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. 2022 Jan 29;55(4):463–469. doi: 10.1002/eat.23682

Accountability in promoting representation of historically marginalized racial and ethnic populations in the eating disorders field: A call to action

Neha J Goel 1,✉, Karen Jennings Mathis 2, Amy H Egbert 3, Felicia Petterway 4,5, Lauren Breithaupt 4,5, Kamryn T Eddy 4,5, Debra L Franko 4,6, Andrea K Graham 7
PMCID: PMC9305786  PMID: 35092322

Abstract

Promoting representation of historically marginalized racial and ethnic populations in the eating disorders (EDs) field among professionals and the populations studied and served has long been discussed, with limited progress. This may be due to a reinforcing feedback loop in which individuals from dominant cultures conduct research and deliver treatment, participate in research, and receive diagnoses and treatment. This insularity maintains underrepresentation: EDs in historically marginalized populations are understudied, undetected, and undertreated. An Early Career Investigators Workshop generated recommendations for change that were not inherently novel but made apparent that accountability is missing. This paper serves as a call to action to spearhead a paradigm shift from equality to equity in the ED field. We provide a theoretical framework, suggest ways to disrupt the feedback loop, and summarize actionable steps to increase accountability in ED leadership and research toward enhancing racial/ethnic justice, equity, diversity, and inclusion (JEDI). These actionable steps are outlined in the service of challenging our field to reflect the diversity of our global community. We must develop and implement measurable metrics to assess our progress toward increasing diversity of underrepresented racial/ethnic groups and to address JEDI issues in our providers, patients, and research participants.

Keywords: accountability, call to action, diversity, early career investigators, eating disorders, equity, ethnicity, inclusion, justice, race

1. INTRODUCTION

Promoting racial and ethnic diversity in the eating disorders (EDs) field in research and practice has long been discussed, with limited change (Cassidy, Sbrocco, & Tanofsky‐Kraff, 2015; Franko, 2007). In 2020, the Eating Disorders Research Society (EDRS) hosted an Early Career Investigators Workshop focused on how the next generation of ED professionals can innovate new strategies to enhance justice, equity, diversity, and inclusion (JEDI). From this workshop, we applied a critical lens to the systemic oppression and structural barriers that have excluded certain racial/ethnic groups from research and the workforce. Our discussion led to the development of a conceptual/theoretical model that suggests a reinforcing feedback loop which maintains racial/ethnic underrepresentation across our field (Figure 1), similar to trends in broader psychological science (Buchanan, Perez, Prinstein, & Thurston, 2021; Roberts, Bareket‐Shavit, Dollins, Goldie, & Mortenson, 2020). Disruption of this feedback loop will require broad JEDI training occurring across the ED field.

FIGURE 1.

FIGURE 1

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Reinforcing feedback loop that maintains underrepresentation of racial/ethnic diversity in the eating disorders field. Rectangles represent the two domains that maintain underrepresentation within and between each domain. Although feedback loops can exist independently, the interaction of the major domains leads to systemic challenges, represented by the ovals. For outcomes to be improved, change must occur within and between each domain

The workshop also generated recommendations for change. These recommendations were not inherently novel, but made apparent that accountability has been missing from JEDI efforts. Considering that many scholars are already engaged in JEDI efforts (e.g., Hargons et al., 2017), it is timely and imperative to offer guidelines that further shape how JEDI is incorporated, sustained, and measured in the ED field. In this paper, we present opportunities to increase accountability in ED leadership and research toward enhancing JEDI. Although we focus on accountability as it pertains to racial/ethnic diversity, race and ethnicity represent only two facets of identity, and intersectionality must also be considered (Burke, Schaefer, Hazzard, & Rodgers, 2020; Crenshaw, 1989). Indeed, race and ethnicity are often linked to other identity factors (e.g., gender, sexuality, socioeconomic status) that impact equitable access to resources (Braveman, Egerter, & Williams, 2011; James et al., 2016). We aim to spearhead a paradigm shift from equality, in which everyone is given the same resources/opportunities, to equity, which ensures access and distribution of resources according to individual need to reach an equal outcome.

