Wednesday, January 19, 2011

My paper on eating disorders

I recently completed a paper I'm pretty proud of that explores a great interest of mine- the development of eating disorders in young women. This paper was a step in what I hopes to be a lifetime of research and advocacy for young women struggling with self-esteem and body image. I welcome any comments or questions you may have. Note: My teacher gave me an A/A- (I hate when professors do that...which is it? A or A-??) I hope you enjoy reading and even learn a thing or two.

A Feminist and Relational Reflection on Restrictive Eating Disorders

I remember as a young child taking a bath, staring at my legs and placing my hands on either side of them, “carving” away the excess flesh I wished would disappear. My mother remembers it too, and tells me I was in fifth grade, probably about ten years old. Not clinically overweight, deemed healthy and active by doctors, by age ten I wished for a different body. What were the causes? Why did they begin right around adolescence? My sister, who grew up in the same household, never had similar issues. I had loving, supportive parents, healthy, secure attachments, teachers who noticed my hard work and quick intellect, sports coaches who applauded my tenacity and teamwork. So why, at such a young age, had I begun to struggle with body image? If I had been a boy, would I still have struggled? What if I had been black, Latina, or lesbian? Had I never been exposed to mainstream media culture, would I have felt the same way? These questions drive my research on the topic of eating disorders.
Eating disorders have long been hailed a disease of the white, middle class, adolescent female (presumably heterosexual.) I certainly fit those descriptions. Yet eating disorders have been found in all ages and varying cultures, and cross socioeconomic and racial boundaries (Thompson, 1992). One specific aspect, however, has proven again and again to predict the development of eating disorders: gender. While eating disorders do affect males, the cases reported are overwhelmingly adolescent females. The National Eating Disorders Association reports that 10 million women are affected by an eating disorder, versus 1 million men. Forty percent identified cases of anorexia are in girls 15-19 years old (Hoek & van Hoeken, 2003). My questions are: why is gender a predictor in the development of eating disorders? Is there a determining factor in female identity development that leaves women vulnerable to cognitive, social, and environmental stressors that can trigger eating disorders? Why is adolescence such a common time to develop an eating disorder?
The development of eating disorders in adolescents, like the propensity for violence in children, is caused by a combination of “head, heart, and hand”, (Begley and Kelb, 2000). Leading research suggests that eating disorders such as anorexia and bulimia are caused by a combination of environmental, cultural, and biological factors. “Doctors now compare anorexia to alcoholism and depression, potentially fatal diseases that may be set off by environmental factors such as stress or trauma, but have their roots in a complex combination of genes and brain chemistry” (Tyre, 2005).
These issues of risk and resilience are particularly important now, as rates of eating disorders are on the rise, and thinness is prized in the media more than ever (Goodwin, 2010). Eating disorders are a complex medical and clinical issue with roots in genetics, biology, cognition, human psychological development, trauma, cultural values of beauty and femininity, and media pressure. There is no one specified, proven cause. I wish to explore how feminist and relational theorists shed light on the complex topic of eating disorders in adolescent girls. Many groundbreaking books and articles have been written in the past twenty years discussing eating disorders and female identity development, which I will discuss here while highlighting both past and recent research.

Biological bases of Anorexia

While my focus here is not the biological bases of eating disorders, it is important to note that genetic, evolutionary and biological factors that have been pinpointed as possible causes. There are several theories that argue that women are biologically and evolutionarily predisposed to restrictive eating disorders (as compared to men). Women have a higher percentage of body fat, allowing them to go without food for longer in times of need, and laboratory studies have shown that female animals are more capable of surviving periods of starvation. From an evolutionary perspective, it makes sense that women more than men are more likely to starve themselves as a response to stress (Gordon, 2000).
Recent studies have attempted to prove, much like violence in teens, that genes that predict anorexia exist. Results show that eating disorders like anorexia do run in families. Anorexia is polygenic, which means it’s development is influenced by a variety of genes, and is closely associated with obsessive-compulsive disorder, anxiety disorders, and depression, all which have genetic links (Gordon, 2000). Other biological traits specific to anorexics are: alterations in neuronal pathways, namely serotonin and neuropeptides, and the tendency to have disturbances in brain serotonin, which regulates mood, appetite and behavior. Yet eating disorders are never simply biological, like mental illness or a chemical imbalance. Those afflicted with an eating disorder, overwhelmingly adolescent females, are most likely genetically predisposed, and the distress of hormonal, biological, mental, and sociocultural changes at adolescence trigger the onset of the disordered thought patterns and eating behaviors.

