Eating Disorders

Eating disorders, particularly anorexia nervosa and bulimia nervosa, are highly gendered phenomena: Approximately 90 percent of known cases occur among girls and young women. In addition, gendered conceptions of the body and personhood shape both people's experiences of these conditions and treatments for them. Research in the social sciences and humanities emphasizes the importance of gender in understanding these complex and perplexing problems.

The cultural and historical specificity of eating disorders underscores the need to analyze the relationship of social categories, including gender, race and ethnicity, and class, to these problems. Anorexia and bulimia appear far more frequently in industrialized societies (American Psychiatric Association 2000). Although some scholars have raised important questions about the assumption of cultural and/or historical particularity for anorexia (Bell 1985, Banks 1992, Lee et al. 2001), most agree that the meanings and manifestations of eating disorders since the 1970s in industrialized settings constitute a uniquely salient focus for attention and research. The role of race and class as well as gender in shaping these disorders is an ever-present and frequently debated concern.

CATEGORIES OF EATING DISORDERS

Anorexia is a form of self-starvation that often is coupled with rigorous exercise, especially since the rise of the fitness movement in the 1970s. It first was identified as a medical disorder in the late nineteenth century (Gull 1874, Lasègue 1873) but occurred extremely rarely until it more than doubled in incidence in the 1970s and 1980s. This increase in incidence represents an actual increase in the number of cases; it is not due simply to greater sensitivity or awareness in identifying the problem (Gordon 2000). Anorexia was recognized officially as a psychiatric disorder in 1980. The typical age of onset is middle to late adolescence. Anorexia is often chronic and lethal; it has the highest mortality rate of any psychiatric illness (approximately 10 percent), and most patients never recover fully.

Bulimia is a binge-purge disorder: Episodes of binge eating are followed by vomiting, the abuse of laxatives or diuretics, fasting, or excessive exercise. First identified in 1979 (Russell 1979), bulimia was recognized as a psychiatric disorder in 1980, and its incidence increased threefold in the 1980s and 1990s. The typical age of onset is late adolescence or early adulthood. Compared with anorexia, little is known about the course or mortality rate of bulimia. Although bulimia can be chronic (most patients have it for at least several years) and also fatal, psychiatrists appear to be more hopeful about the prospects for long-term recovery from bulimia compared with anorexia. However, death caused by electrolyte imbalance from vomiting can occur suddenly among bulimic patients, who can seem healthy on the surface because they are typically within a normal weight range.

Binge eating disorder entails regular episodes of binge eating that ordinarily are not followed by purging or compensatory acts. This disorder was identified in 1994 but is not considered an official eating disorder category in its own right. Individuals with this problem receive a diagnosis of "Eating Disorder Not Otherwise Specified" (American Psychiatric Association 2000). It usually appears in late adolescence or in a person's early twenties and is the most prevalent but least studied eating disorder. It occurs relatively frequently among males, but females are approximately one and one-half times more likely to experience it (American Psychiatric Association 2000).

Officially diagnosed eating disorders are relatively rare; among females, the prevalence of anorexia is about 0.5 percent and that of bulimia is approximately 1 to 3 percent (American Psychiatric Association 2000). However, estimates of significant eating disorder symptoms range from 5 to 10 percent of girls and young women and can run even higher on some college campuses (Boskind-White 2000). Obesity, although common, is not considered an eating disorder "because it has not been established that it is consistently associated with a psychological or behavioral syndrome" (American Psychiatric Association 2000, p. 583).

EATING DISORDERS AS CULTURAL PHENOMENA

Most researchers agree that eating disorders are culturally situated phenomena. It is difficult to explain their rise in incidence in the 1970s and 1980s in industrialized and industrializing social locations without referencing cultural changes during that period. Even so, most psychologists and psychiatrists downplay so-called sociocultural factors such as shifting social ideals of gender in the etiology and treatment of eating disorders. At the same time some proponents of a feminist cultural model "rely on a generic notion of cultural influence and simultaneously medicalize and pathologize all chronic dieting" (Gremillion 2003, p. 27). Simplified representations of nature and nurture are at work in this debate. This problem can be addressed by questioning the status of eating disorders as "pre-given medico-psychological" entities (Malson 1991, p. 31) and by locating eating problems at the intersection of multiple and often contradictory understandings of feminine identity and embodiment (Bordo 1993, Malson 1998). This approach differs from efforts, such as Joan Brumberg's (1989), to integrate biological, psychological, and cultural factors as they currently are understood.

The sociologist Bryan Turner (1984) and the philosopher Susan Bordo (1993) examine developments in Western social contexts that have led to understandings and experiences of the female body as a battleground of gendered conflicts that are specific to consumer culture. Efforts after World War II to promote consumption and the satisfaction of desires coexist with long-standing efforts to control and contain the female body. In this context anorexia is a triumph of control that is wedded to increasingly widespread ideals of slender femininity. Bulimia expresses more directly contradictory cultural imperatives for women and girls in particular to both consume and control the effects of consumption (Bordo 1993).

