Diagnosis and treatment of eating disorders typically are relegated to psychiatry, although cultural critics and feminists have pointed out that culture, rather than merely individual psychology and home environment, may also play a role in causing eating disorders. The majority of people diagnosed with eating disorders are white women, although the number of eating disorder patients that are women of color and men is growing, which further complicates the debate on the cultural versus psychological causes.
Eating disorders—most notably anorexia nervosa and bulimia nervosa—are common in Western cultures, although they occur with increasing frequency in poor and non- Western societies as well. Anorexia nervosa was first considered a disease, and one specific to women, during the mid-1800s; the first cases occurred in educated, middle-class white women. Social historicists such as Joan Brumberg, author of Fasting Girls (1988), see the rise in eating disorders among women at that time as a silent protest against expectations for the roles those women would play in society as passive, submissive women confined to the private sphere. Considering not only anorexia but also bulimia and other related eating disorders, explanations for their occurrences in women range from the pressure of having so many options that historically had not been available to women and the fear of making the wrong choices or failing to live up to expectations, to desperation to be as thin as possible in order to meet and exceed the social norms for female beauty, to more individual concerns such as hating one’s body because of sexual abuse or punishing the body because of a lack of coping method for feelings of anxiety, anger, or even happiness and success.
These ideas about eating disorders inform and are informed by the clinical criteria for determining whether someone has an eating disorder and what kind is established in the Diagnostic and Statistical Manual of Mental Disorders (DSM), a book of diagnostic criteria for mental illnesses compiled by the American Psychiatric Association. Anorexia was the first eating disorder to be included in the DSM in the mid-1950s. The DSM added bulimia as a distinct category in 1980, and in 2000, a new category, eating disorder not otherwise specified, was added to assist doctors in diagnosing those who suffer from disordered eating but do not meet all the criteria for anorexia or bulimia. There are two other disorders that are not recognized in the DSM: binge eating disorder (BED) and compulsive overeating disorder (COE), both of which are thought by some professionals to deserve their own entries in the DSM’s next edition, which will appear in 2013. Sufferers of both disorders are characterized by periodically going on large binges without purging and tend to be overweight, but the difference between BED and COE is that individuals with COE have an “addiction” to food. Both types of individuals, however, are said to use food and eating as a way to hide from emotions, to fill inner voids, and to cope with daily stresses and problems. Common for both disorders is a desire to hide behind the physical appearance of obesity, using it as a blockade against society.
Debates on the Causes of Eating Disorders
There are many theories explaining how and why women develop eating disorders. Most explanations before the 1980s and 1990s constructed the problem and solution as being largely individual for each patient and her immediate family environment. In the classic psychoanalytic model, eating disorders are manifestations of a woman’s psychosexual development. In that case, a woman or girl refuses to eat because she rejects her womanly body and what its health represents—sexual fertility. Along this line of thinking, then, a compulsive overeater may seek to cloak her sexuality in body fat.
These ideas subtly speak to cultural expectations for women’s bodies and the judgment of what is beautiful or desirable in a woman, causing a second generation of critics to notice that the way in which social systems operate to reinforce negative messages to women about their bodies point toward patriarchy, defined as a system of interrelated social structures and practices in which men dominate, oppress, and exploit women. These social values are specific to our capitalistic society, in which the so-called cult of thinness supports food, diet, and health industries. “Weight concerns or even obsessions are so common among women and girls that they escape notice. Dieting is not considered abnormal behavior, even among women who are not overweight. But only a thin line separates ‘normal’ dieting from an eating disorder” (Hesse-Biber 1996). Twiggy, the waifish British fashion model of the 1960s, and the popular Mattel doll, Barbie, are often cited as icons of the impractical expectations society has for the size of women’s bodies. It is commonly known that the average model during the 1950s wore a size 8 and the average woman a size 10; today the average model wears a size 2, and the average woman now wears a size 12. The rise in disparity between model size and real women’s bodies parallels the rise of eating disorders, although experts are divided on the degree to which society is responsible. Joan Brumberg and most leaders of the eating disorder conversation agree that these images play a key role in the development of eating disorders, but psychiatrists say these coincidences might instigate disordered eating behaviors but are not enough to completely explain the development of the diseases anorexia and bulimia.