Eating Disorders, Adolescence, and Relational Theory

There are obvious physical changes that typically develop in both sexes during adolescence. In addition to menstruation, young women develop the trademark “womanly” features, namely breasts and hips, with increased body fat. When this process happens earlier than normal, researchers argue it can lead to increased body dissatisfaction because the marked increase in fat that accompanies puberty distinguishes early-maturing girls from the thin beauty ideal (Randall, et al., 1991). This increase fat is thought to make early menstruation particularly stressful because it is developmentally deviant; it occurs before most girls’ puberty-related weight gain. Other physical changes that occur with puberty may foster feelings of bodily shame because our culture emits negative messages about this aspect of female maturation. Further, it is possible that “the hormonal changes that accompany menarche result in emotional lability” (Stice, 2002, p. 670) and a larger likelihood for psychological issues.
As women develop at younger and younger ages, their bodies are seen as sex objects, especially by older teens or young men, and they receive sexual and romantic attention when their cognitive and identity development hasn’t caught up to their physical development. This can lead to fear of sexuality and sexual advances and feelings of confusion and shame. They develop as young women knowing that being an object, particularly a sexual object, as part of their identity. For many adolescent young women with eating disorders, the restrictive eating behavior is not only a way to gain control over their bodies, but to literally “erase” the sexuality from their bodies by ridding themselves of the fat it consists of (S. Motulsky, class discussion, December 6, 2010).
Adolescence can be a difficult time regardless of gender, and not just because of the biological changes that occur. Noted adolescent scholar Arnett (1999) states that the “hormonal contribution to to adolescent mood disruptions...tends to exist only in interaction with other factors” (p. 322). There are separate, overlapping and oppressive forces acting against both boys and girls during the adolescent years. Yet eating disorders in adolescent girls are far more prevalent, and most occur slightly before or during adolescence (Steiner-Adair, 1986). “Epidemiological studies repeatedly cite adolescence as a time of psychological risk and heightened vulnerability for girls” (Gilligan, et al., 1997, p. 25). So what is it about this period that makes development particularly trying for young women (besides the issues surrounding the biological changes?) How would relational psychologists analyze the shifts that take place in adolescence?
Not surprisingly, prominent relational and feminist psychologists such as Gilligan, Jean Baker-Miller, Catherine Steiner-Adair, Janet Surrey, Susie Orbach and others have analyzed eating disorders and the crisis of adolescence from a feminist and relational lens. These women are experienced mental health clinicians, researchers, authors, and theorists. They argue that eating disorders are a symptom of a developmental and identity crisis in women, “rooted in systematic and pervasive attempts to control women's body sizes and appetites” (Thompson, 1992, p. 547). These theorists argue that anorexia is a symptom of cultural silencing, not just an individual medical or psychopathological issue but a result of a cultural epidemic of sexism and marginalization of women’s unique relational orientation.
Carol Gilligan defines adolescence as a time of developmental and relational crisis, filled with tension between what is asked of young women in their culture and what they desire for themselves (Gilligan et al., 1995). Adolescence marks a crucial paradox for young women: the struggle between independence and autonomy and the centrality and importance of relationships in their lives. Although they are encouraged to be autonomous and independent during adolescence, “the importance of strong relationships does not abate” (Stern, 1990, p. 73). When young girls reach a certain point, often marked by entrance into middle school, first menstruation, puberty, interest in sex and romance, and increased feelings of insecurity and self doubt, they are simultaneously being pressured into independence, individuality, and autonomy. Catherine Steiner-Adair notes the overwhelming sense of loss and confusion during this period: “How impossible it is to grow up as a girl in a girl’s body in a culture that at adolescence suddenly devalues connection, relationships, all the knowledge you have about life” (Robb, 2006, p. 283). Teenagers are expected to separate from their parents, establish themselves as “unique”, and shoulder more responsibility at school, at home, and often in the workplace.
Gordon argues that the female response to the added pressures and identity crises of adolescence is to “choose” thinness as a passive form of resistance to the contrasting cultural expectations set up for young women. Girls who were socialized to become submissive “clinging-vine” wives are asked during adolescence to show autonomy, individuality, and independence, creating intense self-doubt, uncertainty, and feelings of loss of control. In the passive way of many women, adolescent girls in crisis choose the “fashionable dictum to be slim as a way of proving themselves as deserving respect” (Gordon, 2000, p. 94). In a time of great inner conflict and struggle for both individual identity and strong relationships, restrictive eating is a way to both control their lives and honor their inner struggle, outwardly.
Ruellen Josselson (1996) states, “Nowhere in the modern age has the issue of identity been more vexing than in our society’s confusion over the roles it is willing to allot to women” (p. 31). For me, disordered eating that began at adolescence was absolutely wrapped up in gender. Once a carefree tomboy, a fierce soccer competitor who romped in the forest and caught snakes, my body image problems emerged around the time I realized fully that I was not a boy, and could not do the things they do. Not only could I not jump as high or run as fast, I was discouraged from trying. I felt a weight of impending womanhood that manifested in hatred of my own body, that which made me different, that which inhibited me from being loud, outrageous, and goofy. Other girls, thin, quiet, and feminine, were praised by adults and admired by boys. I wanted to be both pretty and admired and interact well with other girls, but I wanted to be myself, too. If I wanted to “be a girl”, I had to act and look like them, but inside, I was fighting it, hard, and the war was waged on my physical self.

