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. 2009 Oct 5;43(7):633–647. doi: 10.1002/eat.20755

TABLE 2.

Perceived impact of stigma and/or shame on care for eating and weight symptoms

ID # Gender Ethnic Identity Selected Interview Excerpts and Context Supporting Experience of Shame and/or Stigmaa Selected Interview Excerpts and Context Supporting Perceived or Apparent Adverse Impact
Ethnic minority study participants
10 F African-American Spoke generally of what it can be like to be black and seeking care for an eating disorder inasmuch as it generates the feeling that “maybe there's something wrong with your racial identity, maybe you shouldn't be doing this, this is not your problem, type attitudes can be really hurtful. You know to already know that you're doing this, less than healthy thing, not only is your health compromised, but your identity is compromised too. That can be a lot.” Feels that the embarrassment that black individuals experience having an eating disorder generally may make it more difficult to seek care.
11 F Asian-American/Chinese Perceived “less encouragement to seek outside help. [ … ] you were taught to be very subservient and feel shame and guilt [ … ]” This perception specifically applied to disclosing symptoms to non-Asian clinicians, but also applied to seeking any type of counseling, “And you know there was also this stigma, I don't know where it came from, of you know having to get counseling for this stuff was, I don't know, like you're mentally ill—you're a nut. You're a kook.” Family attitudes kept respondent from seeking care; felt she needed to “sit and live with it.” Avoided talking about eating struggles, and went many years without “asking anybody for anything.”
17 M Latino; Puerto Rican Felt that seeking help was “silly” and that eating issues were “something I should deal with in myself” and that “It was more of a personal thing than anybody else helping me with it.” Resistant to seeking help; eventually sought help on recommendation of others, though “really was hesitant going in the first place”
18 F African-American In the black community, talking about weight is a “touchy subject,” so “a lot of times things don't get discussed,” even in the context of obesity-related illnesses. She stated that she was “[ … ] shy about, or reluctant to talk about” weight concerns with a screening counselor; “Well, usually for me we won't talk to people about my weight.”
21 M Latino “[ … ] even hide it from my own family. My mother has said that is a personal, that's a personal thing, and you don't go tell people, especially your friends, about stuff like that. [ … ] Unless it's somebody you can really, really, extremely trust a hundred percent like you can do yourself. Like you do yourself. Like I do myself. But I've never said a word to any of my family or friends about it.” Admits some limited disclosure with clinicians: “[ … ] I really didn't bring everything up at the time [ … ]” about eating but also expressed his wish that they had asked him more in-depth questions about it. “[They should …] ask the student to be more in-depth about it.” “[If there were more time], I could spill the beans to him more and see what he would say.”
Non-ethnic minority study participants
2 F White/Polish, Hungarian and Italian descent “I mean because it's just, you know, fat people are always looked at as like weak people, sloppy people, you know they don't care about themselves, they don't want to take care of themselves, but that's not true. And it's been a lot of trying to overturn those stereotypes.” She initially avoided therapy: “At one time I did [avoid care] cause like I said, what my family was saying to me about ‘It’s really not a problem and you're making a mountain out of a mole hill.' ” Concerned that her problem would be seen by health care providers as a lack of “will power.”
Perceived lack of support from family for care-seeking: “You know my family had a big problem with my going to therapy, […] It was like they felt there was something wrong with them because I had to go to therapy […].”
3 F White Ashamed of lack of control over eating, in context of self-image as a good student, athlete, and “really put-together person.” Reported a “crazy fear” that clinicians “aren't going to take you seriously” and “aren't going to think your problems are as bad as other patients,” or that people would talk about her as “ ‘the girl with that problem.’ ” She “let it go on for so long” without telling anyone. “But it was like, ‘well I have to deal with this situation and I can't possibly tell anyone about it, so I have to deal with it myself.’ ” She felt symptoms became entrenched and “a coping mechanism for everyday life.” She eventually sought help.
4 F White/Jewish Embarrassed about overeating. “I'm just embarrassed.” Does not discuss symptoms. Embarrassment kept her from talking to a friend whom she believed would be supportive and possibly knowledgeable about the problem. She also was reluctant to seek support via OA: “[ … ] the counselors at the hospital were trying to get me to go to OA and I wouldn't go. And I wouldn't go because of the name and what it meant [ … ] I'm not going to go to something that has a horrible name [ … ].”
7 M White Embarrassed by what doctor might say: “[ … ] you want to pass the test; you want to look great, and kind of hide the truth.” Did not discuss weight concerns with physician; preferred to talk to counselor or family.
12 F White/German and Irish descent Reluctant to disclose information: “Not, not letting go of too much information, not making my weakness very vivid, because I didn't want to be taken advantage of or to be laughed at or anything…. I was very hesitant to talk about it at first.” And “[ … ] so then telling somebody about it was more just like saying, ‘well yeah, I'm weak. And admitting that, and it just felt bad.’” Generally reluctant to disclose information about eating disorder symptoms. Postponed treatment for several years after she was aware of the onset.
