Dismantling the “SWAG” Stereotype
Why “SWAG” Isn’t So ~Swag~ When It Comes to ED Diagnosis and Treatment
For decades, eating disorders have been framed within a narrow stereotype summarized by the acronym “SWAG” (Skinny, White, Affluent, Girl). This perception has reinforced the misconception that EDs primarily affect a specific demographic and have a trademark “look.” However, a growing body of research demonstrates that EDs do not discriminate. Instead, they occur across all racial, ethnic, socioeconomic, and gender groups. In fact, individuals who fall outside of the SWAG stereotype are not solely affected, but are further disproportionately underdiagnosed and undertreated.
Let’s do a quick fact check and unpack the research—here are some key takeaways that directly dismantle the “SWAG” myth.
EDs only affect those who are underweight
In a large study of young adults, disordered eating behaviors were actually found to be more common among individuals who were not classified as underweight. About 29% of women in the higher-weight group reported disordered eating, compared to 16% of women in the lower-weight group. Among men, the pattern was similar, with 15% of those classified as overweight or obese reporting disordered eating, compared to 8% of men at lower weights.¹
However, most strikingly, people in the higher-weight group were half as likely to receive an official diagnosis from a healthcare provider. Only 2.6% of women and 0.3% of men in this category were diagnosed, compared to 4.9% of women and 0.6% of men at lower weights. This drastic difference may point to some alarming takeaways about potential implicit bias lingering in clinical practice.¹
EDs do not affect BIPOC individuals
In a large-scale three year study that followed over 1,100 young women with body image concerns, researchers found no significant differences in eating disorder onset between ethnic groups. In other words, young women of color developed eating disorders at similar rates to their White peers.²
The study also tested whether risk factors for eating disorders looked different across ethnic groups. Out of 13 potential risk factors, only two showed variation, namely thin-ideal internalization and body mass index. However, these differences did not translate into different rates of developing an eating disorder over time—although they could point towards some interesting differences in the cultural factors that may influence the way ED symptoms are expressed.²
EDs are “diseases of affluence”
A systematic review (summary of a wide range of studies concerning a specific topic) of 62 articles summarizing decades of research found no consistent relationship between high socio-economic status and eating disorder prevalence. Instead, anorexia, bulimia, and binge eating disorder were found to occur across the socioeconomic spectrum.³
Another interesting marker that can be tied into the area is the recent emergence of research around the relationship between food insecurity and EDs. A large-scale study using data collected from children aged 9-14 showed that food insecurity was indeed associated with a higher odds of developing binge eating disorder (BED).⁴ In fact, this relationship has been found to persist with age, with research finding food insecurity to be associated with increased rates of overall ED pathology, BED, and even bulimia in adults.⁵
EDs only affect girls
A systematic review showed that males account for roughly a quarter of anorexia and bulimia cases in the United States.⁶ However, eating disorders often present differently in males, with body image concerns frequently centering on building muscle, as opposed to thinness. In fact, up to 60% of boys in the U.S. report purposefully manipulating their diet to increase muscularity.⁶ Additionally, transgender and non-binary individuals face compounded risk: Another systematic review showed an increased prevalence of ED and body image problems in transgender and non-binary youth.⁷
These findings do not back up the stereotype and instead paint a troubling picture: The people most at risk often face the greatest barriers to care.
So what fuels these diagnosis and treatment disparities?
Implicit bias in healthcare: When providers unconsciously assume that EDs only affect the “SWAG” demographic, symptoms in patients who do not fit the mold may be dismissed or misdiagnosed.
Cultural stigma and lack of awareness: In some communities, conversations about mental health are taboo, discouraging people from seeking help.
Lack of attention to context and culturally sensitive care: Many medical settings do not account for cultural differences in how disordered eating presents, leaving patients feeling unseen or misunderstood. Additionally, environmental factors, like food insecurity and diet-culture centric health/nutrition education, are often unaccounted for.
Access barriers: High treatment costs, lack of insurance coverage, and limited availability of specialized providers (especially in underserved and rural areas) make care even harder to reach.
Moving Forward
When thinking about this issue, the concept of intersectionality comes to my mind. Intersectionality, a sociological framework applied across many disciplines, helps us understand how overlapping social identities shape unique experiences of discrimination or privilege—experiences that ultimately influence health outcomes. Applying this lens to the research we have unpacked brings to light how identity plays a central role in ED diagnosis and treatment, largely predicting one’s likelihood of receiving the care they need.
It is important to note that the research presented here is just the tip of the iceberg, and as time progresses, we are making genuine strides in dispelling this stereotype through more inclusive research and better clinical practice. The concept of intersectionality is now better informing research questions, driving our enhanced understanding on who may be at increased risk and therefore may need more targeted outreach. However, we are still far from where we would like to be ideally.
Making further progress in dispelling the stereotype will take a team effort. As recovery advocates, we play a vital role in raising more awareness about EDs and reducing stigma around the condition through ways as simple as speaking up. On the research front, it is essential that we continue to understand nuances in symptom presentation and unique vulnerabilities between groups, placing specific emphasis on understanding the experiences of those who face multiple disadvantaged identities. Lastly, in clinical care, it is vital that we expand access to culturally responsive treatment and train providers to be well versed in the fact the EDs simply do not discriminate. Acknowledging and addressing these disparities is the only way that we can move toward a system in which all individuals have equitable access to life-saving eating disorder treatment.
So here’s to keeping swag limited to the confidence that comes with recovery 😎
References:
1. Nagata JM, Garber AK, Tabler JL, Murray SB, Bibbins-Domingo K. Prevalence and correlates of disordered eating behaviors among young adults with overweight or obesity. J Gen Intern Med. 2018;33(8):1337–1343. doi: 10.1007/s11606-018-4465-z.
2. Cheng ZH, Perko VL, Fuller-Marashi L, Gau JM, Stice E. Ethnic differences in eating disorder prevalence, risk factors, and predictive effects of risk factors among young women. Eat Behav. 2019;32:23–30. doi: 10.1016/j.eatbeh.2018.11.004.
3. Huryk KM, Drury CR, Loeb KL. Diseases of affluence? A systematic review of the literature on socioeconomic diversity in eating disorders. Eat Behav. 2021;43:101548. doi: 10.1016/j.eatbeh.2021.101548.
4. Nagata JM, Chu J, Cervantez L, et al. Food insecurity and binge-eating disorder in early adolescence. Int J Eat Disord. 2023;56(6):1233–1239. doi: 10.1002/eat.23944.
5. Hazzard VM, Loth KA, Hooper L, Becker CB. Food insecurity and eating disorders: A review of emerging evidence. Curr Psychiatry Rep. 2020;22(12):74–0. doi: 10.1007/s11920-020-01200-0.
6. Gorrell S, Murray SB. Eating disorders in males. Child Adolesc Psychiatr Clin N Am. 2019;28(4):641–651. https://www.sciencedirect.com/science/article/pii/S1056499319300641. doi: 10.1016/j.chc.2019.05.012.
7. Heiden-Rootes K, Linsenmeyer W, Levine S, Oliveras M, Joseph M. A scoping review of research literature on eating and body image for transgender and nonbinary youth. J Eat Disord. 2023;11(1):168–5. doi: 10.1186/s40337-023-00853-5.