Eating Disorders, Psychology, and Identity

Part of the reason why women are primarily affected by eating disorders is that “women have always constructed their identities in different phrasing from men” (Josselson, 1996, p. 31-31). That is, women build their sense of self through her connections to others, discovering their own unique self in the context of important relationships. Yet the focus in Western culture is on individual identity, autonomy, and independence. The dissonance is striking. Gordon argues that eating disorders stem from a struggle with identity, that eating disorders are “an obsession with food, weight, and body shape that becomes a defensive substitute for dealing with the conflicts associated with the achievement of an identity” (Gordon, 2000, p. 55). The conflict Gordon refers to is the marginalization of the female voice in mainstream society as well as psychological theory. Although gender is now considered an important element in developmental psychology, until very recently many pioneering psychologists in the field completely marginalized the female perspective- these developmental theorists basically ignored half the human race in their research and theoretical conclusions. Therefore, they also ignored the female orientation in psychological development, which is centered around relationships as opposed to individuation (Gilligan, 1982). Eating disorders, particularly restrictive eating, are seen by many theorists as a form of submissive resistance against this gender oppression. In a world they cannot control, eating disordered women have power over the one thing they can control: their bodies.

Environmental Influences

It is impossible to discuss eating disorders without mentioning the cult of thinness and physical perfection that pervades Western (and much of non-Western) media culture. Bandura’s social learning theory argues that we learn how to act by observing and modeling others, even symbolic models seen on television, which is a powerful influence on viewers (Crain, 2005). The feminist therapist Mary Pipher once said “Fat is the leprosy of the 1990‘s” (Martin, 2007). Not much has changed since then. As I write this, a reality show on E Television called “Bridalplasty” offers complete surgical makeovers to brides-to-be engaged in various trivial competitions. In 2009 the Victoria’s Secret Fashion Show, a known culprit of the overt objectification of the unthinkably thin female body, brought in 8.3 million viewers, bested only by the extreme reality weight loss show “The Biggest Loser”, which brought in 10.3 million viewers. The popular Victoria’s Secret “fashion” show, featuring women clad only in lingerie, is described as "eating disorder porn," by Harvard pediatrician Dr. Michael Rich. "They (the models) are a fantasy that drives you to extreme behaviors which require overcoming normal physiological and instinctual survival drive” (Katz, 2010). Unfortunately, this notion permeates nearly every aspect of media culture, even in rural areas with lower population. “Media permeation of even the most remote areas of the country makes it unlikely that any ethnic or racial group is unaware of the premium placed on dieting and thinness” (Thompson, 1992, p. 31).
A recent article in Marie Claire magazine stated “I think I'd be grossed out if I had to watch two characters with rolls and rolls of fat kissing each other ... because I'd be grossed out if I had to watch them doing anything” (Kelly, 2010). Television programs and advertisements, movies, magazines, talk shows, and the fashion industry are obsessed with thinness. Even activists groups like PETA (People for the Ethical Treatment of Animals) use hypersexualized, objectified female bodies in their campaign advertisements. From, "400-600 advertisements bombard us everyday in magazines, on billboards, on TV, and in newspapers. One in eleven has a direct message about beauty, not even counting the indirect messages” (Eating disorders and the media, 2007). Of course, not all women exposed to these images and messages will develop an eating disorder. The fact that current media culture sends out both overt and discreet messages that “thin is in” doesn’t determine anorexia, but it influences already young women struggling with biological changes, and psychological, and relational identity crises.

