Informed by our lived experiences with eating disorders, our work providing direct support to communities underserved by existing healthcare structures, and our commitment to social justice, we are deeply troubled by several aspects of the proposed characteristics for “terminal” anorexia nervosa outlined by Gaudiani et al. in Journal of Eating Disorders (10:23, 2022). We have identified two substantial areas of concern in the proposed characteristics provided by Gaudiani et al. and the subsequent publication by Yager et al. (10:123, 2022). First, the original article and the subsequent publication fail to adequately address the widespread inaccessibility of eating disorder treatment, the lack of parameters for what constitutes “high quality care”, and the prevalence of trauma experienced in treatment settings for those who do access treatment. Second, the characteristics proposed for “terminal” anorexia nervosa are constructed largely based on subjective and inconsistent valuations of suffering which build on and contribute to harmful and inaccurate eating disorder stereotypes. Overall, we believe these proposed characteristics in their current form stand to detract from, rather than assist, the ability of patients and providers to make informed, compassionate, and patient-centered decisions about safety and autonomy both for individuals with enduring eating disorders and for individuals with more recently diagnosed eating disorders.

The Eromin Center was founded in Philadelphia in 1973, aiming to provide lesbian, gay, bisexual, and transgender (LGBT) affirmative mental health treatment 6 months before the American Psychiatric Association voted to remove homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM-II; American Psychiatric Association, 1968). This study of archival records and oral histories with Eromin Center staff and volunteers reveals an iterative and improvisational approach to community-based affirmative care. Rather than waiting for national leadership or institutional change, they aimed to respond directly to otherwise unrecognized needs of LGBT people through psychotherapy and social services-what we are calling clinical activism. Without training or guidance from research, they tended to base their work on their own experiences, an approach with inherent limitations in particular because most of the staff were White, cisgender, and identified as gay and lesbian. They attempted to address these limitations until Eromin's closing in 1984. Largely overshadowed by the broader policy changes in mental health care, Eromin's work provides a crucial case study in community-based clinical activism and affirmative practice with continuing salience today. Public Significance StatementThis historical case study of an early LGBT counseling center reveals the central role that clinicians played in developing affirmative forms of mental health treatment for LGBT people. The findings challenge conventional histories of LGBT mental health care, which emphasize the removal of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1968). This research shows instead how clinicians in the field actively worked to change clinical practice and social beliefs.

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