In the biological model, eating disorders are related to depression and bipolar disorder— both of which may be caused by chemical imbalances and thus corrected with medication. The only drug that has been approved by the U.S. Food and Drug Administration for the treatment of eating disorders is Prozac, to be used in bulimia patients. There are many studies into medication for anorexic patients, and some trials have yielded individual successes, but because the anorexic’s body chemistry is abnormal because it is in starvation mode, many drugs have little or no effect. Hesse-Biber criticizes the disease model of eating disorders, because it locates the problem as being within the individual rather than being outside oneself. She acknowledges that the disease model is good in that it frees patients from guilt, but she notes that this model benefits the health care industry—replacing a potential feminist view that society needs to be healed with a medical view that the victim needs professional treatment.
Family and Home Environment Explanations
Yet another model posits that eating disorders arise as symbolic representations of family dynamics. In this case, a power struggle between parent and child, especially the mother, may motivate a girl to find power over one thing she can control—what she eats. In this case, treatment and diagnosis involve the entire family. Feminist psychoanalyst Kim Chernin (1981) argues that eating disorders primarily develop as a response of overly controlling parents or environments that do not nurture a girl’s journey from childhood to womanhood; psychiatrist Mary Pipher (1994) views eating disorders as responses to our culture’s social dictate that a good woman is passive, quiet, and takes up very little space. Chernin and Pipher do agree, however, that eating disorders develop in situations that prevent the victim from saying or acknowledging to herself what she thinks, feels, or wants. In this way, then, eating disorders can be seen as survival strategies in response to emotional, physical, and sexual abuse; sexism; classism; homophobia; or racism—in other words, responses to trauma. Contemporary researchers and scholars mostly agree that eating disorder behaviors are coping mechanisms that give the sufferers a feeling of empowerment. By refusing to eat, bingeing, or bingeing and purging, a woman gains some influence over her environment. Control over the body becomes a substitute for control a woman may wish to have over her economic, political, or social circumstance. Th us, weight loss or gain may not be a primary motivation for disordered eating.
Increased Recognition of Eating Disorders among Racial Minorities
African American singer Dinah Washington died as result of an overdose of diet pills and alcohol; Puerto Rican poet Luz Maria Umpierre-Herrera writes about her struggle with anorexia; and African American writer Gloria Naylor writes about generations of eating disordered women in Linden Hills (Th ompson 1996). According to Becky Th ompson’s research on minority women, many of them were taught to diet, binge, and purge by older relatives who had done so themselves, which suggests that, although statistics show that eating disorders are on the rise in U.S. minority cultures, this may simply be the result of more careful research rather than an actual sharp increase. Health professionals assume and are taught that eating disorders are a white women’s disease, so in women of color eating disorder symptoms would be dismissed or treated as something else. Particularly because Hispanic and black women are culturally stereotyped as plump or obese, whereas Asian women are stereotyped as thin, doctors would ignore those visual cues as signs of eating problems. Exacerbating this situation is that most minority women also see eating disorders as a “white” problem, so they are more reluctant to recognize signs of disorder in themselves or seek help. This explains why most women of color who are treated for eating disorders are in more severe states than white women with the same disorders.
Women in African American and Hispanic communities have traditionally been larger than women in white communities, and minority communities have been more tolerant and even celebratory of the large female body as a symbol of health and wealth. One explanation for their larger size is food custom, but researchers have found that women in those communities also exhibit compulsive overeating behaviors, using bingeing as a way to cope with stress. Bingeing then is a way to find temporary relief from oppressive social and economic conditions such as sexual abuse, poverty, racism, and sexism. Since the 1980s, eating disorder diagnoses, particularly of anorexia, have risen among the African American population. Some experts note that this rise parallels the increasing affluence of middle-class black families, who find themselves embracing traditionally white values, including the obsession with thinness. This trend is also noted among upwardly mobile young Hispanic women and adolescents who see thinness as a key to success. A study conducted among a diverse selection of college-age women revealed that minority women who identified with their ethnic groups had fewer obsessions with thinness and realistic body goals compared to women who rejected their cultural identities and also subscribed to the thin ideal for themselves, resulting in a much larger percentage of eating-disordered behaviors (Abrams, Allen, and Gray 1993).