Eating Disorders, Cross-Culturally

Eating disorders were once thought to be an issue solely for white, privileged, educated young women- “starving amidst plenty” (Orbach, 1986, p. 50). I can remember my first year of undergraduate education, writing my first paper on eating disorders, and I confidently pointed out to my professor that “anorexia is an issue for white adolescent girls!” She kindly yet firmly pointed me toward Becky Thompson’s “A Hunger So Wide and So Deep”, work by Patricia Hill Collins, and other feminist scholars. These scholars and others, plus new research, have proven that while a large portion of those with eating disorders are white upper middle class adolescent females, that demographic is in no way the limit to the reaches of eating disorders. In fact, eating disorders among racial minorities are currently on the rise (Daverin, 2010). While feminist research has certainly made incredible bounds in the correlation of gender oppression and eating disorders, many of the arguments for sociocultural causes of eating disorders are focused on white, middle class, heterosexual women.
The claim that eating disorders afflict only rich white girls is partly due to the fact that very little research has been done on any other population: those in the Black, Latino, or Asian populations, or those in low-income communities (Thompson, 1992). The causes for eating disorders found in white, hegemonic populations cannot justifiably be generalized across race, class, sexuality, religion, and culture. For example, the idea that eating disorders are caused by societal and cultural pressures for women to be silent, passive, and dependent on men do not necessarily apply to African-American women, whose respective cultures don’t necessarily value passivity, or to lesbians, who don’t have romantic or sexual relationships with men (Thompson, 1992). As Meg Lovejoy states, “Feminist conceptualizations of body image disturbance and eating problems have traditionally focused on the experience of white women exclusively (Lovejoy, 2001, p. 240). But clinicians, doctors, and researchers cannot simply tell Black, Latina, and lesbian women with eating disorders, “No, you’re not anorexic, your culture wouldn’t encourage that. That’s for white girls! Research proves it.” Lesbian and women of color with eating disorders cannot be considered outliers- their struggles against racism and heterosexism must be examined for their role in the development of disturbed eating behaviors.
It is dangerous to assume that the pressures that white women in Western societies face do not affect women of color, for example, that women in minority populations are less affected by eating disorders because they experience less pressure from their respective communities to be thin. While “the sociocultural model of eating pathology predicts that ethnic minority individuals should be at lower risk for eating disordered behaviors than Whites because the former putatively experience less cultural pressure to be thin” (Randall, et al, 2005), this doesn’t mean generalizations should be made for all women of color. Results do show that women of color experience less internalization of external pressure to be thin than white women (Randall, et al, 2005), but this does not include, for example, women who identify as bi-racial, or women of color living in a homogenous white environment. As environmental pressures to be thin increase, it would be impossible for their influence to not leak into minority communities. “It is possible that ethnic minority status no longer confers a protective benefit for eating pathology because mainstream culture and values espoused by the media, family, and peers may reach all ethnic groups” (Shaw, et al, 2004, p. 12).
Adolescence is a particularly challenging time for women of color because of the addition of their minority status into the fray. Young black girls living in white environments, for example, may not receive the same attention from white boys because they are considered too different to be desirable. “These issues of emerging sexuality and the societal messages about who is sexually desirable leaves young Black women in a very devalued position” (Tatum, 1997, p. 57). Perhaps that devalued black girl will see the rejection of her self as a rejection of her body. Perhaps in an attempt to be more “white” and garner more male attention, she will restrict her eating, leading to an eating disorder.
In addition, racial stereotyping and mainstream health professional’s lack of familiarity with ethnic diversity may have also obscured attention to women of color (Thompson, 1992). In an increasingly diverse world and with the high mortality rate of eating disorders, it is absolutely necessary to evaluate and compare the prevalence and effect of eating disorders cross-culturally, and to be aware of not just gender but also racial, class, and sexual inequality in the dynamics of body image, self esteem, and eating disorders.

