? If the thought of receiving eating disorder treatment feels overwhelming or too foreign to consider, read on below for helpful information on where to start and what to expect from treatment.
First things first: Do I have an eating disorder (or disordered eating)?
How do you know if your eating behaviors are problematic or maybe just a bit eccentric? One question to ask yourself is if your thoughts about your weight, shape, or eating habits interfere with your life (such as making you feel bad about yourself or preventing you from going out with others). Another is to pay attention to how you feel before or after eating—do you feel anxious, guilty, or upset? Other signs or symptoms of disordered eating include:
If you can relate to any of these statements, you may consider talking to an ED professional. You can also access online screenings through trusted websites such as NEDA http://screening.mentalhealthscreening.org/NEDA or McCallum Place Eating Disorder Treatment Centers https://www.mccallumplace.com/do-i-have-an-eating-disorder.html.
I might have an eating disorder—now what?
If you think you might struggle with an ED or disordered eating, the best thing you can do for your health and well-being is reach out to a professional. You can start by talking to a therapist, dietitian, psychologist, or psychiatrist with experience in EDs about your concerns. Research shows that if you have an eating disorder you will have the best chance of recovery if you are treated by a professional who is an eating disorder specialist. It is a good idea to ask about their ED experience or to find someone with a CEDS designation (Certified Eating Disorder Specialist). Although many professionals are willing to work with EDs, they are not all ED experts. Most ED professionals will recommend treatment options, such as going to regular outpatient appointments or looking into a higher level of care, like day programs or residential treatment. Some ED treatment centers offer free assessments and provide recommendations for levels of care to fit your needs. You can find ED referrals through the National Eating Disorders Association (http://www.nationaleatingdisorders.org/find-help-support), Eating Disorder Hope (https://www.eatingdisorderhope.com/treatment-for-eating-disorders/therapists-specialists), or by contacting Dr. Cheri Levinson at email@example.com.
Eating disorder treatment: What to expect
If you find that you need more than outpatient ED treatment (or a professional suggests you need a higher level of care), you may be referred to a day program or a residential program. Though spending most of your day (or overnight) at a treatment center may seem overwhelming, most programs are designed to take place in a therapeutic environment and have the goal of integrating you back into your normal life as quickly as possible. Below are general components of treatment programs that you can expect.
Prior to treatment: Once you find a program that looks like a good fit, call the admissions or intake office to inquire about an assessment. They will schedule a time to ask you about your personal information and history and will likely ask you to see your doctor for a medical workup. They will also call your insurance provider and discuss what types and portions of treatment they are willing to pay. Once they get this information, they will make treatment recommendations and set up an admission date if necessary.
Day 1: Arrive at the treatment center and expect to fill out lots of paperwork. You will be introduced to treatment professionals, other clients, and staff. Staff will go over program guidelines with you and layout what the program will be like. This day will probably feel like a whirlwind! I advise our clients that the first couple of days are the most difficult—between new faces, a new environment, and the fear of the unknown, there are lots of factors that can make the first few days feel scary. Typically by the 3rd or 4th day, though, clients are used to the routine and begin getting to know their peers and the staff. Soon after, they begin developing bonds with others and learn to trust the treatment center as a safe environment comprised of people who care about them.
Weights: Most programs will collect weights regularly, such as daily or weekly. This can feel a bit awkward at first, but most people get used to it quickly. In fact, it is part of your treatment & recovery!
Treatment team appointments: Throughout treatment, you will meet with your treatment team regularly. Your treatment team will likely be made up of a therapist, dietitian, and doctor, all of whom will set up a treatment plan for you and work with you towards your goals.
Meals: This is often the most anxiety provoking component of treatment. People often wonder, “Will I be forced to eat or not be allowed to eat enough? What happens if I feel too anxious during meal times?” Rest assured that, while not always easy, you will be given a personalized meal plan that will be exactly what you need. Your dietitian will work with you to educate you on what types of meals and portions are best for you.
Groups: An important part of treatment is developing skills and insight that will assist you in recovery. There are a variety of therapeutic groups each day that take place outside of meal times. These often include skills and processing groups, nutrition, art, and other specialized treatment modules (like cognitive behavior therapy) that aid in the healing process.
