Cross Cultural Eating Disorders

It’s commonly held knowledge that eating disorders are a Western phenomenon. They came about because of beauty standards, small models, and photoshopping. They’re on the rise! Panic! It’s an epidemic!

Only this isn’t necessarily supported by a hard look at the data. One of the problems with assessing whether or not eating disorders exist in other cultures is that the diagnostics for the disorders were developed in the US and Western Europe, leading to a focus on the presentations that we tend to see in those places. As an example, one of the diagnostic criteria for anorexia is “Intense fear of gaining weight or becoming fat, even though you’re underweight.” While this is the motivation for many people to refuse food, it is not true of everyone who displays many of the symptoms of anorexia, and may simply have different motivation.

There are a few different sources of data that contradict the idea that eating disorders are culturally bound or that they are caused by Western beauty ideals. We can look at history or we can look to minorities or other countries that may not have been wholly influenced by Western concepts.

Historically, we have strong evidence that people have been choosing to starve themselves for hundreds of years. The book Fasting Saints and Anorexic Girls traces the history of self starvation from the earliest records through to the first recognition of eating disorders as psychiatric conditions. While the book suggests that these are distinct phenomena because in the past few people have practiced self starvation due to a fear of fatness, behaviorally it shows many parallels.

One particular group of individuals that have similar behaviors to modern patients with eating disorders are religious fasters. These tended to be young women who had little control over their lives in many ways and who chose to abstain from food for extreme periods of time in order to be morally better by ignoring their bodies and focusing on their spirits.

The book includes some quotes from people who chose to restrict their food intake in times past, and concerns about morality, space, selfhood, and perfection come up again and again, just as they do in current conversations about eating disorders. Many of the experiences are couched in religious terms, but the underlying fears (“I am not good enough”, “there is something wrong with my body”, “I need to be better”, “I don’t want this life”) could just as easily be pulled from a study of eating disordered patients today.

Individuals throughout history have chosen to abstain from food, often falling into something like depression and priding themselves on their ability to go without for long periods of time. Their motivations have changed as their social milieu has changed, going from religious, to entertainment, to aesthetic. However many of the sentiments that these individuals express ring similar across time and space.

“It’s like I never knew what self-respect was all about until now. The thinner I get, the better I feel . . . I’m proud of my stoic, Spartan existence. It reminds me of the lives of the saints and martyrs I used to read about when I was a child . . . This has become the most important thing I’ve ever done.” This kind of quote could easily be from a religious faster or a modern individual with anorexia.

Over at Science of Eating Disorders, Tetyana posits “Religious and spiritual reasons are not the only factors that could be contributing to AN in non-Western countries (or Western countries before the ‘thin ideal’). Personally, it would seem to be, that anorexics in those times, would just attribute their desire for weight loss to those reasons much like today it is often attributes to a fear of being fat. But, both of those could just be post hoc rationalizations on the part of the sufferer, to make sense of their otherwise perplexing desire to restrict their intake and lose weight. That’s my feeling.”

I’ve written elsewhere about how restricting food made me feel powerful, godly. I often imagined that my body was not subject to the same requirements that others were. Only the weak needed food, but I decided my morality, my meaning, and my body for myself.

“Comparable to the ascetic practices in the history of Christianity are the fasting practices in the Chinese Daoist tradition (Eskildsen, 1998). These practices sought to transform the body as a means of gaining immortality…  The history of Chinese thought thus suggests that, in certain traditions at least, the emaciated body has been highly valued and pursued in a manner highly reminiscent of Western observances.”

But in addition to historical examples, we can also look at current cases of eating disorders in non-Western countries. It’s a common trope that these are rare, and when they do appear they are evidence of growing Western influence in the country. The problem with that assumption is that many individuals who might be diagnosed with an eating disorder but lack fatphobia are not given the diagnosis. The unthinking assertion that the rise of eating disorders correlates to increased Western influence doesn’t look at the lived experiences of individuals in non-Western countries.