Heterosexism and Eating Disorders

Heterosexism has been largely present in the research done on eating disorders. The women in studies on eating disorders are typically assumed to be heterosexual, with the exception of a few researchers who employ current feminist methodologies, like Becky Thompson and her work with women of color and lesbians. An example of this dearth of research is with a 1996 article titled “Women, Sex, and Food: A Review of Research on Eating Disorders and Sexuality” by Michael W. Wiederman. In an article about sexuality and eating disorders, in the journal The Journal of Sex Research, there is zero mention of sexual orientation or homosexuality whatsoever.
In addition, like with women of color, lesbian women have been considered to be less vulnerable to feminine cultural pressures to be thin than heterosexual women (Heffernan, 1996). Yet just because a woman is attracted to women doesn’t make her any less of a woman in terms of gender identity, orientation, and desire for relationships- so why wouldn’t she be impacted by a sociocultural obsession with thinness that affects straight women? A gay woman is still (obviously) a woman, who, especially in adolescence, is dealing with the struggle between autonomy and desire for relationships. Not to mention the intense personal and psychological issue of coming out, which often happens during identity development in adolescence, and homophobia from parents, friends, communities, and the media (Hammack, 2005).
Recent feminist research has identified clear factors among lesbians that contribute to eating disorders. Lesbians who have internalized a high degree of homophobia are more likely to accept negative attitudes about fat, and lesbians who directly associate their eating disorder with heterosexism are those who knew at a young age that they were lesbians, and resisted heterosexual norms (Thompson,1992). Homosexual women who internalize the prejudice and oppression from the government, media, societal messages, family, and peers are at a higher risk for an eating disorder. In addition, women who resisted what felt inauthentic to them (heterosexual norms) were probably faced with criticism and shame, which they turned on their own bodies. It is clear this area requires more careful research, conducted with the knowledge that women are faced with multiple forms of oppression such as heterosexism, that while not often acknowledged, is damaging to the adolescent female psyche and may directly influence the development of eating disorders.

“Sub-Clinical” Eating Disorders

Throughout my adolescence and into my early twenties I was afflicted with disordered eating, though I never reached a low enough weight to alert friends, family or doctors, and I maintained good grades and healthy relationships. Yet for several years my thoughts were entirely consumed with my body and how much I hated it and wished to change it, which diet might work, which foods to avoid. I counted calories obsessively but would binge when feeling anxious or depressed. I constantly stared at other women and compared my body to theirs, never once measuring up. So while I was never clinically anorexic or bulimic, no doctor or clinician would ever consider my habits or thought patterns healthy or normal. My belief is that countless women wake up just like I did, feeling the very same way. There were times I actually wished for anorexia, just so my pain, shame, and longing could be physically acknowledged on my body. Given my own experience and from what I know of female peers, I believe it will be important to include not just clinically diagnosed eating disorder patients in prevention initiatives, but those who exhibit body dissatisfaction and unhealthy eating habits as well, also known as “sub-clinical” eating disorders.
Those afflicted with “sub-clinical” eating disorders do not meet criteria to be diagnosed with an eating disorder such as anorexia or bulimia and may not consistently exhibit patterns of eating disorders, but may starve, binge, or purge periodically, or take laxatives or diet pills to control their weight. They may engage in exercise purging, where they binge and exercise in excess to rid the excess calories. Some exhibit few or no symptoms, and may maintain relatively normal weight, but are wracked with obsessions about their body weight, shape, size, and calorie intake. They may think about food from the moment they wake up until the moment they fall asleep. Although these women, like myself, may lead relatively normal lives and appear healthy, they are anything but, and should be included in addition to symptomatic anorexics and bulimics in prevention initiatives.

Prevention Initiatives

Prevention of eating disorders are typically categorized into universal, selective, and indicated strategies. Universal strategies aim at educating the wide mainstream audience, selective methods aim to educate and prevent possible eating disorders in high risk populations, such as elite dancers and gymnasts, and indicated approaches work to treat individuals who have already demonstrated symptoms of an eating disorder (Luce, et al, 2003). As the internet becomes increasingly accessible and computers more affordable, researchers are seeking the value of eating disorder prevention using internet strategies.
Researchers at Stanford University in collaboration with the Stanford University Medical Media and Information Technologies group created an online program called Student Bodies, consisting of psychoeducational readings and spaces for reflection, a web-based body image journal, and a moderated chat room. Over several years they administered the program to high school and college-aged female students, and the students involved reported improvements in their body image, concerns about weight and body shape, attitudes about eating, and eating behaviors. The chat rooms were found to be especially useful, as they allowed anonymous users to speak with each other and discuss their feelings about cultural pressure to be thin and how to become more critical viewers. The same ideas of psychoeducation and an open-comment forum are being replicated in more widespread initiatives to improve body image and satisfaction and self esteem. Two examples of progressive, comprehensive internet eating disorder prevention strategies are with the Dove Campaign for Real Beauty and
As eating disorders become more and more prevalent and life threatening, writers, artists, activists, doctors, mental health professionals and members of the media are speaking out against unhealthy messages in the media and working to prevent the onset of eating disorders. The Dove Campaign for Real Beauty and Dove Movement for Self Esteem, co-founded by feminist activist, psychotherapist, and author Susie Orbach, is a worldwide marketing initiative (workshops, television advertisements, and web pages) aimed at spreading images of real, natural women in all shapes, colors and sizes, celebrating diverse ethnicities and bodies, teaching girls and young women about body positivity, and increasing self esteem, Their website encourages readers to “Imagine a world where beauty is a source of confidence, not anxiety, where every girl grows up to reach her full potential, where we all help build self-esteem in the people we love most.”
Similarly, is a website aimed at combating sexist, objectifying, and oppressive media messages. Their website states that their mission is to “equip women and girls with tools to understand and resist harmful media messages that affect self-esteem and body image” (, 2010). Not all young women, like me, were so lucky to have had feminist professors that taught us to watch movies, television, and read magazines with an intensely critical eye, down to the body positioning of models and actresses, at times overtly portraying sexual submission, oppression, or gendered violence. To most women, the messages sent by mainstream media are taken at face value and consumed to be truth about the way women should look, act, feel, think, and be. offers galleries of advertising images with feminist critiques, advice on how to act as a critical media consumer, and information and statistics about the way images in the media are manipulated and targeted toward certain populations.
While I may never have all the answers to my questions about my personal struggle with body image, I can know that I’m not alone. Steiner-Adair (1986) notes that by age five, little girls have been socialized to literally hate the idea of fat. She argues that restrictive eating disorders are a symbol for a culture that does not value female development or female relational desires. Fortunately, as we have seen in preventative measures, over twenty years later some changes in that culture have been made. Female development and relational desires are no longer silenced. But eating disorders remain a symbol for gender oppression. More and more women, on diverse cultures, are developing them, despite knowledge and research done in the psychological, medical, and feminist fields of theory. It will take much more careful research, aware of the various forms of oppression women face throughout their course of their development, to fully understand, treat, and prevent this affliction.

**Note: I would like to add that despite my reflections in the paper on my own struggle with body image and self esteem, I am now (and have been for several years) in a really healthy place, physically and mentally. Working as a trainer has been a huge part of that, for which I am very grateful.**


  1. Enlightening and important, I enjoyed your paper quite a bit. Though I selfishly would like you to develop your discussion of the cultural influences of eating disorders a bit more. I would be interested in reading more research and analysis of the link between a girl's identity and the cultural influences of eating disorders.

  2. I'm always on the lookout for good research and information on this topic! Some good online sources are:

    -check out the "cultural issues" section, lots of good info!

    -their blog gives lots of current information about media influence

    I'd be happy to discuss with you or share more info with you on this topic.