Bordo's work suggests that a widespread insistence on distinguishing anorexia and bulimia as discrete psychiatric entities conceals the gendered politics of consumer culture that links the two and connects both with a continuum of phenomena that range from chronic dieting to obesity. Significantly, it is not uncommon for patients with anorexia to develop bulimia; also, the prevalence of binge eating disorder is as high as 50 percent (the mean is 30 percent) when samples are drawn from weight-control programs (the prevalence rate is 0.7 to 4 percent in community samples) (American Psychiatric Association 2000).

Mark Nichter and Mimi Nichter (1991) and Robert Crawford (1985) emphasize the importance of class relations in analyzing eating problems. Pressure to manage the contradictions of control and release as well as constraint and freedom at the level of the individual body may influence those who are upwardly mobile most acutely. In this light assessments of obese or seemingly unfit individuals as "lazy" valorize the cultural norms that are implicated in eating disorders. Similarly, representations of bulimia as a "bad" or failed other to anorexia (Burns 2004) arguably scapegoat individual sufferers for problems that are shaped socially and economically.

GENDER AND PSYCHIATRIC TREATMENT

Although treatments for anorexia and bulimia have improved over time, mortality and relapse rates remain high. Difficulties in treatment often are attributed to patients' pathology and tenacity, but a growing number of scholars argue that therapies often unknowingly reproduce problematic sociocultural and gender norms that contribute to patients' struggles. Ideologies of individualism and self-control in the therapeutic management of eating can reinforce the hard-earned sense of self-reliance that is part and parcel of eating problems (Eckerman 1997, Gremillion 2003, MacSween 1993). These ideologies pose irreconcilable dilemmas for women and girls who are taught to sacrifice their own needs for those of others (Boskind-Lodhal 1976, Steiner-Adair 1986, Orbach 1986). In addition, many treatment programs unwittingly perpetuate beliefs about motherhood and feminine "nature" that imply the need for heroic measures to achieve health. A sense of defeat and relapse often follows (Gremillion 2003).

Therapies that do not acknowledge the fact that eating disorders are shaped culturally and historically are likely to perpetuate taken-for-granted understandings of gender that allow these disorders to flourish. The need for a contextual reading of illness and health applies not only to doctor-patient relationships but also to the formulation of treatment protocols and the constitution of gendered relationships within professional treatment teams that often attempt to model health (Sesan 1994, Wooley and Wooley 1985). Formal studies of alternative treatments that acknowledge a politics of gender (White and Epston 1990, Steiner-Adair 1994) are lacking, but anecdotal evidence and pilot study results (Madigan and Goldner 1999) suggest a significant improvement in treatment outcomes.

THE POLITICS OF INCLUSION: GENDER, RACE, CLASS, AND SEXUALITY

Disordered eating affects males as well as females. The effects of consumer culture, particularly as they relate to concerns about body size, shape, and image, are increasingly present in the male body (Nemeroff and associates 1994). Significantly, eating disorders are most prevalent among men and boys who engage in activities that involve weight restrictions, such as bodybuilding, wrestling, dancing, gymnastics, and jockeying (Andersen and colleagues 1995). There is a broad consensus that eating problems are clinically similar between males and females.

However, no clinical or cultural analyst disputes the fact that eating disorders are much more widespread among females. Any attempt to represent eating problems as "equal opportunity" along the axis of gender fails to acknowledge significant gender inequalities that affect the politics of body size and self-control. However, males with eating disorders may be stigmatized as insufficiently "masculine" (Kearney-Cooke and Steichen-Asch 1990) and therefore may be less likely than women and girls to identify these problems openly. It is possible that eating disorders are more prevalent among males than is realized (Hepworth and Griffin 1995). Associations in the literature between eating disorders and homosexuality in males should be evaluated in light of stereotypical views about appropriate masculine behavior.

Scholars who critically analyze representations of eating disorders as white and middle-class phenomena have raised similar questions about whether these disorders are overlooked in particular groups. Eating disorder patient populations are likely to be socioeconomically privileged disproportionately in part because of preconceived ideas about typical patient profiles (Dolan 1991, Gard and Freeman 1996, Gremillion 2003, Thompson 1994a). Evidence is mounting that eating disorders cut across ethnic and class boundaries (Striegel-Moore and Smolak 2000). However, rather than simply attempting to identify eating disorders as they are known among various populations, it is important to ask how these disorders are defined in the first place because official definitions may preclude recognition of significant eating problems.

The sociologist Becky Thompson (1994b) shows that pressures for girls and women to be slim, which can lead to a range of eating problems, are associated with several narratives of privilege, such as whitening, moving up the social ladder, and becoming appropriately heterosexual. At the same time she argues that these powerful narratives do not capture all the meanings of eating difficulties in people's lives. For instance, "dissatisfaction with appearance often serves as a stand-in for topics that are still invisible" (Thompson 1994b, p. 11) such as racism, sexism, poverty, and sexual abuse. According to Thompson, "Doing justice to the social context in which difficulties with food arise requires an integrated analysis—one that accounts for the intersecting influence of gender, race, sexuality, nationality, and class" (Thompson 1994b, p. 360).

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                                        Helen Gremillion