2. LEADERSHIP: ACCOUNTABILITY TO THE RECRUITMENT, RETENTION, AND PROMOTION OF RESEARCHERS FROM HISTORICALLY MARGINALIZED RACIAL/ETHNIC GROUPS

Increasing JEDI in the ED field requires recruiting, retaining, and promoting underrepresented researchers whose social and cultural backgrounds and lived experiences contribute to diverse research questions, methodologies, and populations served (Guy, Afifi, Eissenberg, & Fagan, 2020; see Figure 1). We highlight four domains to propel accountability toward these goals. Although enacting change is a collective responsibility, sustainable change will be maximized through accountability among leadership across multiple levels of influence (e.g., mid‐career and senior researchers, ED professional organizations, ED editorial boards).

2.1. Create and promote safe, inclusive, and supportive spaces with appropriate resources to facilitate long‐term careers in ED research

Disciplines that are typically dominated by a majority group (e.g., White men) create and reinforce environments that attract similar peers (e.g., Lett, Orji, & Sebro, 2018). This has the potential to make those who do not fit these identities feel unwelcome, marginalized, and excluded. Improving JEDI includes creating safe, inclusive, and supportive spaces and structures for researchers to convene and/or affiliate, and providing mentoring opportunities for individuals from marginalized racial/ethnic populations. Inclusive environments focus on respect and encourage active exchange of ideas, dialogue about our own biases and prejudices, and diverse perspectives that are critical for advancing our field (Dewsbury, 2017).

Accountability to this goal requires assessing current diversity within the ED field and measuring change over time. For example, the EDRS and Academy for Eating Disorders (AED) currently do not gather members' demographic data. However, research labs and ED professional organizations can survey members for demographic information (while explaining the importance of gathering such data to maintain transparency) and publicize the results. If underrepresentation exists, leadership can enact initiatives to promote diversity and facilitate opportunities for all individuals to engage in self‐reflection and trainings about how to be active in JEDI initiatives. This helps prevent “cultural taxation,” or having individuals from underrepresented racial/ethnic backgrounds be required or expected to carry the burden of providing mentorship, supporting JEDI initiatives, and holding the field accountable for increasing diversity (Joseph & Hirshfield, 2011; Padilla, 1994).

An instrumental component of establishing safe spaces is the willingness of those in power to engage in JEDI practices. Leaders and mentors can explicitly state how power and privilege shape policies that systematically disenfranchise socially marginalized groups, and simultaneously engage in ongoing self‐reflection to confront implicit biases that influence the way each of us interacts with others. We also encourage such leaders to become informed through scholarship that provides suggestions for incorporating JEDI practices across contexts, including mentorship relationships (e.g., Banaji & Greenwald, 2013; Sue, 2015), and to engage mentees in conversations about how to implement non‐discriminatory practices in their labs. This work enables individuals to express their opinions without fear of retribution, which is critical to sustaining an inclusive environment. Indeed, lab and organizational leaders can create and publicize guidelines of JEDI expectations, including what constitutes a breach and actions to take when a conflict occurs. Leadership can also reaffirm members' commitment to the guidelines and invite feedback for improvements through regular review (e.g., elicit suggestions via an anonymous survey). External auditors (e.g., from allied disciplines and fields) could help assess the guidelines' merits. Overall, these recommendations are offered to help ensure the responsibility for establishing safe spaces does not primarily and inadvertently fall only on individuals from marginalized racial/ethnic groups and encourages every leader/mentor in the ED field to work toward creating and promoting inclusive spaces.