Increased Recognition of Eating Disorders among Men
The ratio of women to men with eating disorders is 9–1, although some researchers suspect that more men suffer from eating disorders and go untreated, particularly with bulimia, because it is easier to hide than anorexia (Crawford 1990). Like women of color, men with eating disorder symptoms may go unnoticed by physicians because they do not fit the classic diagnostic and treatment models, which tend to focus on women. Men who are more vulnerable to developing eating disorders participate in athletic activities that have regular weigh-ins, such as wrestling. Disordered eating and overexercising is sometimes ordered by a coach so that a team member will be a certain weight for a tournament, and this unnatural obsession with weight and weight control can lead to the wrestler using starvation as a means of weight control. Gay men may also be more susceptible to eating disorders because of the importance of appearance in gay culture. In a study comparing gay and straight men, homosexual men were found to be more preoccupied with their body sizes and appearances and more likely to suffer from body dysmorphia than their heterosexual counterparts (Crawford 1990). Experts forecast that eating disorders in all men will continue to rise as the marketing of men’s health and beauty products becomes increasingly aggressive with “metrosexual” men, straight men who are overly concerned about their grooming, clothing, and overall appearance; and they, too, seek to make their bodies conform to the thin standard already set for women (Patterson 2004).
Debates will continue regarding whether eating disorders stem from biological, psychological, environmental, or structural factors. What researchers do know is that women of various socioeconomic backgrounds are disproportionately represented in the diagnosis and treatment of eating disorders, as defined by the DSM. Many eating disorder activists argue that the cult of thinness requires a more critical look at the culture at large, including gendered patterns of family life, girls’ and boys’ socialization, and the effects of various forms of oppression on individuals. Thus some activist-scholars argue that stopping the cycle of girls being socialized into the cult of thinness is a public, not a private, enterprise (Hesse-Biber 1996). Activism such as boycotting companies and products whose marketing includes the use of the thinness ideal is one approach that has been used by the Boston-based Boycott Anorexic Marketing group, which was effective during the mid-1990s in getting Coca-Cola and Kellogg to portray athletic instead of waifish women. More recently, this kind of activism has been taken on by marketers themselves, particularly with Dove’s ad campaign that features women’s bodies with “real curves.” Groups such as the Eating Disorder Coalition have been lobbying the U.S. Congress to provide more money for eating disorder research and to force insurance companies to cover medical treatment. In addition, new research results continue to be released that points to other factors contributing to the prevalence of eating disorders among white, middle-class women as well as among men of various backgrounds and women of color—research that will surely shape future debates on their causes.
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- Abrams, S. K., L. Allen, and J. Gray, “Disordered Eating Attitudes and Ethnic Identity.” International Journal of Eating Disorders 14 (1993): 49–57.
- Bruch, Hilde, The Golden Cage: The Enigma of Anorexia Nervosa. Cambridge, MA: Harvard University Press, 1978.
- Brumberg, Joan Jacobs, Fasting Girls: The History of Anorexia Nervosa. Cambridge, MA: Harvard University Press, 1988.
- Chernin, Kim, The Obsession: Reflections on the Tyranny of Slenderness. New York: Harper Perennial, 1981.
- Crawford, David, Easing the Ache: Gay Men Recovering from Compulsive Disorders. New York: Dutton, 1990.
- Greenfield, Laura, Thin. HBO documentary. 2006.
- Hesse-Biber, Sharlene, Am I Thin Enough Yet? The Cult of Thinness and the Commercialization of Identity. New York: Oxford University Press, 1996.
- Maine, Margo, Body Wars. Carlsbad, CA: Gurze Books, 1991.
- National Association of Anorexia Nervosa and Associated Disorders, 2010. http://www.anad.org/
- Patterson, Anna, Fit to Die: Men and Eating Disorders. Thousand Oaks, CA: Sage, 2004.
- Pipher, Mary, Reviving Ophelia: Saving the Selves of Adolescent Girls. New York: Random House, 1994.
- Rumney, Avis, Dying to Please: Anorexia, Treatment and Recovery. Jefferson, NC: McFarland, 2009.
- Thompson, Becky W., A Hunger So Wide and Deep: A Multiracial View of Women’s Eating Problems. Minneapolis: University of Minnesota Press, 1996.