“Like a tree, my body is truly incredible.” – One Student’s Experience with the Love Your Tree Campaign

Love Your Tree (LYT) is a creative arts campaign designed to help students develop positive body image, improved self-esteem and enhanced media literacy skills, all of which can serve as protective factors against the development of eating disorders. Inspired by the work of author and playwright, Eve Ensler, this campaign empowers students of all ages to use art and creativity to challenge harmful appearance ideals and narrow definitions of beauty.

With the 13th annual campaign now behind us, we sat down with Kate Helminiak, a sophomore at Notre Dame Prepatory School to talk about her involvement in LYT and the inspiring poster she created. Her artwork was selected by a panel of health and mental health professionals to be the official poster of the 2019 campaign.

While the Notre Dame Prepatory School art department and school community has been participating in the LYT Campaign for the past 13 years, this was Kate’s first year taking part. Her initial interest began after she attended in a LYT workshop at her school presented by Brianna Garrold, art therapist and LYT facilitator. Kate said that an image of a friend who had struggled with an eating disorder was in her mind during the workshop. After the class viewed examples of LYT student artwork, she remembered her friend’s struggles and how she had worked hard to recover. Kate said this memory, “inspired me to do more” and so, she set out to design a poster based on her friend’s “mindset while she was going through her eating disorder and how she got through it.

The poster Kate ultimately submitted to the campaign depicted the beauty of what the body and mind can do while incorporating the LYT metaphor of the body as a tree. In the poster, which she made using colored pencils, a young girl is sitting down with legs crossed and her hair growing upward and outward like branches towards the sky. She has a reflective quality about her, almost as though she is meditating with the faintest of smiles that seems to convey peace with oneself. During our interview, Kate described the branches as that of a willow tree. To her, the willow tree itself represents how vast and complex our minds can be. In further describing her poster she explained that “none of the branches are the same,” and that “the vines that come down help to shelter our minds.

Everyone who participates in the LYT campaign is encouraged to submit an artist statement with their work. Kate, chose the phrase Like a tree, my body is truly incredible. When asked why she chose this phrase, she stated that the word incredible was a step up from other words she thought about to describe what our bodies can do each day. She wanted to emphasize how amazing and complex a body can be. Kate also explained how the LYT campaign helped her see how negative body image can affect so many students her age. She says, “It opened my eyes to see how long and far eating disorders and mental disorders stretch and how many people are impacted.” She also highlighted how fortunate she and her classmates were to have the opportunity to talk openly about mental health and how helpful it can be to use art to communicate about complex topics like body image.

At the end of each year’s LYT campaign, a special reception is held where students, teachers and families get to see all of the students’ artwork on display. The community exhibit celebrates the diversity of beauty and empowers viewers to embrace and appreciate all bodies while rejecting damaging media messages. When asked about the exhibit Kate stated that her favorite part was seeing and talking to the different students who participated. She said she loved seeing the connection between each student and their art. “It was really interesting to see which student did which poster and how their poster connected to the message they wrote.” This was a common sentiment from the crowd of over 200 who also attended that day.

As our discussion came to a close, Kate expressed gratitude that her poster was selected among more than 300 posters to receive the top award in 2019. She hopes to have more opportunities to advocate for positive body image among her fellow teens in the years ahead.

To learn more about the Love Your Tree campaign and how your school can participate in the 2019-2020 campaign, visit loveyourtree.org or email bgarrold@sheppardpratt.org for more information.


Written by Julie Seechuk, BSW
Social Work & Community Outreach Intern
Julie is currently pursuing her Masters in Social Work at Salisbury University online with an intent to graduate May of 2020.  Julie received her Bachelor’s Degree from Salisbury University in 2015 with a double major in Psychology and Social Work. In addition to pursuing her Masters and interning at The Center for Eating Disorders, Julie also works part-time as a Community Relations Coordinator for a Pediatric Oncology Nonprofit called The Cool Kids Campaign located in Towson, Maryland. During the 2018-2019 school year Julie assisted with resource development, event coordination, social media and website maintenance, community outreach to schools, and The Center’s free weekly support group.

 

Eating Disorders & The Transition to College


In many ways, it is not a surprise that the transition to college can be so challenging. Moving from a home with your family into campus housing, often hundreds of miles away, with roommates you’ve never met can be quite a shock. It’s rarely easy for anyone. For many young adults however, the stress and unique social and environmental factors associated with this transition can contribute to the development, or exacerbation, of an eating disorder. Consider the following statistics:

  • In a survey of 185 female students on a college campus, 58% felt pressure to be a certain weight, and of the 83% that dieted for weight loss, 44% were already at a normal weight.1
  • 9% of 20-year-old males reported struggling with a clinical eating disorder.2
  • Of nearly 3,000 students on a university campus, 3.6% of the males experienced eating disorder symptoms.3
  • The rate of eating disorders among college students at one college increased from 7.9% to 25% for males and 23.4% to 32.6% for females over a 13 year period.4

College is supposed to be fun, educational and provide plenty of opportunities to be inspired by future career possibilities. So what makes this transitional time such a hotbed for eating disorders? The Multi-Service Eating Disorders Association (MEDA) offers several reasons why college students could be at increased risk for eating disorders. These include:

  • New peer groups or difficulty forming new friendships
  • Newfound self-reliance; no longer living under parental rules
  • Cafeterias and dining halls with an unlimited amount of food; making food choices independently may be difficult particularly when paired with conflicting messages about dites, nutrition and calories 
  • Fear of the “Freshmen 15”
  • Dorm-living
  • The desire to fit in; an intense pressure to be “perfect”
  • Academic and financial stress
  • Difficulty managing transitions

While many colleges offer support and resources for students who are struggling with the transition or mental health problems in general, students do need to seek them out. This isn’t as easy as it sounds considering a recent study on eating disorder prevalence in college students found that most were not aware that they had an eating disorder or, if they were, they were not willing to seek treatment.According to the research, the five most common reasons why college students may feel uncomfortable or refuse to seek treatment include:

  • Lack of perceived need and urgency
  • Perceived stigma surrounding diagnosis and treatment
  • Limited availability of services
  • Denial of illness
  • Lack of motivation for recovery inherent in ED

It’s important to know that you’re not alone and that help is available on and off-campus. It’s also important to know that eating disorders are serious illnesses that, if untreated, can progress rapidly and may become life-threatening.

Where can I go for help?

If you are a college student struggling with disordered eating, an unhealthy relationship with exercise, or negative body image, there are steps you can take to cultivate a more balanced and fulfilling time on campus.