2.2. Identify and implement initiatives to recruit and retain researchers from historically marginalized racial/ethnic groups

Recruitment and retention efforts should be transparent. This includes leaders detailing recruitment/retention plans, how goals will be measured, and how initiatives will be modified (when indicated). These goals should be explicitly stated on member/public‐facing materials (e.g., websites, lab manuals). Then, evidence‐based initiatives can be implemented, such as forming equitable partnerships with communities that primarily serve underrepresented populations (Wallerstein & Duran, 2010) and enhancing the pipeline of researchers into our field. In academia, administrative leadership and ED lab directors can collaborate with student organizations or government programs (e.g., McNair Scholars) to provide undergraduate students from marginalized racial/ethnic communities opportunities to be involved in research and other scholarly activities. Organizations and institutions also can create structural changes that encourage accountability to JEDI, including incentivizing ED researchers to engage students from marginalized communities and allocating funds for professional development to scientists from racially/ethnically underrepresented backgrounds to attend conferences and conduct research (e.g., funding pilot research). Additionally, institutions can enhance the pipeline by offsetting costs for early career scientists (e.g., high school through post‐doctoral trainees) to participate in organizational activities through tiered payment systems. Although many ED professional societies have made significant progress toward this effort, leadership can expand these efforts by (a) explicitly stating how fees are utilized and, (b) creating metrics to monitor whether the tiered payment structure directly diversifies representation within organization memberships and at meetings.

Leadership also needs to retain senior members from marginalized communities. There is a limited pool of potential ED mentors from historically marginalized populations who can successfully shepherd underrepresented minority students and junior researchers (Jennings Mathis et al., 2020). Thus, leadership can be more intentional when asking senior leaders from marginalized communities to engage in service and mentorship, and instead ask all members in our field. In academia, leadership can recognize JEDI contributions and/or offer compensation for such efforts (e.g., buyout time, workload decrease). Professional organizations can create social networks for researchers from marginalized communities to have professional and emotional support as well as collaborative engagement in mentorship. Finally, instead of encouraging assimilation into the ED field, leadership can recognize and accommodate cultural norms of socialization that may be associated with success for individuals from marginalized communities. For example, instead of only recognizing the accomplishments of individual researchers or activists within the field, ED leadership can establish awards to promote group or collaborative achievements, which may be better aligned with more collectivist and interdependent cultures.

Another avenue for retention is enhancing researchers' professional skills and networks. For instance, journals can offer mentored reviewing programs for early career scholars from marginalized backgrounds. Doing so increases the diversity of reviewers and gives scholars timely, personalized feedback early in their career. The International Journal of Eating Disorders has such a program.

Once initiatives are implemented, organizations can (and should) regularly monitor progress of outreach efforts and their outcomes, iterate as needed, and remain transparent.

2.3. Equitably promote researchers from underrepresented racial/ethnic groups

Increased equity in research also entails equity in opportunities for advancement, as well as accessibility to said opportunities. In the United States (U.S.), early career researchers from historically marginalized racial/ethnic groups are less likely to receive awards, more likely to face additional barriers (e.g., racism and discrimination), and are often overlooked for opportunities like awards and accolades relative to White peers (Clark & Hurd, 2020). One way to combat these inequities is for professional organizations, higher education institutions, and other governing bodies to reevaluate the criteria and review process for awards. First, evaluate the accessibility of award information, implement initiatives to increase access to the award criteria and process (e.g., requirements, how to submit, deadlines), and promote transparency through information sessions (FAQ, peer review). This helps address academia's “hidden curriculum” whereby unwritten expectations are accessible to those from the dominant culture through mentors and peers and may be less known to individuals from racially/ethnically underrepresented backgrounds or institutions without senior researchers in the ED field. Second, offer multiple awards across a diversity of opportunities such as advocacy, clinical work, and community‐based engagement. Third, implement a masked review process, when appropriate, to mitigate the influence of stereotype bias (Roberts & Verhoef, 2016).

Organizations should also consider the potential consequences of “diversity awards.” Although diversity awards provide opportunities for racially/ethnically underrepresented individuals, they can foster a “separate but equal” mentality. Namely, they may give the illusion of equitable candidate selection, but in actuality, convey the dual message that diversity awards are for applicants from marginalized racial/ethnic groups, whereas unrestricted awards (e.g., no eligibility criteria based on race/ethnicity) are for applicants from dominant cultural groups. Germano and colleagues (2021) found that, when presented with both diversity and unrestricted awards, applicants from marginalized racial/ethnic groups were more likely to prioritize submitting to diversity awards over unrestricted awards, even when the monetary prize was less. This limits the diversity of the applicant pool for awards that are often more prestigious and lucrative, and contributes to unrestricted awards being disproportionately awarded to White individuals (Germano et al., 2021). Rather than eliminating diversity awards, increase the financial value of diversity awards, and/or update the purpose and criteria of unrestricted awards to emphasize cultural diversity (Germano et al., 2021).

