When you read the words “eating disorder,” what comes to mind?
Do you visualize a young woman? Is she White? Able-bodied? Emaciated?
For decades this is who we have been taught to associate with disordered eating. That anyone else might struggle with food and body image concerns has been overlooked for a few reasons, including selection bias: Research on disordered eating tends to draw from clinical samples, meaning that people without formal diagnoses are excluded. This is particularly true of poor people for whom accessing costly and time — intensive medical care is impossible.
Fortunately, public perception about disordered eating is changing. Non — profit organizations are challenging weight and gender bias in treatment settings, providers with experiential knowledge are starting to frame disordered eating within its cultural contexts, and colonized groups are creating healing spaces outside the constraints of western capitalism. A few “non — traditional” celebrities have also spoken up.
We still have work to do, but we’re slowly making progress. Except, that is, when it comes to unhoused people. Based on omissions from the academic community, non — profit marketing, clinical brochures, online support groups, and treatment centres themselves, homeless people don’t get eating disorders.
As someone who was homeless with an eating disorder, I’m here to say we do. And we’re more common than you think.
I wasn’t homeless because of my eating disorder, but it was one factor that led to my parents expelling me from our family home at nineteen. I was legally an adult, but I was also unwell and had the emotional capacity of a child. I spent the better part of three years at a youth homeless shelter, and I was severely bulimic throughout.
When I tell people this now, they’re surprised, particularly if they’re familiar with the astronomical cost of binging and purging. When I say I was bulimic, I don’t mean that I vomited on occasion. I didn’t “overeat” from time to time, and my behaviours had almost nothing to do with body image. Instead, I gorged on tens of thousands of calories daily, purging hastily when I was on the cusp of gastrointestinal rupture before wiping my mouth and continuing. I did this for two, four, eight hours consecutively, and I did it all while homeless.
What was it like? In a word, exhausting.
I was homeless in Vancouver, Canada’s notorious “Downtown Eastside” neighbourhood. Here, there are no shortage of non — profits catered to street — entrenched young people. Most don’t address the root causes of poverty (and some perpetuate it), but they do offer food — lots of it.
The shelter I stayed at served three meals a day. Clients ate with staff in a cafeteria — style dining room, where cooks filled our plates with indiscernible piles of starches and ground meat. The food was bland, but quality was irrelevant — all that mattered was quantity. Fortunately, there was always enough for seconds, thirds, and fourths. I ate as much as was possible before our thirty — minute meal block ended. Afterward, I purged in the group bathrooms adjacent the common room until all that came up was stomach acid and bile — concrete signifiers that I was done.
The logistics were complex. I mentioned I had bulimia during my shelter intake, but staff didn’t realize the implications of this until they watched me eat. There was nothing subtle about my binging, and some purposefully avoided me at meals while others were expressly cruel. They repeated the snide remarks I had gotten from family (as though having self — control hadn’t occurred to me), but after several tearful attempts at self — advocacy, they eventually left me alone.
Eating disorders are known for secrecy, and while I would have preferred to keep mine private, this is a luxury for the housed. The things many take for granted — bedroom doors, for instance, or access to a single — use bathroom — aren’t readily available, so I made do with what I had.
I developed a food — acquisition routine: A drop — in centre down the street served meals exactly one hour later than the shelter, so I rushed there post — lunch, chain — smoking and eating whatever I had managed to smuggle out of the cafeteria. Following this, I ran to another service for a third lunch, and because it was a repository for expired food from every coffee shop and grocery store within several blocks, I stayed there, gorging and avoiding eye contact, until it was time for dinner. Finally, I collapsed back at the shelter, depleted and hopeless after another wasted day.
When I look back, I’m impressed with my tenacity. I was innovative out of necessity, and at the time bulimia was effective harm — reduction. I grappled with concurrent addictions, and the hours I spent binging were less dangerous than alcohol and drugs. This was especially true because the shelter I stayed at had a “no tolerance” policy for substance use. In lieu of meaningful trauma care, then, I self — soothed with whatever wouldn’t get me discharged.
I see now that my circumstances reflected a number of systemic failures. I come from a wealthy background, and I wouldn’t have been homeless to begin with has my parents knew how to cope with raising a neurodivergent child. Their ableism, and specifically the belief that my eating disorder and substance use were a reflection of being lazy and not attempts to cope with sensory overwhelm, was echoed by front — line workers. Neoliberal conceptions of “personal responsibility” underscore our current approach to homelessness, and blame from my family was replicated each time the shelter expelled me for being intoxicated. Paradoxically, I had started drinking alcoholically because bulimia was so painful, and I thus walked a tight — rope of binging just enough to quell my cravings for alcohol without doing it so much that I had to drink to stop.
I wasn’t the only one who dealt with this. Most of my peers had been raised in poverty, so while our upbringings contributed to tangible differences in how we navigated homelessness, many had dual issues with food and substances. That others restricted, binged, and purged was glaringly obvious, yet no — one acknowledged it, let alone developed institutional infrastructure to address it.
Years later, I was haunted by the insight that I hadn’t been anomalous. Once my life had changed, my experiences while homeless prompted me to write my Masters’ thesis on the co — occurrence of substance use and eating disorders among unhoused youth. I hoped to draw attention to the fact that disordered eating can induce or exacerbate substance use, and that addressing one without the other is akin to playing whack — a — mole.
Not surprisingly, the interaction of eating and substance use disorders has been well investigated among three populations: those in treatment for disordered eating, those in treatment for alcohol and drug addiction, and wealthy college students. Since my study was the first to examine this phenomenon in unhoused people, it was exploratory in nature: I wanted to generate more interest among academics and front — line workers about disordered eating, and I naively thought that naming the problem might lead to someone in power caring.
I have since left academia, largely because I’m disillusioned with the lack of tangible impact that research has on the lives of oppressed people. That said, I still think my results are worth discussing.
As expected, most of my participants used substances to mitigate the effects of self — starvation. This wasn’t a novel finding, as the same patterns have been documented in people from all socioeconomic backgrounds. Unlike the “drunkorexia” that has been described in dieting college students, however, my participants didn’t always have a choice: Not all had access to the free food I did, especially those who had “aged out” of services, so they consumed alcohol or drugs when eating wasn’t possible.
“If I don’t eat my stomach is completely like, growling so hard I feel like a goddamn pitbull is going to burst out of there [but] alcohol numbs the pain.” — Nathanial
While substances also cost money, they were more attainable because getting them didn’t require performing. Whereas street — based transactions are direct and can entail payment plants, obtaining food meant “putting on a little green bowtie and dancing” (Nathanial) for the gaze of non — profit staff. However, for some participants, circumstantial self — starvation later became intentional. No — one is insulated from body ideals, and some developed indicators of anorexia or bulimia after accidental weight — loss due to poverty was positively reinforced.
This corroborates other studies showing that food insecurity may prompt disordered eating. Whereas we once thought that bulimia was reserved for wealthy women, for example, we now know that rates of self — induced vomiting and laxative abuse are as high or higher among those living in poverty. Alongside aesthetic norms, this is biological: Prolonged restriction induces physiological reactions that encourage binging, irrespective of one’s wealth. We are not meant to starve, and our bodies respond by asking for compensatory energy. This is why many in the early stages of eating disorder recovery experience “extreme hunger,” and in treatment settings are told to sate it while being assured that it will pass. However, interrupting the binge — purge or binge — restrict cycle is impossible when one is poor. Instead, binging may intensify after people have received government assistance or visited the food bank, and because even unhoused people are taught to care about appearance, some begin vomiting or restricting post — binge to ameliorate their guilt.
Next, for Indigenous groups and people of colour, the intersections of poverty and racialization also correlate with disordered eating. Most of my respondents were Indigenous, and their traditional food systems have been decimated through resource extraction and land theft. Not only did they encounter barriers to appropriate diagnoses and treatment referrals because providers are less likely to recognize eating disorders in non — White people, they were exposed to conflicting cultural beliefs about what “wellness” should entail. Contending with the trauma of colonization, lack of food equity, and poverty was a recipe for eating problems, and because of gaps in formal education between them and their peers in the same age brackets, talking about disordered eating also sounded different.
For example, I approached my project as generally as possible by omitting diagnostic labels during interviews. I did so because I knew that many of my participants wouldn’t have been exposed to clinical knowledge, and they may not identify as “anorexic” or “bulimic.” This strategy was useful, because while each of my participants described binging, purging, and restricting, only two could actually name and define one eating disorder.
Interviewer: “Have you ever thrown up on purpose after eating?”
Dawn: “Yeah, I used to make myself puke in elementary school.”
Interviewer: “Have you ever heard this behaviour be referred to as a symptom of an eating disorder?”
This speaks to what sociologists call “cultural capital” — knowledge acquired through socialization in the education system and other institutions about social norms and values. Cultural capital is linked to economic status, and people with lots of it are more likely to talk and think in ways that align with medical practitioners. Insight into disordered eating is a form of “health literacy,” and unhoused people don’t typically possess much of it. Interestingly, however, my participants were extremely literate when it came to discussing substance use. They had encyclopedic knowledge of the short — and long — term effects of certain substances, they understood the physical and psychological ramifications of addiction, and they could discuss precursors to substance dependence in detail. I concluded that because homeless youth are stigmatized as substance users, they have unexpected degrees of health literacy about this specific topic. When it comes to disordered eating, though, they aren’t seen and thus struggle to recognize it within themselves or articulate how it makes them feel.
As anticipated, none of the youth or front — line workers I spoke to felt that low — barrier services were equipped to address disordered eating. Although I was conducting my study years after getting housed, the same institutional indifference to eating disorders was prevalent based on what I heard. I’ve since considered how this is reflected in formal treatment centres, and the extent to which treatment is equipped to address disordered eating in young people who are poor.
In British Columbia, most eating disorder supports are privately funded. There are a handful of publicly — funded outpatient services, but adhering to rigid schedules and getting to and from appointments is a barrier for those who are often transient. Inpatient treatment is even less accessible: While some hospitals have emergency beds for those with the most acute symptoms, wait lists are long and, as importantly, none of these programs accepts clients who also struggle with substance use. Thus, even if a homeless youth decided they had an eating disorder, sought treatment, and was officially diagnosed, their likelihood of being admitted anywhere is (almost) nil.
Even if they could get admitted, though, treatment quality matters. Given that most centres are staffed by middle — class White women, an unhoused youth receiving gender — inclusive and racially — appropriate care is unlikely. Few places are equipped to deal with the ramifications of complex trauma, and even fewer deliver trauma care through a non — western lens. I can’t imagine many who are street — entrenched suddenly being expected to knit, talk about feelings, and resonate with the behavioural standards expected in these spaces. Treatment would have to be imagined with different cultural standards, and doing so is low — priority when it comes to political will.
So where does that leave unhoused youth with eating disorders? If they’re like me (that is, they come from an atypical background, they have extraordinary resources at their disposal relative most, and they are equipped with a hefty dose of White privilege), they stay alive, they never recover, they definitely don’t sleep at night, but they learn to self — manage — mostly. Most, however, aren’t as “lucky.” Almost all my closest friends from my years unhoused are dead, and more than a few of them had concurrent eating and substance use disorders. I’m not suggesting that offering eating disorder services would address the myriad structural forces that create homelessness in the first place, but it may enable some to live slightly gentler lives.
In hindsight, I feel no shame about doing what I had to do to survive. Neither eating disorder nor addiction treatment has ever met my needs, and the incessant messaging that I’m “diseased” after enduring decades of abuse has further disempowered me. To me, disordered eating and substance use are not symptoms of illness: They are valiant attempts to make intolerable circumstances tolerable, and being a disabled young person who has been abandoned by her primary caregivers is about as intolerable as life gets. When it comes to disordered eating, though, I wouldn’t have minded recognition. While I am now able to speak for myself, I see too many others whose voices are disappeared. And because the fight for systemic change is a long — game, in the interim it would be nice to see unhoused people the validation they deserve.