  1. Identify treatment resources and support groups on or near you. Here is a great list of potential organizations, people and resources that might be able to help on most campuses.
  2. Incorporate basic self-care into your schedule.
  3. Get the facts about weight and diets; dispel the myth of the Freshmen 15
  4. Take some simple steps to strengthen your support system and break out of the loneliness or isolation you may be feeling.

Whether in college or any other stage of life, it’s crucial to ask for help and to learn that asking for help is a strength, not a weakness. Remember that you can’t tell how someone is handling the transition to college just by looking at them or their social media feeds. Many of the students around you may also be struggling in silence with similar feelings and symptoms.

For more information about eating disorders, body image and treatment options, visit eatingdisorder.org.

If you are a campus-based health provider and would like more information about eating disorders or trainings, please contact Jennifer Moran, Psy.D., College Liaison at The Center for Eating Disorders at Sheppard Pratt.


Seechuk_julie_2018.jpg

Written by: Julie Seechuk, BASW, Community Outreach Intern
Julie is currently pursuing her Masters in Social Work at Salisbury University online with an intent to graduate in May of 2020. Julie received her Bachelor’s Degree from Salisbury University in 2015 with a double major in Psychology and Social Work. In addition to pursuing her Masters and interning at The Center for Eating Disorders, Julie also works part-time as a Community Relations Coordinator for a Pediatric Oncology Nonprofit called The Cool Kids Campaign. As a community outreach intern, Julie assists with resource development, event coordination, social media and website maintenance, community outreach to schools, and The Center’s free weekly support group.


References

  1. Multi-service Eating Disorders Association. (2018). Eating Disorders College Students. Retrieved from: https://www.medainc.org/wp-content/uploads/2015/09/MEDA-College-Guide.pdf
  2. Allen, K., Byme, S., Oddy, W., & Crosby, R. (2013) “DSM-IV-TR and DSM5 eating disorders in adolescents: prevalence, stability, and psychosocial correlates in a population-based sample of male and female adolescents.” Journal of Abnormal Psychology.
  3. Eisenberg, D., Nicklett, E. J., Roeder, K., & Kirz, N. E. (2011). Eating disorder symptoms among college students: prevalence, persistence, correlates, and treatment-seeking. Journal of American college health: J of ACH, 59(8), 700-7.
  4. White, S, Reynolds–Malear, J., Cordero, E., “Disordered Eating and the Use of Unhealthy weight control methods in college students: 1995, 2002 and 2008” Eating Disorders–Journal of treatment and prevention.

Eating disorders in film: Important reminders during awards season #popcultureED

 


Over 13 percent of teen girls suffer from an eating disorder by the age of 20. It’s not just girls either: disordered eating is almost as common in males as females and can extend long into adulthood. When we get right down to it, eating disorders are serious and people living with them have a higher risk of dying compared to same-aged peers. Still, disordered eating is often joked about and normalized in pop culture. This ‘awards season’, we’re nominating moments from popular movies of the past that show just how common distorted ideas about bodies, diet and food are in our culture. We still love some of these classic comedies, but let’s be careful to challenge unhealthy behaviors as we watch.

GIPHY Video Audience Giving a STanding Ovation

Unfortunately, some movie scenes can be quite triggering for folks with eating disorders and those in recovery. It’s not uncommon to see detailed ED thoughts and behaviors in films that that are never challenged or paired with appropriate education. So, we’ve taken a few movie examples below and added important reminders and fact-checking opportunities.

It’s possible to enjoy films while also thinking critically about their messaging. You might also want to actively decide whether to watch or not to watch before engaging with specific films that you know will normalize or showcase disordered eating.

First up on our #popcultureED tour is…


“THE DEVIL WEARS PRADA”

This movie, starring 2019 SAG awards winner Emily Blunt, reminds us that no goal is ever worth starving for. Emily Blunt’s character frequently makes comments about her restrictive eating and undeniable pursuit of a thinner body.

Nourishing your body consistently is a better way to keep yourself healthy enough to reach your career goals and be present to enjoy them. If you’re struggling to overcome thoughts that equate thinness with success, you’re not alone. Take a step and ask for help before things get worse. Whether you’re a fashion designer, a father, a teacher, or an artist, you deserve to be free of food and weight obsession.

 


“ROMY AND MICHELLE’S HIGH SCHOOL REUNION”

Romy and Mishelle share all sorts of diet obsessed banter in this movie, including this extremely dangerous quip. Reality Check: Candy is delicious, but it doesn’t provide nearly enough energy on its own for everything your amazing body does each day. All foods can fit in a healthy pattern of eating but one type of food on its own – whether candy or kale – can never meet all your nutritional needs. Incorporating a variety of fun and nourishing foods is best.

 


“MEAN GIRLS”

Did you know that some of the most common side effects of dieting are mood changes, depression and irritability. That could be one reason why Regina was always so negative and, quite frankly, pretty nasty to the people around her. Luckily, this movie does teach us that trying to be “perfect” can take its toll.

Did you know that perfectionism is a risk factor for the development of eating disorders?  Perfectionism can also cause you to miss out on opportunities to learn from mistakes and may ultimately get in the way of living a balanced, rewarding life.

 


“A CINDERELLA STORY”

Our bodies need different nutrients to fuel them. Cutting out entire food groups or sources of energy can cause major problems for your body (and really limit your options when eating out). One of the side effects often noted by people with eating disorders is that they begin to isolate from friends and family since they no longer feel comfortable eating around other people or they literally can’t find anything on the menu that fulfills the “rules”.

Social isolation can lead to all sorts of other diffculties and can worsen depression and anxiety. If you’ve noticed that you or a friend are retreating from meals or other previously enjoyed activities it might be time to seek support.

 


“ZOOLANDER”

Derek and Hansel are misinformed when it comes to losing weight. The fact is, purging is not an effective way to lose weight or prevent weight gain. In fact, over time, purging behaviors are associated with weight gain (and a whole host of serious medical consequences). On top pf being misinformed, the characters explode in laughter when Matilda opens up to them about her own history with bulimia.

This is obviously a comedy but it’s still important to remind ourselves while watching that purging is NEVER funny and purging is never a safe behavior. Don’t be like Derek and Hansel. If a friend shares with you that she or he is struggling, take it seriosly. If you need resources to help a friend, check out the Let’s Check In Discussion Guide.