Lastly, researchers should strive for accountability in equitable authorship by recognizing the contributions of authors from underrepresented racial/ethnic groups.

2.4. Advocate for change to embrace JEDI efforts that are historically undervalued and/or underrecognized in institutional structures and individuals

Many ED scholars—often from marginalized racial/ethnic groups—have already fostered progress by, for example, serving on JEDI taskforces, presenting to lay audiences, and establishing mentorship programs for underrepresented groups. However, these efforts are often underrecognized and under‐rewarded by institutions compared to publishing manuscripts, for instance. Since meaningful JEDI efforts take time and may not be reinforced for advancement within traditional academia, we must create defaults that incentivize such efforts. Institutional leadership can develop incentives and/or requirements for JEDI activities and integrate JEDI efforts into hiring, promotion/tenure reviews, and annual reviews that inform compensation structures (e.g., stipend, course buyout, counts as service) for all faculty. To monitor the implementation and efficacy of ongoing initiatives, academic departments and organizations can establish JEDI committees that oversee graduate training and editorial practices for academic journals, for instance. Such initiatives force scientists and academic institutions to be accountable in pursuing JEDI efforts and provide measurable mechanisms for monitoring progress. Lastly, similar to our other recommendations, academic departments can explicitly define and track the efficacy of JEDI initiatives and adjust as needed.

3. RESEARCH: ACCOUNTABILITY TO ENSURE OUR RESEARCH BENEFITS UNDERSERVED POPULATIONS

In addition to diversifying our workforce, we encourage scientists to commit to scholarship that benefits underserved populations and goes beyond understanding EDs using data from a homogenous population (e.g., young, White cisgender females from Westernized societies). Although EDs can affect anyone, regardless of race/ethnicity, gender, or cultural group (Cheng, Perko, Fuller‐Marashi, Gau, & Stice, 2019), and we know they do (e.g., Marques et al., 2011), historically marginalized racial/ethnic populations are less likely to be recruited, assessed, and retained in ED research (Egbert, Hunt, Williams, Burke, & Mathis, 2022; Goel, Thomas, Boutté, Kaur, & Mazzeo, 2021). When recruitment of diverse study participants is limited, study results become less generalizable to underrepresented groups, perpetuating the myth that EDs affect only young, White cisgender females from Westernized societies. In turn, research findings and outcomes continue to focus on this homogenous group (see Figure 1). We present two domains to help our field stay accountable to ensuring our research benefits underrepresented populations.

3.1. Improve representation of historically excluded racial/ethnic populations in research

We encourage scientists to commit to recruiting more racially/ethnically diverse samples in all ED studies, and this task should not be disproportionally placed on researchers from underrepresented racial/ethnic populations and/or those who pose questions that specifically address EDs in marginalized racial/ethnic groups. Toward this goal, researchers can utilize community‐engaged practices and purposeful sampling, employ culturally sensitive language during the consent process, and use culturally appropriate measures that have been normed and validated with the population of interest (Kawamura, 2015; Wallerstein & Duran, 2010). When it is not feasible to recruit a more diverse sample and/or use culturally appropriate measures, scientists should acknowledge these limitations and their impact on findings. Additionally, scientists can consider adding techniques from qualitative research, such as reflexivity statements, to articles. In reflexivity statements (also known as positionality), authors acknowledge how their cultural identities and perspectives are imbued with an inherent bias that influences their interactions with the research design, participants, and interpretation of study findings (e.g., Creswell & Poth, 2018).