Other components of treatment: Depending on the treatment center, there will be nurses and/or doctors on staff who are available if a medical issue comes up. Patient care staff are available if clients need something, such as using the restroom or just talking after a hard day. There may also be exercise specialists to help clients who struggle with unhealthy or limited exercise, and some programs even have specialists who help athletes seeking recovery from their eating disorder while training for their sport.
A sample day program schedule may include:*
9:30am: weights and vital signs obtained
10am: snack (if applicable)
3pm: snack (if applicable)
7:30pm: program ends
*During the day, treatment team members may meet with patients in place of attending groups.
Treatment discharge: As you progress through treatment and get your eating habits and health back on track, you will begin preparing for discharge. A good treatment team will help you make a plan for what you’ll do after treatment, and they should help you find outpatient professionals so you can continue care in a meaningful way. Though many people want to know how long they’ll be in treatment, it is hard to give an exact length of time because of the highly individualized components of care. Some people need a few weeks to get on track, while others require a longer treatment stay to reach their health goals.
Taking the next step
Deciding to seek help for an eating disorder or disordered eating is not easy, but it is worth it. There is hope out there! Below are a list of resources if you would like to begin your journey to recovery. You can also contact Dr. Cheri Levinson if you have questions or would like to discuss treatment options.
Dr. Cheri Levinson: firstname.lastname@example.org
National Eating Disorders Association: www.nationaleatingdisorders.org
Eating Disorder Hope: www.eatingdisorderhope.com
McCallum Place Eating Disorder Centers: www.mccallumplace.com
Why Being Perfect Isn’t Always What It Seems: The Link Between Eating Disorders
By: Leigh C. Brosof
We all know someone who is (or perhaps recognize within ourselves) a perfectionist: the person who gets good grades or excels at their job, is involved in a myriad of activities outside of school/work, and seems to never settle for anything but the best. This can’t possibly be a bad thing, right? While having high standards is not necessarily harmful, high levels of perfectionism can create vulnerability for certain problems to develop, especially in terms of disordered eating. In fact, perfectionism is recognized as a vulnerability factor for eating disorders.
In order to understand why perfectionism can be harmful at times, it is first important to define exactly what perfectionism is. Colloquially, perfectionism is defined as anything less than perfect being unacceptable, where being “perfect” means living up to standards of extreme excellence or not making any mistakes (Merriam-Webster, 2016). This is actually a pretty complex definition when you look at it, and that’s why perfectionism is defined in a slightly different way by researchers. Researchers view perfectionism as a multi-dimensional construct, meaning that it’s made up of multiple parts (Frost et al., 1990).
More specifically, perfectionism can be broken down into two parts: adaptive and maladaptive perfectionism (Hewitt, Flett, Turnbull-Donovan, & Mikail, 1991). Adaptive perfectionism is when an individual has high standards for themselves. Maladaptive perfectionism can also be called evaluative perfectionism. In this type of perfectionism, individuals become preoccupied over making mistakes, which then leads to self-critical evaluation. Whereas adaptive perfectionism is healthy because it pushes an individual to do his or her best and set high expectations (DiBartolo, Frost, Chang, LaSota, & Grills, 2004), maladaptive perfectionism is harmful because it means that nothing we do will ever be good enough and that we set unattainable standards for ourselves. This can obviously lead to disappointment and feelings of inadequacy.
So, how does this relate to eating? If an individual sets unattainable standards for themselves in all areas of their life because of perfectionistic tendencies, then this can lead to negative outcomes for mental health, such as anxiety and depression, as well as disordered eating attitudes and behaviors (DiBartolo, Li, & Frost, 2008). In fact, some research has linked a specific type of perfectionism to eating disorders (Bardone-Cone et al., 2007). This type of perfectionism is the excessive worry over making mistakes.
Researchers have proposed different theories as to why perfectionism may lead to eating disorders. For instance, some researchers have proposed that disordered eating behaviors manifest after an individual high in perfectionism internalizes the thin-ideal (or the societal belief that being thin is the ideal body type). This thin-ideal set by society, however, is unattainable. The pursuit of this impossible thin-ideal along with the self-criticism that accompanies maladaptive perfectionism might lead to disordered eating. Other theories suggest that perfectionism may lead to other negative outcomes, such as low self-esteem or fears of being judged by others based on appearance and that these outcomes then lead to disordered eating behaviors (Brosof & Levinson, 2017; Mackinnon et al., 2011).