 


“CLUELESS”

Cher and her friends engage in awful lot of weight shaming, diet talk and appearance bashing throughout this movie. (It’s actually hard to find a single scene without it).

Critical body talk and weight shaming – even when self-directed – has a lot of negative consequences. When you criticize your own body, it impacts you and the people around you negatively, making everyone more distracted by and less accepting of their own appearance.

Our thoughts affect our feelings and behaviors so it’s important to learn how to curb negative self-talk and practice saying kind things to yourself. Remember, your vibe attracts your tribe. Work on body acceptance and you’ll be more likely to attract friends who are body positive too.

 


“BRING IT ON” 

Sports have the power to promote self-esteem but not with a coach like Sparky Polastri who flat out disparages bodies and encourages restrictive eating disorders among his athletes.  Any coach who puts an emphasis on weight is bad news for the whole squad.

Not eating enough to fuel your workout can reduce strength, speed, and stamina and lead to increased risk of injury from things like stress fractures, fainting and muscle cramps – not what you want when you’re on top or bottom of the pyramid!

Sparky’s advice is way off; athletes burn a lot of energy through their training, so they actually need to eat more than non-athletes to properly fuel their bodies. Never be afraid to get a second opinion if a coach is steering you wrong.

 


“PITCH PERFECT”

Food shaming is ALL AROUND US in the movies and in real life so we get pretty used to hearing stuff like this. Something you think is a harmless joke about what someone is eating might actually have major repercussions for them.

We never know how the people around us feel about food or their bodies, so it’s best not to make offhand comments about what they should or shouldn’t be eating. Also, burgers are great and can be enjoyable and nourishing at any age!

 


“LITTLE MISS SUNSHINE”

Did anyone else’s heart break a little when Richard told Olive that ice cream would make her fat? In real life, instilling a fear of fatness does not keep kids (or adults for that matter) from gaining weight, but it can contribute to negative body image and disordered eating, including bingeing on foods that are deemed by adults to be forbidden or off-limits.

A better message for kids? All bodies are good bodies and it’s OK to enjoy a variety of different foods. You might also want to check out these other 8 tips for raising body positive kids (who are also competent eaters).

 


The Oscars

As you watch the Oscars and other awards shows this season, let’s cheer on the great acting and fun story lines while also keeping in mind how popular films – even comedies and parodies – can influence our own thoughts and expectations regarding food, weight and eating.

Join the conversation with us on social media using #popcultureED.

If you’ve had an eating disorder in the past or are in the early stages of recovery, sometimes it helps to have a specific support plan for watching potentially triggering or body shaming movies. Read more about that here: How to stay recovery-focused when interacting with triggering media

Don’t forget, eating disorders are serious and risky if untreated. The first step is awareness; If you suspect that you or someone you know has an eating disorder, visit  eatingdisorder.org or call 410-938-5252 for a free phone assessment.

4 social media changes you can make for the New Year…in 5 minutes or less


The pressures of resolutions and new beginnings after the holiday season can be overwhelming. So why not make a change that will help free up time and headspace while also improving body image?  Your social media life may be an area to evaluate…

Social media has undoubtedly become more and more prominent in our lives. On the one hand, these sites have showcased benefits, such as maintaining social connections and sharing meaningful content and life experiences with others1. On the other hand, problematic social networking site use (or SNS), such as commenting on others’ pictures and “lurking,” have been shown to have negative consequences on body image, self-esteem, and eating disorder symptoms. Even taking selfies, and excessively editing and manipulating these images, has been associated with greater body-related and eating concerns2.

As you reflect on the past year, think about how much time you spent scrolling through social media and comparing likes. What if you could start the new year off with a healthier and more productive approach to care for yourself and your self-esteem? These four simple tips can help you change social media behaviors in the new year.

 

1. Limit Overall Social Media Use


On average, we use social networking sites for over an hour a day3. While some of this social media time may be used in productive ways, maladaptive use of these sites for over an hour a day could lead to significant negative thoughts and feelings. Think about unplugging and limit time spent scrolling!

  • Set aside a specific time every day to use your favorite sites.
  • Delete the apps off your phone, limiting access to social media only from your computer.
  • Use digital reminders or post-it notes on your computer to remind you of other activities you might enjoy more than scrolling through a social media feed. Texting a friend? Planning a vacation? Registering for a class?

 

2. Think Critically About Social Media


For some, it might seem impossible to remove social media entirely in a world where use is growing rapidly. So, while we can limit use overall, it can be greatly beneficial to change the way we perceive what we are exposed to when we are using social media. While scrolling through Facebook and Instagram and viewing everyone’s carefully selected and manipulated “best-self”, be sure that you are thinking critically about what you are seeing and posting.

  • Remind yourself that images are often edited and re-edited!
  • Be mindful of comparing yourself with peers or celebrities’ photos on social media.
  • Notice if you are starting to feel poorly about yourself when scrolling and decide if it would be a good time to log off.

 

3. Remove or Block Negative Content


Exposure to content that promotes the “thin ideal”, or the promotion of a desire to be skinny or fit, is more common now than ever in a world of body-altering photo applications and “photoshopping” in the media. Many individuals with an eating disorder are prone to participate in negative social comparisons and are more likely to internalize the “thin ideal,” making them more susceptible to the negative effects of this type of imagery. Take some time to go through your social media and analyze what you are being exposed to and how it makes you feel.

  • Are anyone’s photos making you feel poorly about yourself?
  • Is a celebrity promoting disordered eating or dangerous products (like cleanses or detox teas) to maintain a “perfect figure?”
  • If images or accounts are not helping you work towards recovery, hide the posts or block photos.

 

4. Follow More Positive Accounts


While the negative effects of social media have been the focus here, there are many reasons why these platforms have skyrocketed in recent years. Sites such as Facebook and Instagram can be great to share accomplishments, keep in contact with distant friends, or even see what your favorite musician or politician is up to. We can help to control what kind of messages and content we are exposed to by changing who we follow on social media.

  • Fill your feed with positive role models, quotes, and positive peers to help create a body-positive environment that focuses on more than appearance to achieve self-worth.

Below are just a few examples of body positive or recovery-focused Instagram accounts you can choose to follow in the new year!

 


 

Written By:

Ava Sardoni, Research Assistant
The Center for Eating Disorders at Sheppard Pratt 

Ava is currently pursuing her Master’s in Clinical Psychology at Loyola University Maryland, with intent to graduate in May of 2019. She also earned her Bachelor of Arts in Psychology at Loyola University Maryland, graduating in May of 2018. Her past research projects include researching the relationship between specific personality traits and motivations for using online dating applications.