3.2. Commit to detailed inclusive reporting and dissemination

To hold scientists accountable, ED journals can require authors to justify, collect, and report comprehensive demographic data that can augment the overall impact, interpretation, and generalizability of findings (Buchanan et al., 2021). We encourage researchers to shift attention away from reinforcing a “home‐field disadvantage” perspective (e.g., establishing White populations as the “standard” by which all other groups are compared) to a more equitable approach (e.g., normalizing and legitimizing research that exclusively focuses on the experiences of marginalized racial/ethnic populations; Medin & Chandler, 2010). Inclusive research also means embracing methods like qualitative methods and community‐engaged research approaches—both of which specifically center underrepresented populations' voices in research and seek to promote health equity (Creswell & Poth, 2018; Wallerstein & Duran, 2010). Notably, the dissemination of findings based on these methods often benefits from longer word limits than is common in ED journals. Therefore, ED journals could expand their word limits to better enable inclusive reporting. We also encourage scholars to pursue work on protective factors and/or utilize strength‐based approaches to exploring ED risk and resilience in historically marginalized groups (Tse et al., 2016); doing so reinforces a more holistic view of health that acknowledges how individuals already possess adaptive skills that can be leveraged to alleviate (or avoid) suffering. Scientists can be accountable to underserved groups by using lay‐friendly mediums, such as graphical or video abstracts, to disseminate findings beyond the scientific community. Finally, ED journals could publish annual reports aggregating data about both important findings and demographic characteristics of underrepresented populations across published papers, and across journals in the field, and highlight noteworthy trends, next steps, and continued areas for improvement (Egbert et al., 2022; Roberts et al., 2020).

4. CONCLUSIONS

Individuals from marginalized racial/ethnic populations are systematically underrepresented as scientists and leaders, participants, and patients broadly and within the EDs field. While efforts to diversify the ED field have long been attempted (e.g., Cassidy et al., 2015), we present recommendations for increasing accountability that can shift the paradigm from equality to equity and enhance racial/ethnic inclusivity. We believe these recommendations can be applied to and refined for other underrepresented populations globally, as many of these same issues are relevant to non‐U.S./Western locations (e.g., immigrants, religious minorities, and sexual and gender minorities).

Our recommendations rely on developing and implementing measurable metrics to assess our field's progress—at multiple levels of influence—with the goal of increasing racial/ethnic diversity among providers, leaders, participants, and patients. Failure to do so runs the risk of reinforcing the myth that EDs only affect White, Westernized cisgender women, alienating underrepresented racial/ethnic groups from entering the ED workforce and stymying our ability to advance clinical science. We encourage focused efforts toward measurable, meaningful, and equitable change.

CONFLICT OF INTEREST

The authors have no conflicts to declare.

ACKNOWLEDGEMENTS

This study was supported by funding from the National Institutes of Health, grants F31 MD015679 (Neha J. Goel), K01 DK116925 (Andrea K. Graham), and KL2/Catalyst Medical Research Investigator Training (Lauren Breithaupt). The authors would like to acknowledge and thank all of the individuals who participated in the Early Career Investigators Workshop during the 2020 Eating Disorders Research Society Conference—Rachel Kolko Conlon, Lisa Anderson, Friederike Tam, David Kolar, Danielle MacDonald, Anna Marie Ortiz, Tim Brewerton, Shirley Wang, Sasha Gorrell, Shruti Shankar Ram, Meredith Kells, Claire Pinson, Brittany Matheson, Lindsay Bodell, Annie Haynos, Laura Berner, Danielle Kahn, Janell Mensinger, Megan Kuhnle, Jean Forney, Rowan Hunt, and Trevor Steward.

Goel, N. J. , Jennings Mathis, K. , Egbert, A. H. , Petterway, F. , Breithaupt, L. , Eddy, K. T. , Franko, D. L. , & Graham, A. K. (2022). Accountability in promoting representation of historically marginalized racial and ethnic populations in the eating disorders field: A call to action. International Journal of Eating Disorders, 55(4), 463–469. 10.1002/eat.23682

Action Editor: Natasha L Burke

Funding information KL2/Catalyst Medical Research Investigator Training; National Institute of Diabetes and Digestive and Kidney Diseases, Grant/Award Number: K01 DK116925; National Institute on Minority Health and Health Disparities, Grant/Award Number: F31 MD015679

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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Associated Data

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Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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