Blacks With Bulimia

WASHINGTON - When stress mounts for Stephanie Covington Armstrong, she catches herself before reaching for comfort food. Instead she chews over what's really bothering her. "Once I can identify that, then I'm quickly able to just shift," she says. "I've gone through a lot of therapy, so I'm very aware if I'm on the road to practicing behavior that's unhealthy,"  Cynthia Gordy of The Root writes.

Armstrong's mindfulness is worlds away from the years during which she responded to anxiety by binge eating, followed by hunching over the toilet to vomit, abusing laxatives or taking three consecutive aerobics classes and then doing thousands of sit-ups. Like the estimated 4.2 percent of American women who suffer from bulimia nervosa at some point in their lifetime, Armstrong was gripped by an obsessive cycle of bingeing and purging.

As a black woman, she also reflects growing research that debunks the myth that bulimia is an affluent white girl's disease—and shows that African Americans are actually more likely to suffer from the disorder.

"Our community doesn't talk about this stuff," says Armstrong, who chronicled her battle in the 2009 memoir Not All Black Girls Know How to Eat: A Story of Bulimia. "I have girlfriends who've been bulimic, who casually mention it without really having any depth of conversation. Because what black woman wants to admit she can't eat? No one's tougher than us. And no one is willing to talk about it."

The Face of a Disorder

A pioneering 2000 study of black women and eating disorders, published in Archives of Family Medicine, found that black women were just as likely as white women to report recurrent binge eating and vomiting. It also concluded that black women are actually more likely to abuse laxatives or diuretics.

"Not much was surprising because we did this study to provide evidence that eating disorders exist in the black community, which until recently was not a widely held belief," Denise Wilfley, a lead researcher, told The Root. As director of the Weight Management and Eating Disorders Program at Washington University in St. Louis, Mo., which treats patients in the largely African-American city, she had long known that this was the case. "But we were surprised to find that black women used more 'nontraditional' purging methods, like laxatives and diuretics." Because the public strongly associates vomiting with bulimia, Wilfley theorizes, black women may use other means without realizing that they are in fact participating in bulimic behaviors.

Subsequent reports have produced even more stereotype-shattering results. A 2009 study showed that not only were African-American girls 50 percent more likely than white girls to be bulimic, but girls (black or white) from the lowest income bracket were also significantly more likely—153 percent more likely—to experience bulimia than their peers in the wealthiest group.

"We had also held the popular conception that bulimia was more common among girls from white, middle- to high-income families, so the results surprised us," Michelle Goeree, a lead researcher in the study, said. It made more sense after the researchers realized that many insurance policies don't cover the doctor's visit where eating disorders are diagnosed, thus throwing off the documented numbers. "If two girls suffer from bulimia nervosa, but one is from a low-income family and the other from a high-income family, which girl is most likely to be diagnosed if it often requires a visit to the expensive psychiatrist?"

A 2011 study published in the Journal of Adolescent Health also confirms that bulimic behavior is more common among African-American youths. In fact, young people from various racial backgrounds, including Asian Americans and Latinos, were found to practice extreme food-related behaviors, such as vomiting and laxative abuse, two to 10 times more often than their white counterparts. 

Causes and Effects

The field of research further challenges conventional wisdom that says black women always love their curves, celebrating thickness on the strength of a community that is more accepting of different body types. Gayle Brooks, an African-American psychologist and clinical director of the Renfrew Center—an eating disorders treatment center in Coconut Creek, Fla.—says that black women feel increasingly pushed to change.

"In our society, the more you achieve and make in the world, the more you're pressured to acculturate," she said. "Oftentimes, young African-American women want to fit in, and feel they have to let go of some of the cultural norms that might have protected them in the past." Yet Brooks went on to say that it's usually not a drive for thinness at the heart of eating disorders among black women. It typically involves exposure to some type of trauma, from physical abuse to poverty, racism or a struggle with ethnic identity.

"The biggest misconception is that this is only about being thin," says Armstrong, noting that most people with bulimia are either a normal weight or slightly overweight. "I don't believe that's the first reason. It comes from some kind of trauma and a need for control -- you don't just wake up one day and decide to throw up."

In Armstrong's case, the trigger was being raped by an uncle when she was 12. Having grown up in a fatherless Brooklyn, N.Y., household, she says that being assaulted by her single male role model left her feeling worthless. "I had no other men in my life who loved me to help me see, 'This person is messed up.' For me it became, 'I'm messed up.' " Studies show that roughly 60 percent of people with bulimia have suffered sexual abuse.

Armstrong turned to bingeing and purging as a coping mechanism for her anxiety and low self-esteem after getting the idea from a magazine article intended as a cautionary tale for teens. Laxative abuse and excessive exercise soon followed. "At the height of it, I was throwing up eight to 10 times a day. Afterward, there would be this calm," says Armstrong, now in her 40s. "I could not control the external circumstances of my life, but I could control my relationship to food."

Meanwhile, her family and friends never connected the dots. Watching her inhale large quantities of food, they just marveled at her ability to stay skinny. "It was like they were envious, which only fueled a feeling of superiority," she said. After living with her secret for seven years—so obsessed, depressed and suicidal that she could barely function—she finally sought help and checked into a 12-step program. "I was desperate around food, and at a certain point I just couldn't live like that anymore."

A Secret Shame

Despite the research indicating that bulimia occurs disproportionately among African-American women, stories like Armstrong's are virtually invisible in both the study and treatment of eating disorders and in the black community. Brooks explains that, because black women don't fit the presumed profile, education efforts have not been directed at them, causing family and friends to miss warning signs. Furthermore, many doctors and therapists fail to make proper assessments.

"Doctors tend to not recognize it in African-American women, so they don't make appropriate referrals for treatment," Brooks says, adding that studies have shown that it takes longer for black girls to be diagnosed with eating disorders than it does white girls who have the same symptoms.

There's also the matter of black women hiding bulimia because they think it's a "white" disease. "This attitude may lead black women to experience a double layer of shame—shame because eating disorders are seen as the result of vanity run amok, and shame because it may be viewed as a betrayal of their cultural roots," says Wilfley. "The issue may also go back to a general reluctance on the part of many members of the black community to recognize mental illness and seek help."

Armstrong agrees that there is a "code of silence" around mental health disorders. "Whenever we have an experience that makes us fall outside of the Strong Black Woman archetype, we go quiet," she says. "We assume that as black women, we can handle our whole lives. If someone goes to therapy, many of us assume they're crazy. If you need help, we think there's something wrong with you."

Today Armstrong, a married mother living in Los Angeles, works with the National Eating Disorders Association's Diversity Task Force and speaks at colleges, high schools and organizations to help raise awareness. "I'm recovered now and don't struggle at all," she says. But in her outreach, she has met hundreds of African-American girls and women still suffering in the shadows. "I would just love to see people get the help they need, without the fear of judgment and the isolation. It's time to talk about it."