References:

  1. Cohen, R., Newton-John, T., & Slater, A. (2018). ‘Selfie’-objectification: The role of selfies in self-objectification and disordered eating in young women. Computers in Human Behavior, 79. 68-74. https://doi.org/10.1016/j.chb.2017.10.027
  2. McLean, S.A., Wertheim, E.H., Masters, J., Paxton, S.J. (2016). A pilot evaluation of a social media literacy intervention to reduce risk factors for eating disorders. International Journal of Eating Disorders, 50. 847-851. doi: 10.1002/eat.22708
  3. Uhls, Y.T., Ellison, N.B., & Subrahmanyam, k. (2017). Benefits and Costs of Social Media in Adolescence. Pediatrics, 140(Supplement 2, S67-S70. Retrieved from http://pediatrics.aappublications.org/content/140/Supplement_2/S67.long

Is your school or classroom a body-positive space for students?


It is widely accepted, from preschool to high school, that teachers and school staff play a big part in helping students to develop positive self-esteem. Many of those same teachers may not be aware that one of the most significant factors in an individual’s overall self-esteem is body image. So why does the way we see/think/feel about our bodies matter so much and what does that have to do with our classrooms? Consider the following:

  • 31% of adolescents do not engage in classroom debate for fear of drawing attention to how they look.1
  • 20% of teens say they stay away from class on days when they lack confidence about their appearance.1
  • On days when they feel bad about their looks, 20% of 15 to 17 year old girls will not give an opinion and 16% will avoid school altogether.2
  • A study of more than 11,000 teens found that students who saw themselves as overweight (regardless of actual weight) had lower academic performance than those who did not. This is important because it means the perception of being overweight – likely because of cultural bias and negative stereotypes that come with that – was a more significant determinant of academic performance than medically defined obesity.

If the way kids feel about their bodies impacts attendance, classroom engagement, academic performance and individual self-esteem, it makes a lot of sense for schools to be paying attention to body image.  Below are just a few ways you can work to establish a school environment that is body positive and doesn’t reinforce harmful weight stigma, appearance ideals or the diet mentality.


6 Guidelines for a Body Positive Classroom


Representation matters. 

Do a thorough scan of books, posters and other materials around your classroom. Do they include a wide representation of people with diverse bodies – both in weight and shape but also skin color, gender presentation and physical ability? Will all kids see themselves represented in the positive imagery around your classroom?

If your class involves physical fitness or health messaging, consider whether your resources show kids and adults of all shapes and sizes being active or just thin/muscular people? Are fatter bodies exclusively used in imagery meant to deter or shame people for specific behaviors? If you’re in need of new imagery, check out these inclusive stock fitness photos from The Body Positive Fitness Alliance.

Above all, remember that kids who feel good about their bodies, regardless of their weight, are more likely to engage in healthy behaviors and less likely to engage in risky or harmful behaviors like smoking and bingeing.4 To help bring body positivity into your class, add books and resources to your lesson plan or syllabus that promote body acceptance and provoke age appropriate conversations about the natural diversity of bodies. Messaging that focuses on 1) how health behaviors can make us feel, or 2) developing gratitude for the functionality of our bodies as opposed to what they weigh or look like, can promote self-care and confidence. A list of age-specific body positive resources is included at the end of this post – please scroll down to check it out!


Leave all personal diet-talk at the door and enforce that rule with fellow teachers and school staff.

We know that kids are listening to the adults around them even when we don’t think they are. Casual background discussions about cutting out carbs, trying a new “cleanse” or berating oneself for eating a cupcake are not as innocent as you might think. When little ears – or even mature high school ears – overhear their favorite teacher or respected mentor talking about food and bodies in critical or shameful ways they can internalize those messages. There are many reasons why we encourage adults not to introduce kids to dieting, including the fact that kids who diet are up to 18 times more likely to develop an eating disorder.5

Furthermore, there is no long-term evidence that any fad diets like keto, paleo, Whole30, Atkins or otherwise lead to reliable or sustainable weight loss. In fact, diets have been associated with longterm weight gain. Specifically, adolescent girls who diet are at 324% greater risk for obesity than those who do not.6


Normalize the variety of healthy body changes that take place before and during puberty. 

For example, it’s completely normal (and necessary) for a young girls’ body to store up extra fat before she gets her period for the first time. It’s also common for boys and girls to gain weight and fill out just prior to growth spurts in height. Remember this happens at very different times for different kids. If they experience these normal changes as abnormal or bad, it puts them at risk for body dissatisfaction and disordered eating. But If kids (and teachers and parents) can learn to anticipate these changes they may be more likely to trust their bodies as they grow and mature.


Incorporate MEDIA LITERACY into your curriculum.

It doesn’t matter if you teach preschool story time or AP Literature, there are countless opportunities to talk about how to handle cultural messages kids receive about beauty, appearance, health, and weight. The Center for Eating Disorders provides body image and media literacy workshops for educators and parents as well as arts-based campaigns like the Love Your Tree campaign. We also encourage school staff to pursue training in evidence-based prevention programs such as The Body Project and to work with local organizations to incorporate student activism projects that challenge the thin ideal and inspire brands to do better.

 

Weight-based bullying is more common than all other forms of teasing. Establish a policy against weight-based bullying and actively work to reduce body commentary in general.

What’s the difference between a teacher proclaiming “you look amazing! Have you lost weight?” and a student teasing her classmate for “packing on the pounds” over the summer? Not much actually. They both reinforce a negative bias towards larger bodies and establish an unnecessary focus on appearance/size. In our culture it is assumed that saying something one thinks is “nice” about someone’s body is a good thing but praising specific aspects of one’s appearance can be just as detrimental for the school community as a whole because it reinforces the dangerous appearance ideals. Consider the following scenarios:

Malik gets nicknamed “string bean” by the principal because he had a growth spurt and grew much taller and slimmer than his peers. Malik was already feeling self-conscious about his height and knows the principal was just kidding around but now he does everything he can to avoid seeing him in the hallways.

Dean came back to school a size smaller and friends are requesting her “weight loss secrets”. They don’t know she was in treatment for an eating disorder over the summer and has developed heart problems and other health complications as a result.

So what is a school or classroom policy that addresses all of the situations above? Something similar to “We just don’t comment on other peoples bodies” can be the most effective message to dissuade body-talk (praising or teasing) among students and staff.


