Iatrogenic harm in eating disorder treatment: a lived experience-led call for epistemic justice and accountability

Psychological treatments for eating disorders (EDs) can be beneficial, but treatment benefit is not, by itself, evidence of safety. A treatment may reduce ED symptoms while still causing iatrogenic harm (IH), and current evidence does not allow confident claims about whether IH is more common, less common, or as common as treatment benefit, because harms remain poorly defined, inconsistently monitored, and inadequately reported. This correspondence argues that the under-recognition of IH in ED care is not only a methodological problem, but also an epistemic one. When patients report being harmed or traumatised by treatment, their accounts may be dismissed, pathologised, or reframed as resistance, non-compliance, lack of insight, or treatment-interfering behaviour. Such responses can compound harm and prevent services from learning from patient testimony. The article further argues that IH is not experienced uniformly. Marginalised communities may encounter distinct forms of harm when treatment models are neuronormative, non-affirming, culturally incongruent, or inattentive to structural inequity. Person-centred ED care must therefore ask not only whether a treatment works on average, but for whom it is safe, meaningful, accessible, and accountable. The way forward requires prospective IH monitoring, patient-reported outcomes, open-ended and qualitative methods, repair-oriented practice, and lived experience-led co-design. Lived experience involvement is essential because people who have experienced harm can help define what counts as harm, which outcomes matter, how disclosures should be interpreted, and what accountability requires. Claims about the benefits or evidence-based status of psychological treatments for EDs are incomplete when safety is inferred from benefit or effectiveness alone while IH remains underdefined, undermeasured, and underreported.