Internalized bias is an “unfair belief, assumption or generalization about an individual or group of people based on personal characteristics that occur without one’s knowledge” (Government of Canada, 2023). These biases operate outside of one’s awareness and can directly contradict our beliefs and values. Internalized bias is universal, meaning everyone has it, and it influences all human interaction. As a clinician, understanding internalized biases is essential for providing optimal patient care, especially when treating eating disorders.
Types of Internalized Bias in Eating Disorder Care
The primary types of internalized bias that impact eating disorder care (EDC) include weight bias, gender bias, socioeconomic status (SES) bias and parental blame bias.
Weight Bias and the Balanced View Approach
Weight Bias
Weight bias is the “negative attitudes, beliefs, assumptions and judgements towards individuals based on their weight, shape, appearance or BMI” (ODPH, 2019). It involves generalizations that individuals are to blame for their weight. It assumes individuals in larger bodies are lazy, lack self-discipline and are non-compliant with medical treatments. Weight bias results from both conscious and unconscious thoughts and can lead to prejudice, stigma and discrimination. Although weight bias can affect individuals of any weight, it most commonly targets folks living in larger bodies.
Weight stigmatization is a risk factor for disordered eating behaviours, and experiencing weight bias may increase eating disorder (ED) symptoms. Frequent weight-related teasing is also associated with an increased risk for binge eating, restrictive eating and maladaptive weight control behaviours among youth.
Examples of weight bias in EDC include:
- Assuming a patient has a binge eating disorder because they are living in a larger body
- Having a lack of optimism about treatment outcomes of patients living in larger bodies
- Believing and assuming that behavioural factors lead to a higher weight status
Strategies to combat weight bias in EDC:
- Understand that restrictive EDs can occur at any weight
- Avoid the assumption that because someone is of higher weight, treatment won’t be successful
- Consider environmental and genetic contributors
- Ensure your clinical environment is accessible, safe and respectful to all patients regardless of their weight
- Consider if weighing is essential to providing patient-centered care
- Ask permission before weighing a patient
- Consider blind weights so the patient does not see their weight
- Consider how your clinical setting accomodates people of all sizes and ensure you have appropriately
- Implement and practice the balanced view approach
The Balanced View Approach
The Balanced View Approach is an evidence-based resource and guide designed to reduce weight bias among clinicians.
Strategies for implementing a balanced view approach include:
- Initiating a conversation about weight respectfully.
- Do talk about:
- Eating foods that make you feel good and that you enjoy
- Positive qualities unrelated to size, shape and appearance
- Social determinants of health
- Finding activities you enjoy for mental health and physical well-ebing
- Do not talk about:
- Using food or activity to control weight
- “Good” or “bad” foods
- Do talk about:
- Emphasize health-promoting behaviours rather than weight loss
- Recognize food as something more than “fuel”
- Listen to and explore the context of people’s lives
- Work collaboratively with your patient
- Understand a person’s beliefs about their weight and themselves
Gender Bias in Eating Disorder Care
There is a common belief and assumption that EDs only affect females, but this is a myth. Eating disorders and disordered eating can affect all genders and gender identities. A key factor of gender bias in EDC is that men remain underrepresented in ED research, which may lead to gender-biased diagnostic criteria and assessment tools. It is essential to consider this when treating EDs.
Gender-diverse patients may have risk factors for disordered eating. Research has shown that gender non-binary individuals are 2-4 times more likely to develop disordered eating than their cisgender peers. Elevated rates of body dysmorphia also exist within this population.
Socioeconomic Status Bias in Eating Disorder Care
SES bias stems from the common belief and assumption that EDs are more common in individuals with higher SES. This is a myth, and research has shown a relatively equal distribution of EDs across all SES categories.
Important SES considerations for EDC:
- Limited access to treatment
- Food insecurity
- Financial barriers
Parental Blame Bias in Eating Disorder Care
The belief that parents cause eating disorders is a common misconception and stereotype. EDs are complex mental health disorders and their development is multifactorial. For example, a parent commenting about their own body image may lead to children having negative thinking patterns about themselves. This negative thinking may contribute to the development of an ED but does not cause it.
It is common to be met with resistance from parents of children living with EDs. Suggested approached for resistant parents include:
Determining Your Internalized Bias
Harvard University’s Project Implicit offers the Implicit Association Test (IAT), which measures your attitudes and beliefs to determine unconscious biases you may have. The test is free to complete and can be accessed via the link below:
Confronting Your Internalized Bias
Once you have determined any internalized biases you may have, probing questions can be used for self-reflection. These include:
- Do your biases:
- Influence how you communicate with patients?
- Impact the amount of time you spend with patients?
- Affect the treatment interventions you suggest?
- Are you less comfortable with patients of a different race, gender, SES or weight than you?
Strategies to Combat Your Internalized Biases
- Introspection
- Mindfulness
- Perspective-taking
- Checking your messaging
- Individuation
- Learning to slow down
Summary
Internalized bias occurs without one’s knowledge and leads to unfair beliefs, assumptions or generalizations about an individual or group of people. It influences interactions and combating it is essential for providing patient-centered care. Weight bias, gender bias, SES bias and parental blame bias are the primary types of biases that impact EDC.
Our Eating Disorder Care for Primary Care Providers online training discusses internalized bias in eating disorder care. If you’re interested in learning more, you can register for the training below.