Encourage colleagues – administrators, school nurses, coaches and physical education teachers – to review the evidence for any interventions they are implementing with regard to weight, health or nutrition. 

Every school should be asking whether there is quality, health-focused research to back up the intervention and does this program have the potential to do more harm than good? The truth is, many of these practices lack research and may have harmful consequences, yet many schools and childcare centers continue to implement them. Examples of such campaigns and curriculums currently include:

  • Publicly weighing kids in gym or health class
  • Giving kids assignments that require them to count calories and track their food
  • Hosting “Biggest Loser” weight-loss competitions among school staff
  • Sending home BMI report cards for students or calculating BMI in class.
  • Shaming kids’ lunch items or teaching very young kids to label food items as good/bad or healthy/junk.

When it comes to BMI report cards, even the Centers for Disease Control (CDC) notes in their report that “Little is known about the outcomes of BMI measurement programs, including effects on weight-related knowledge, attitudes, and behaviors of youth and their families. As a result, no consensus exists on the utility of BMI screening programs for young people.7

There is no indication that providing kids and parents with BMI information leads to any significant behavior change or improved health outcomes. Furthermore, unless safeguards are solidly in place, a risk of harm exists when children are simply told there is something wrong with their body size. Risks for body comparison and weight-based teasing also increase.8

What else are you doing to reduce weight-based teasing and make your classroom a safe place for students of all shapes and sizes? Tweet us @CEDSheppPratt today and share your experiences. 

 


Body Positive Resources:

For School Administrators:

Preschool/Elementary Kids & Parents:

Middle School:

High School/College:


Links to References:

  1. Ignoring it doesn’t make it stop.
  2. Beyond stereotypes: rebuilding the foundations of beauty beliefs.
  3. Perception of Overweight is Associated with Poor Academic Performance in US Adolescents
  4. Does Body Satisfaction Matter? Five-year Longitudinal Associations between Body Satisfaction and Health Behaviors in Adolescent Females and Males
  5. Onset of adolescent eating disorders: population based cohort study over 3 years
  6. Risk Factors for Body Dissatisfaction in Adolescent Girls: A Longitudinal Investigation
  7. A Report on the Facts and Concerns About BMI Screening in Schools

NEDA Congressional Briefing on Eating Disorders

CED Co-Director, Dr. Steven Crawford, among panelists to speak on Capitol Hill

The National Eating Disorders Association (NEDA) in conjunction with the Congressional Mental Health Caucus hosted a Congressional Briefing on Capitol Hill on October 2, 2018. This briefing was held to educate representatives and legislative aides about eating disorders in overlooked populations. Panelists at the briefing included Chevese Turner (moderator), Mike Marjama, Claire Mysko, Janell Mensinger, PhD, and Steven Crawford, M.D.

Dr.Crawford, co-director at The Center fo Eating Disorders at Sheppard Pratt, began by discussing the different eating disorders and the risks and causes associated with them. He explained the differences in each disorder and the ways someone can help if they notice symptoms of an eating disorder in someone they care about. These include, seeking more information on the subject, locating resources, not focusing on weight, and encouraging the person to seek specialized treatment.

Dr. Janell Mensinger, an Associate Research Professor at Dornsife School of Public Health at Drexel University, presented on eating disorders and population weight. Her presentation focused on people in higher weight bodies and she explained how weight-related harassment is over four times more common than bullying. She stressed that we, as a society, need to shift focus from weight to health and provided research that shows eating disorders and extreme dieting are increasing among people in higher weight bodies.

The next panelist Claire Mysko, CEO of NEDA, spoke about a prevention program called the Body Project. The Body Project is a group-based intervention that helps decrease eating disorder symptoms and body dissatisfaction in high school girls. There are currently 388 trained facilitators for this program across the United States. Mysko also mentioned how NEDA is working on a similar program for young men.

The final panelist was former Seattle Mariners Catcher Mike Marjama who now serves as a NEDA Ambassador. Marjama presented his personal struggle with body dissatisfaction and an intense desire to change his body, which led to extreme behaviors around food and exercise, an eating disorder diagnosis and eventually hospitalization. His treatment and recovery however, led him to a baseball career and renewed appreciation for mindfulness and balance. After retiring he decided to speak openly about his disorder and his story has since been featured on Good Morning America. As an Ambassador for NEDA his goal is to help boys and men see through outdated stereotypes about eating disorders so they can get the help they need.

Eating disorders are one of the most dangerous mental health issues and should not be taken lightly. Unfortunately, they are too often overlooked in people with higher weight bodies, in athletes of all calibers and in traditionally marginalized populations. Our hope is that the information shared in the Oct 2nd hearing will assist legislators in creating policies that not only support prevention and treatment for eating disorders but improve overall public health.

Additional Advocacy Resources:

  • Get involved, learn about state-specific legislative actions and become a NEDA advocate.
  • Read summaries of current legislative actions, read about current initiatives and get involved with advocacy days on Capitol Hill with the Eating Disorder Coalition.
  • You can find out more about The Center for Eating Disorders’ recent advocacy work here.

Written by: Julie Seechuk, Social Work Intern 

It’s Hot Outside!  Take the Plunge and Wear the Bathing Suit* How to break the avoidance/anxiety cycle so you can have more fun


It is a well-accepted notion in psychology that avoidance of a particular item or situation can lead to anxiety.  This anxiety leads to more avoidance which leads to more anxiety and on and on…and on.  For individuals with eating disorders, avoidance can take many forms including food avoidance, social avoidance and emotional avoidance. However, there is one particular type of avoidance that seems to blossom and intensify in the summer months and in warmer climates1… body avoidance.  Body avoidance is refraining from wearing seasonally appropriate, more revealing, cooler clothes due to fears about having one’s body exposed or being more visible.  Perhaps the most dreaded, and most often avoided, is the bathing suit. It is the one clothing item pretty much required to take part in some of the most fun and refreshing summer activities… jumping into a cool pool, running into the chilly ocean, or floating on top of a serene lake.

For people who have a preoccupation with weight and shape, oftentimes just the thought of wearing a bathing suit can stir up a lot of negative body image thoughts and tremendous amounts of anxiety.  In an effort to escape those thoughts and feelings, many people go to great lengths to not wear a bathing suit at all (avoidance). While the goal might be to not feel badly, as discussed earlier, avoiding the feared situation and the discomfort momentarily actually leads to more anxiety in the long-term. And so, the avoidance/ anxiety cycle begins.

The only way to stop this exhaustive and stressful process from continuing is to stop avoiding the feared situation.  In this case, it is to face the bathing suit head on…to wear a bathing suit, feel very anxious, survive the situation, and repeat.  Over time, a new, less threatening, response to one’s fears will ultimately develop and the anxiety will slowly subside.  The best strategy for doing this is to fully exposure yourself to wearing a bathing suit.

  • First, make a plan to visit a pool or beach in the next week and commit to wearing a swimsuit for a set period of time.
  • Second, know that you will likely feel extremely anxious initially but allow yourself to feel your full anxiety. Knowing that you feel very anxious and that you can survive the anxiety is a key element of exposing yourself to your fears.
  • Next, once this first exposure is complete and your anxiety has decreased, make a formal plan to put on your bathing suit as much as possible in the days ahead. Plan to reward yourself after the exposure- take yourself to a movie that you have been wanting to see, put $10 in a jar to work toward buying that new piece of furniture you’ve been eyeing, or treat yourself to a long phone conversation with an old friend.
  • Finally, repeat. The feared stimulus (aka the bathing suit) has to be worn regularly and without escape in order for the anxiety reduction to stick.  Track your anxiety and monitor to see that as the exposures progress, your anxiety starts to go down.

Science tells us it is best for positive outcomes to jump in feet first on body image exposure experiences like this. However, if it feels too overwhelming, consider breaking it down into smaller steps like first just wearing your bathing suit* around the house when you’re home alone, then wearing it in your backyard, then somewhere with just a close, trusted friend. Remember that the longer you put it off, the scarier it will seem. If you can start today, by the end of the summer you may actually be able to associate wearing a bathing suit with feeling refreshed and rejuvenated, instead of feeling distracted and fearful.

If you are struggling to take the plunge, consider working with a behavioral therapist who can offer guidance by providing education and support for helping to develop a systematic planned exposure schedule.

*Insert here any feared and avoided article of clothing- tank tops, shorts, skirts, light colored clothes, fitted clothes, dresses, formal attire.

Looking for more summer inspiration? Check out these other posts about overcoming negative body image and making the most of your summer season

Body Positive Summer: Step 1 – Stop Critiquing Your Body. Start Critiquing the Thin Ideal.

Body Positive Summer: Step 2 – Stop Comparing. Start Contrasting.

Body Positive Summer: Step 1 – Set yourself up for success.


Laura Sproch, Ph.D.

Written by Laura Sproch, PhD.
Research Coordinator & Outpatient Therapist
Dr. Laura Sproch is a licensed clinical psychologist who serves as Research Coordinator and outpatient individual and family therapist at The Center for Eating Disorders at Sheppard Pratt. Currently, Dr. Sproch is initiating treatment outcome studies, managing quality improvement projects, and developing novel research projects in an effort to contribute to the field’s understanding of effective eating disorder treatment methods. Dr. Sproch received her Ph.D. in Clinical/School Psychology from Hofstra University in Hempstead, NY where she completed her dissertation examining cognitive similarities between differential eating disorder diagnoses.  Dr. Sproch originally joined the CED team in 2011 as a postdoctoral fellow on the inpatient and partial hospitalization units acting as a family, individual, and group therapist.  She has also worked with adolescents and adults struggling with disordered eating at a variety of levels of care, including at Friends Hospital in Philadelphia, PA and ‘Ai Pono: The Anorexia and Bulimia Center of Hawaii in Honolulu, HI.  Her professional interests also include family-based treatment, psychological assessment, school psychology, and research on the transdiagnostic model for eating disorders

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References:

Sloan, D. M. (2002). Does warm weather climate affect eating disorder pathology?. International Journal of Eating Disorders32(2), 240-244. doi: 10.1002/eat.10077

 

 

8 Tips for Raising Body Positive Kids (Who are also Competent Eaters)


If your goal is to raise kids with high levels of self-esteem, eating competence, body satisfaction and a healthy weight (which is different for everyone) then join the chorus of advocates saying #wakeupweightwatchers and ditch the diet mentality for yourself and your family.  We know weight-loss diets don’t work. We also know they can cause serious harm, especially when introduced to kids and teens.  Let’s prevent the weight loss industry from profiting off our children’s generation.

So if dieting doesn’t work to help kids maintain a healthy weight, what is a parent to do?  These 8 tips are a great place to start.

  1. Make a commitment to having family meals together as often as you can within your family’s schedule. Having regular sit-down meals as a family has been shown to be a protective factor against a range of health and mental health problems including disordered eating.1,2,3,4 
  2. Introduce and incorporate a variety of foods from different food groups at every meal. This doesn’t assume your kid will actually eat them but it’s important to expose them, even if it’s just on someone else’s plate.
  3. Teach and model body acceptance (as opposed to body criticism or body comparison). Kids are always listening and watching how the adults around them relate to their own bodies.
  4. Support your child’s natural ability to regulate hunger and satiety. Promote trust in their ability to self-regulate. We recommend learning more about Ellyn Satter’s Family Feeding Model and the Division of Responsibility in feeding.

Research has shown that size acceptance and learning to use hunger and fullness cues produces sustainable improvements in blood pressure, cholesterol levels, physical activity, self-esteem, and depression compared to dieting.” 5

 

  1. Engage in physical movement as a family with the goal of adventure, fun, coordination and social connection. Try not to frame exercise as punishment, as a way to gain permission to eat or as a means to an end (i.e. weight-loss).
  2. Incorporate all foods without fear or mixed messages. Food is energy and fuel but it’s also okay for it to be enjoyable too. Don’t forbid specific foods or categories of foods (unless there is an allergy of course). Refrain from using food as a reward at home and in the classroom as this can confuse kids, encourages them to eat in the absence of hunger or may lead to a pattern of rewarding oneself with food.6
  3. Refrain from labeling foods as “good foods” vs “bad foods”. Connecting foods with negative labels like bad, toxic or junk foods, can send kids a message that food is related to morality. Even young kids may internalize these labels. Ex) I ate a bad food, therefore I must be bad or I should feel badly. This can trigger strong feelings of guilt or shame related to eating as well as increased emotional eating.
  4. Support healthy sleep habits. Kids who don’t get enough sleep, or have chaotic sleep schedules, show changes in hormones that regulate hunger and appetite. Not getting enough sleep can also impact the way a child’s body metabolizes certain foods.7

While these tips are meant to be a very basic place to start, they might still feel overwhelming since we live in a culture of toxic messages about food and weight. It’s hard to let go of anxiety about our kids’ eating behavior and weight. These can also be difficult to implement if you have your own history of body image struggles, eating disorders or dieting.