Importantly, by better understanding how perfectionism relates to eating disorders, we now also know that we can create interventions to target perfectionism to help treat eating disorders. For instance, one type of treatment might be having a patient practice making mistakes to help them learn that making a mistake does not lead to terrible outcomes. We can also help prevent eating disorders by helping people already high in perfectionism through similar interventions.
It is important to remember that everyone makes mistakes and that making mistakes is normal! In fact, making mistakes is how you learn. It is also important to know that there is no such thing as a “perfect” body or a “perfect” diet. All of our bodies are different in order to do different things and need to be fueled according to our own needs. You are worthwhile person and you are good enough, no matter what. If you are or someone you know is struggling with disordered eating or other mental health problems due to perfectionism, there is help. We are currently offering a perfectionism group treatment, please reach out if you are interested in joining. You can also call the National Eating Disorder Association helpline at 1-800-931-2237.
Dr. Levinson is featured in a story on positive self-image, read the story here:
Listen as we discuss the research ongoing in the EAT lab:
https://soundcloud.com/uofl/12-05-16-uofl-today-ruther-levinson-brosof (starts at 17:20)
Reflections on the Eating Disorder Research Society and Association for Behavioral and Cognitive Therapies Meetings
Reflections on the Eating Disorder Research Society and Association for Behavioral and Cognitive Therapies Meetings
by: Cheri A Levinson, Ph.D.
The last weekend of October was a busy one, as I was attending two meetings at once! I had the chance to attend the Eating Disorder Research Society for the first time, as well as the Association for Behavioral and Cognitive Therapies. I left both conferences full of new ideas. Here are some of the highlights of what I learned:
Heather Thompson-Brenner presented work on disseminating the Unified Protocol for Emotional Disorders in a Residential Care Facility (for eating disorders). This work is really exciting because it suggested that targeting underlying emotional disorders may be an effective treatment in a residential level of care. I am not aware of much work identifying treatments that work in such a high level of care, let alone one that is targeting symptoms of multiple disorders. I am hopeful we will see more of this in the coming years.
Eric van Furth presented his work on the top research priorities for eating disorders identified by patients, carers, and families. Some of the top priorities were identifying if clinicians should target the eating disorder or the underlying problems first, comorbidity, and the development of personalized treatment (and see below on how we might develop these treatments). Dr. Furth also discussed his hope that funding agencies would pay more attention to what patients and carers asked for. I whole-heartedly agree. This type of research seems like a great starting point for identifying clinical research that is applicable and helpful to the people who are actually suffering from these problems.
Some other highlights from EDRS. Laura Berner presented her work showing that there are brain regions that are associated with feelings of loss of control eating, research was presented showing patients did better when randomly assigned to day treatment than to inpatient treatment, and Patrick Kennedy gave the keynote address urging eating disorder researchers to think more globally about connecting with other non-eating disorder groups.
Now on to ABCT. I didn’t get to spend as much time at ABCT, but there were two highlights that stood out to me. First, Robert Krueger presented his work showing how the level of analysis impacts how psychopathology is defined. At the broadest level all psychopathology clumps together, it then separates into two clusters (externalizing and internalizing) and then an OCD cluster emerges. And guess what falls into the OCD cluster? Eating disorders!
Last, Aaron Fisher presented work using ecological momentary assessment to develop personalized interventions. I had several discussions with other colleagues about this idea and I am really excited about the possibilities that might come from these methods. Let me explain using network analysis. If you assess symptoms say 100 times across several weeks, you can use this data to build an individual network of symptoms. You can then identify what symptoms may be of specific importance within the individual and develop treatments targeted at that symptom. Why am I so excited about this idea? Anorexia nervosa is a particularly heterogeneous disorder and I think this method might pave the way for personalized treatments specially designed for each individual.
All in all a great (two!) conferences. I’m already looking forward to next year.
Check out the Courier Journal article that Dr. Levinson helped with: