Young Asian American women tend to have cultural and family influences that discourage them from seeking help for eating disorders, according to new research led by Yuying Tsong, Cal State Fullerton associate professor in human services.

Compared with a general population with eating disorders, young Asian American women displayed some common themes, the study found, including:

Lack of knowledge of eating disorders, which extended to their parents

Lack of knowledge of treatment available or how to seek treatment

The study is one of few in eating disorder literature to examine Asian Americans in particular, Tsong said; most focus on white Americans. But what research there is indicates that while Asian Americans are at equal risk for eating disorders, they are often misdiagnosed or under-diagnosed.

“So there is a stereotype that Asian American women don’t have as many eating disorders as white women do,” Tsong said.

Compounding matters is the fact that Asian Americans are half as likely as white Americans to seek mental health services in general, a 2016 review of studies on the subject showed.

The topic has intrigued Tsong since she did post-doctoral clinical work in counseling at UC Irvine and noticed that concerns with body image often came up with Asian American women, even if they hadn’t sought help specifically for that issue. She talked with other clinicians, including her collaborator on the most recent study, Cal State Fullerton associate professor Rebekah Smart, from the Department of Counseling, and discovered they shared similar experiences.

The latest research builds on a study published in 2011 by the two women, who led a team that collected observations from 12 therapists with expertise in eating disorders. The therapists viewed Asian American clients as being under considerably more pressure to be thin and to achieve, compared with clients across all cultures. Parents strongly encouraged thinness, perhaps influenced by the belief that it was key to their daughters’ success in the United States.

Most of these clients were first- and second-generation and still in the stressful process of acculturation. The messages they were receiving, according to the 2011 study, were to adapt to the U.S. mainstream through professional success; conform to Asian gender standards; not embarrass family by being other than very thin; and attract the best possible mate.

At the same time, the young women were required by respect for their elders to not reject food offered to them.

Eating disorders offered the young women a way to cope with this stress by emotionally disconnecting or expressing distress covertly. Many of the therapists surveyed, most of whom are also Asian American, said treatment included helping parents understand notions of individuation, privacy and boundaries, and explain that while these are Western concepts, they exist in Asia too.

The 2011 study cites 2001 research on ethnic minority women that sounds like a psychological Catch-22: The more acculturated to Western culture they were, the greater the likelihood of eating disorders; and the less acculturated, the more cultural conflict and stress, and the greater the likelihood of eating disorders.

But there was little research done on the barriers that Asian American women experience when they seek help for eating disorders, what keeps them engaged in treatment and reasons for stopping treatment early.

So Tsong and Smart, along with three students in the Department of Counseling, recruited Asian Americans who had experienced disordered eating behaviors or body image concerns. The final sample totaled 212 participants with an average age of just under 25, including students at Cal State Fullerton. About three quarters were female, and a little more than half were second-generation.

The team categorized barriers preventing the students from seeking mental health services into personal, social, structural, stigma, beliefs and mental health literacy.

For example, personal reasons included not wanting to acknowledge there was a problem, not knowing how to articulate it, or feeling shy or embarrassed. As one participant said: “I never thought to seek treatment because it was an issue that I didn’t ever want to share with others. For me, it was embarrassing to tell others that I had felt terrible about my body and the way I looked.”

Social barriers included family and religion. One participant said she avoided treatment “because my mom thought I looked nicer when I ate less. She doesn’t even know what eating disorders are.” Another said, “My family would go bonkers.” And a third was told that a large weight loss “was just a phase … something that I could easily change if I prayed more.”

A stigma over seeking therapy contributed: “I knew it wasn’t healthy and have tried to stop on my own. I didn’t like the idea of being seen as the, ‘broken’ Asian girl with problems.”

Lack of time or money played a part for some, while others said they didn’t know their disordered eating was a problem or that a therapist could help.

Next, Tsong and her fellow researchers will tackle that last barrier.

“I am conducting research on mental health literacy — how able we are to recognize eating disorder symptoms in ourselves or in other people; how able we are to find resources to help; and if we can use literacy as a prevention or intervention strategy to reduce stigma and promote help-seeking attitudes and behaviors,” Tsong said.

She is also looking at data that identify “facilitators” that encourage Asian Americans to seek treatment for eating disorders, such as having easy access to counseling.

“An example could be that a friend or a family member can recognize that they are stressed and recommend that they seek counseling,” said Tsong.

Several study participants mentioned they sought help because their university provided free counseling sessions on campus. The primary reason they stopped counseling was because they graduated and no longer had easy access to therapy (having to drive too far or not knowing where to find a therapist) and their insurance did not cover it.

Tsong and Smart recently presented a Continuing Education workshop at CSUF to other counseling professionals and students.

Said Tsong: “We continue to receive responses from Asian American women and clinicians that work with this population about how little there is in the literature on this topic.”

Students working on the 2017 study were Melissa L. Ward, Alexandria Dilley and Shuo Coco Wang. The research received support from CSUF and the American Psychological Association’s Office of Ethnic Minority Affairs.

Help available on campus

Counseling & Psychological Services in CSUF’s Student Wellness has counselors on staff with expertise in eating disorders as well as Asian/Pacific American psychology.

Call 657-278-3040 to make an appointment.