If you’re worried that your own relationship with food or weight might be complicating the way you approach these issues with your kids or teens you’re not alone. It can be helpful to get support from a therapist with eating disorder expertise or other non-diet practitioners. At The Center for Eating Disorders at Sheppard Pratt we provide a number of services that can help, including:

If you’re interested in any of these services, please call (410) 938-5252 for more information. 

Previous Post: 10 reasons NOT to introduce dieting during childhood & adolescence


References:

  1. Losing weight won’t make you happy
  2. Are Family Meal Patterns Associated with Overall Diet Quality during the Transition from Early to Middle Adolescence?
  3. Family meals during adolescence are associated with higher diet quality and healthful meal patterns during young adulthood.
  4. BENEFITS OF FAMILY DINNERS
  5. 10 Reasons to Stop Dieting Now
  6. Secrets of Feeding a Healthy Family: how to eat, how to raise good eaters, how to cook
  7. The connection between sleep and growth

Additional Recommended Reading: Weight Science: Evaluating the Evidence for a Paradigm Shift

 

10 reasons NOT to introduce dieting during childhood & adolescence


Weight Watchers recently announced that it will offer free memberships to teens starting this summer. This announcement led to parents, physicians, dietitians and therapists around the world speaking out – and rightfully so – about the harmful effects of encouraging dieting in our kids. Why? Weight-loss diets have not been shown to provide any long-term health benefits.  Furthermore, dieting remains a major predictor for the development of eating disorders and worsens negative body image.

If you have kids or teens in your life that are feeling the pressure to diet or lose weight,  here are ten important facts and considerations to bear in mind.


1. Restrictive diets negatively impact children’s normal stages of growth and development. 

“Dieting is associated with potential negative physical health consequences. Nutritional deficiencies, particularly of iron and calcium, can also pose short- and long-term risks. In growing children and teenagers, even a marginal reduction in energy intake can be associated with growth deceleration1  

2. Dieting is a major risk factor for the development of eating disorders. It can be hard to recognize eating disorders in teens or children, as many harmful attitudes about weight and food have become normalized in our culture. However, the problem is very real. And eating disorders don’t discriminate by gender, body type, ethnicity, or social status. According to Dianne Neumark-Sztainer, Ph.D., in the U.S. alone, more than 50% of adolescent girls and 33% of adolescent boys have used unhealthy weight control behaviors. Even when such behaviors don’t develop into clinical eating disorders, they can still have a significant negative impact on physical and mental health.

3. Dieting disrupts children’s innate ability to eat intuitively. Dieting teaches kids to override natural hunger and fullness cues which can have lifelong negative effects.

4. Diets rely on externally mandated measures of food or fullness which  undermine our kids’ innate ability to eat and trust themselves. Using external systems such as “points”, charts or other arbitrary ways to monitor food intake teaches kids to shut down or ignore their own internal regulatory systems and to mistrust their own bodies when it comes to hunger (see #3 above) or in other important situations as well.

5. Focusing on weight is problematic as it is not a reliable measure of health. Furthermore, weight-focused discussion in and of itself is a risk factor for weight gain and eating disorders.

“Several studies have found that parental weight talk, whether it involves encouraging their children to diet or talking about their own dieting, is linked to overweight and EDs.” 2

6. Dieting teaches kids to associate eating with feelings of guilt and shame as opposed to viewing food as fuel and energy.
Enough said.

7. Dieting negatively impacts body image. Weight fluctuations, common with dieting behaviors, often end up fueling a cycle of body dissatisfaction and disordered eating. In other words, dieting results in more preoccupation with weight and shape.

8. Findings clearly indicate that dieting and unhealthy weight control behaviors predict significant weight gain over time.3 Weight loss diets are actually associated with higher lifetime BMI. The more diets they’re on, the higher the BMI is likely to be. Did you catch that? Over time, diets have the opposite effect of what they say they promise.

9. Weight loss diets are associated with decreased metabolism, food preoccupation, cravings, and binge eating.4

10. Weight loss diets are associated with increased rates of depression and decreased self-esteem.5,6

Once we all understand the facts about how diets actually impact children (and adults), we can help families focus on implementing actual evidence-based strategies that we know are more likely to result in positive outcomes and healthier kids.

The question becomes: How can family members and friends best support our nation’s youth towards a peaceful relationship with food and positive body image without introducing potentially harmful diet routines?

Check out our next post, 8 Tips for Raising Body Positive Kids (Who are also competent eaters) for some basic ideas and strategies.

References:

  1. Dieting in adolescence
  2. Preventing Obesity and Eating Disorders in Adolescents
  3. Dieting and Unhealthy Weight Control Behaviors During Adolescence: Associations With 10-Year Changes in Body Mass Index
  4. Intuitive Eating Category: Studies
  5. Risk and protective factors for depression that adolescents can modify: a systematic review and meta-analysis of longitudinal studies.
  6. Losing weight won’t make you happy 

Contributors:
Rebecca Hart, R.D.
Caitlin Royster, R.D.
Rebecca Thomas, R.D.
Kate Clemmer, LCSW-C
Hannah Huguenin, R.D.

Transition and Recovery with Ryan Sallans: A Reflection on TU’s Eating Disorder Awareness Week Event


What does it mean to live authentically? 

Honoring your truth.

In other words, understanding, accepting, and nurturing your various, intersecting identities, to live your best life. This was a major theme throughout a special event held in February at Towson University (TU) to help recognize National Eating Disorders Awareness Week.At the event, speaker Ryan Sallans shared his personal experience of gender identity development and eating disorder recovery with the TU community. Organized by TU’s Counseling Center, the event was well-attended and brought together various university and local organizations, including The Center for Eating Disorders at Sheppard Pratt, TU’s Center for Student Diversity and The TU Body Image Peer Educators (BIPE). Sallans is a well-known public speaker, author, and health educator, and has been featured on Larry King Live, NPR, The Advocate, and many other news and popular media outlets.

 

Documenting Self-Discovery through Transition and Recovery

Throughout his talk, Sallans highlighted the delicate balance between taking care of oneself and navigating important relationships that often change throughout transition. Of course, each individual’s experience is different and Sallans did well to emphasize his is only one story among many.

Despite transgender and gender non-binary identities being discussed more openly than ever, there remains a stark deficit in information regarding the intersection of body image, gender identity development, and eating disorders. Studies have suggested the prevalence of eating disorders is higher among transgender individuals when compared to the general population (Reisner et al., 2016; Watson, Veale, & Saewyc, 2016). This health disparity is likely influenced by the pervasive effects of transphobia in our society, which sets the stage for inequality and discrimination at home and beyond, creating unique risk factors for the trans community (Bockting, Miner, Swinburne-Romine, Hamilton, & Coleman, 2013; Watson et al., 2016).

Pair this with the fact that no one is immune to the influence of the multi-billion dollar beauty industry consistently sending a message that, in order to be happy, we must look a certain way. Each one of us, regardless of gender, is sold (to some extent) on the idea that by controlling our bodies, we can achieve happiness, wealth, and popularity. Those working in the eating disorder field have historically referred to this as the internalization of the “thin ideal” or the acceptance of unrealistic or narrow beauty standards (Thompson & Stice, 2001). Transgender individuals are not immune from this culturally normative body dissatisfaction.  But people with eating disorders who identify outside of the restrictive gender binary may also experience amplified body dissatisfaction because their gender identity and their sex assigned at birth do not match (Algars, Alanko, Santtila, & Sandnabba, 2012; Strandjord, Ng, & Rome, 2015).

Furthermore, adjusting to a changing body and gender expression (for those who opt for cosmetic, hormonal, and other gender-affirming interventions), as well as the public commentary this process often evokes, presents its own unique challenges that impact body image and self-esteem (Couturier, Pindiprolu, Findlay, & Johnson, 2014).

 

How does one survive, and thrive, when faced with such challenges?

Sallans encouraged everyone in the room that night to stay hopeful and connected, which for him means sharing life stories to better understand those that are different. His comments suggested tremendous patience and empathy for his loved ones’ process of arriving at a place of acceptance with his transition, while also emphasizing the need to disconnect at times to protect oneself. Sallans identified a number of strategies and resources he has found useful, starting with a non-judgmental awareness of his needs, his boundaries, and his triggers. He explored the role of psychotherapy, as well as self-guided research on lesbian, gay, bisexual, and transgender issues, in helping him to turn towards his inner truth and wisdom.

Consistent with national guidelines on psychotherapy with LGBTQ individuals, Sallans benefited tremendously from collaborating with an affirmative therapist; someone he was able to confide in during times of confusion and fear surrounding gender identity, at a time when very few were even considering gender outside of the binary. The trust and respect he built with his therapist created a safe space to discuss gender issues and eating disorders, which provided the platform for recovery and ultimately allowed for closer and more authentic connections with family and friends. Outside of therapy, Sallans said he found it incredibly useful to communicate about his emotions and take time out for himself. He acknowledged the need to unplug from negative relationships (and social media) and engage in routine self-care, which for him often includes going for walks and being in nature.

Self-care, use of coping skills for managing negative emotions, positive sense of identity and community, and feeling like you can count on those closest to you are universal factors associated with resiliency (Rutter, 2012). These factors are even more relevant for those who identify outside of the gender binary (Hill & Gunderson, 2015; Watson et al., 2016). If you or a loved one is struggling with an eating disorder and questioning gender identity, see the resource links below to gather information, find community, and get professional support.

 

For information regarding affirming and evidence-based treatment options and programs at The Center for Eating Disorders at Sheppard Pratt, please contact us at (410) 938-5252 or email us at eatingdisorderinfo@sheppardpratt.org.

 

Additional Resources:
https://www.ryansallans.com (Ryan Sallans’ Official Website)
www.genderspectrum.org
www.glaad.org
www.pflag.org
www.thetrevorproject.org
https://www.chasebrexton.org/our-services/lgbt-health-resource-center


Written By: Andrea Castelhano, PsyD, Outpatient Therapist – Dr. Castelhano is a licensed clinical psychologist in the outpatient department at The Center for Eating Disorders at Sheppard Pratt. She earned her doctorate in Clinical Psychology at the American School for Professional Psychology at Argosy University, DC where she received training in cognitive behavioral therapy and mindfulness-based approaches to psychotherapy. She also received specialized training in eating disorders, anxiety disorders, and co-occurring self-harm and suicidality. Additionally, she has provided affirmative therapy to individuals in the LGBTQ+ community throughout her training and professional career. Affirmative therapy is a therapeutic approach that respects individuals of all sexual orientations and genders, recognizes the impact of intersectionality on identity development and life experience, and addresses issues including discrimination and heterosexism as they relate to the individual’s broader treatment goals. Dr. Castelhano joined The Center for Eating Disorders in 2018 and brings her experience from a variety of clinical rotations, including a year-long practicum at Children’s National Medical Center Outpatient Eating Disorders Clinic,  APA-accredited clinical internship at Laureate Psychiatric Clinic and Hospital, and post-doctoral fellowship with the University of Tulsa Counseling and Psychological Services Center. She provides individual, family, and couples therapy, as well as psychological testing services. She is fluent in Spanish and Portuguese.


References

Algars, M., Alanko, K., Santtila, P., & Sandnabba, N.K. (2012). Disordered eating and gender identity disorder: A qualitative study. Eating Disorders: The Journal of Treatment & Prevention, 20, 300-311.

Bockting, W.O., Miner, M.H., Swinburne-Romine, R.E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103, 943-951.

Couturier, J., Pindiprolu, B., Findlay, S., & Johnson, N. (2014). Anorexia nervosa and gender dysphoria in two adolescents. International Journal of Eating Disorders, 48, 151-155.

Hill, C. A., & Gunderson, C. J. (2015). Resilience of lesbian, gay, and bisexual individuals in relation to social environment, personal characteristics, and emotion regulation strategies. Psychology of Sexual Orientation and Gender Diversity, 2, 232-252.

Reisner, S.L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., Dunham, … Baral, S.D. (2016). Global health burden and needs of transgender populations: A review. The Lancet, 388, 412-436.

Rutter, M. (2012). Annual research review: Resilience – clinical implications. The Journal of Child Psychology and Psychiatry, 54, 474-487.

Strandjord, S.E., Ng, H., Rome, E.S. (2015). Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned. International Journal of Eating Disorders, 48, 942-945.

Thompson, J.K. & Stice, E. (2001). Thin-ideal internalization: Mounting evidence for a new risk factor for body-image disturbance and eating pathology. Current Directions in Psychological Science, 10, 181-183.

Watson, R.J., Veale, J.F., & Saewyc, E.M. (2016). Disordered eating behaviors among transgender youth: Probability profiles from risk and protective factors. International Journal of Eating Disorders, 50, 515-522.