14 F White/Polish descent Family considered seeking treatment a weakness: “[ … ] my parents said, ‘well if you tell people, then they are not going to let you play tennis and they are not going to let you do this,’ so I had a bit of fear in me that they weren't going to let me participate in sports anymore, that I was going to have this stigma surrounding me.” Dissuaded from seeking treatment because: “[…] it was just the fear that my family kind of put into me that it's a bad thing—it's going to hurt you for the rest of your life if it ever goes on your record that you've had this problem.” Parents asked her not to seek specialty care for the eating disorder: “Because I would have a record. And if I ever wanted a job in the future, they would see that and basically the whole stigma thing.”
15 F White Admits limiting disclosure with peers: “I think that it's not to really talk about it. I mean, I do to a certain point, but there's OK places to talk about it and not OK places to talk about it.” And with her clinician: “I'm not always like truthful about things. I just usually, I don't say anything about it. Like if something's bothering me or I don't want to say it cause it's like, I don't know, something's that's probably needs to be known but I'm afraid that, it's like embarrassing for me to talk about, I won't talk about it.” Perception of social acceptability limits disclosure to peers; embarrassment limited disclosure to a clinician.
20 F White Embarrassment over eating issues as a “character flaw” in otherwise high-achieving self-perception. “And so you're embarrassed to ask what other people think or if you should go get help.” Uncomfortable discussing eating issues. Delayed seeking care: “I wouldn't go at first;” but later sought care after deciding “[an eating problem is] embarrassing and it's ugly, but it's not a big deal.”
22 F White Reluctant to disclose weight concerns to friends: “I, I just, I was ashamed about it. I didn't think that they would understand.” as well as to professionals: “I felt awkward about [asking for professional help for weight concerns].” Reluctant to seek support and professional help in high school; felt able to seek professional help in college.
24 F White Eating/weight concerns are “personal business” and an uncomfortable topic to discuss. “I really don't like to talk about it at all.” “I don't sit down, I wouldn't pull someone aside and just say, ‘I need to chat about my weight.’ That's just something I wouldn't do.” Limited help-seeking: Brought up eating/weight concerns once with primary care doctor, but is unlikely to do so again because of “not liking to talk about it.” Sought therapy and medication for nonweight issues, but did not discuss eating or weight with those clinicians.
25 F White/Hungarian descent Embarrassed to discuss dieting. Sense that others aren't concerned about her eating habits; they don't understand: “Cause people aren't, they're not that concerned with it right then and there. And they don't understand, either.” Also: “Some people, if they, they just think you don't have enough will power. Or they just think you're lazy. Do you know what I mean? Like some people won't take it as like a medical problem.” Initial non-disclosure (except sometimes to mother) about eating habits to clinicians when she was younger: “I don't think I would really know to go to the doctor and ask the doctor. I was probably embarrassed to go to the doctor and talk about it.”
27 F White/Irish-Catholic Experienced shame and discrimination related to her weight: “And it was looked upon if you were obese you were glutton. You're a sloth.” Nonspecific impact on relation with her clinicians; for example, she stated: “You know I made sure I looked OK even though I was huge. It was like dressing up on the outside to hide the [expletive deleted] on the inside ’n stuff. And I carried it off pretty good.” Also describes difficulty in self-disclosure due to shame: “I get sick to my stomach knowing I have to go in and tell him what's been going on. Yeah, it's not easy.” and admits to limiting disclosure initially in treatment.
28 F White/Italian/French-Canadian descent “I was, it was a perfect combination of ashamed and feeling like no one would do anything or could do anything about it. It wasn't an issue that other people could help you with, I thought you know, you just got to buck up and eat better.” Family did not support her seeking treatment for this problem. “I mean I don't think that my family's really big on going to the doctor's unless you were dying, you know? And you know weight concern is more like a moral issue. In a way, make it like, ’You eat too much,' or ’Don't be such a pig and you'll be fine with your weight' kind of thing.” Many years delay in seeking treatment.
30 F White/French and German descent “Afraid they [clinicians] would think I was certifiable and put me in a funny farm.” She stated: “If you want a big black mark against you, go to the psychiatric ward.” Fear of hospitalization led to non-disclosure to clinicians about emotional reasons for restricting food; she stated: “It's a pretty good motivator to keep your mouth shut.”
Also: “I still think it is sort of a taboo subject. It is just not something that people talk about. Umm…. It is just not recognized as a problem. It is some sort of personal weakness if you can't deal with these things. If you are fat it is a personal weakness. A character flaw.”
a

Direct quotations from study participants are placed in double quotation marks; bracketed ellipses denote nonessential text removed for streamlined presentation; investigators' interpretation of pronouns or implicit context placed in square brackets.

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