Again, from Science of Eating Disorders:

“For example, one study found that in British Asian girls, dietary restraint was correlated with traditional (rather than Western) values (Hill & Bhatti, 1995). This finding was supported in a study by Mumford and colleagues (1991) who essentially found the same correlation. On a Caribbean Island, with little Western media, Hoek et al (1998) found that the prevalence of AN was comparable to Western countries and a study by Apter et al (1994) showed that a group of village Muslim women (with minimal exposure to Western values) had eating pathology scores that were indistinguishable from patients with AN.”

Many of the patients quoted in this article don’t talk about a strong desire for thinness or weight loss, but point to their bodies as the site for other struggles in their lives, particularly around control and selfhood.

“… food restriction arose from a sense of powerlessness in the family context, it is possible that the patient experienced her emaciation as egosyntonic, with her low body weight consonant with the goal of not wanting “to ‘give in’ to her family, especially her mother, who forced her to eat even when she was not in a mood to.”

Again, these individuals exhibit many of the same behaviors as individuals diagnosed with eating disorders in the Western world, but don’t show the obsession with thinness or fatphobia that we assume is an essential part of an eating disorder.

An eating disorder is a coping mechanism that allows an individual to survive extremely difficult situations or feelings. Physically, it has effects that make it easier to live through strong emotions: it numbs out painful things, it leaves you sleepy and sedated, and it also provides a kind of high that makes you feel accomplished and safe. These are biological results. They are the same no matter where you are or when you’re living. And they are effective at helping someone survive a difficult situation no matter what kind of difficult situation that is: it could be not living up to religious expectations or not fitting into a beauty ideal.

And so I am continually dismayed at ridiculous articles like this that seem to think eating disorders are not only limited to the West, but also limited to young, naive, shallow teen girls who can’t figure out how to do basic things like feed themselves. Diagnosis, demographics, and etiology are complex and confusing. If you don’t know a little something about mental health, don’t write about it.

How Do We Talk About Eating Disorders?

I’m currently working on a post for Teen Skepchick about eating disorders in a cross cultural perspective. At the moment, I’m just in the research stage of this post, so I’m reading a lot about the research that’s been done about cross cultural eating disorders and about the differences in symptoms, causes, and etiology of eating disorders in different cultures.

And I have to say that I am deeply upset by the way we talk about eating disorders. I am particularly upset because I’ve been reading academic articles, pieces by graduate students studying psychology, and other articles that are surveys of the literature on eating disorders. These should be held to the best standards we have. Unfortunately, no matter where I look (except for in very particular blogs written by people with eating disorders, particularly Science of Eating Disorders), I hear the same things over and over and over again:

“When we expose our girls to thin models and beauty ideals they develop eating disorders”

“Girls of African American descent aren’t likely to get an eating disorder because their culture values voluptuous bodies”

“Eating disorders only crop up in other countries as they become infiltrated by Western beauty ideals”

I am SO sick of the conversation around eating disorders being dominated by conversations about models and images of women in the media and the desire to be thinner. It cannot be that difficult for people to understand this, but I’ll say it again: an eating disorder is a mental illness. It is not a diet. It is not even an extreme diet. It is not a desire to lose weight. It is a coping mechanism to deal with difficult things in your life that you can’t cope with otherwise.

There is VERY little evidence that eating disorders are caused by skinny models. What there IS evidence of is that eating disorders are caused by low self-esteem, family disruption, trauma, other mental illnesses (depression, anxiety, OCD, BPD, bipolar, and addiction are common), abuse, or other difficult situations that you need a way out of. It is such a cliche by now that eating disorders aren’t about food, but I cannot stress it enough: eating disorders aren’t about food! They aren’t about looking pretty or beautiful. I have YET to meet someone with an eating disorder who says they just want to be pretty. I hear them say that they’re depressed, that they can’t cope, that they’re lonely, that they don’t feel acceptable when they’ve eaten, that they feel out of control around food, or that they use food to numb out emotions and manage other parts of their lives.

It is not helpful to keep refocusing the conversation on how someone’s body looks and the beauty ideals. This continues to reinforce them as what’s important, and it focuses the issues on the body again, instead of addressing whatever mental stress has occurred. It simplifies the matter to a point that is unhelpful, and makes treatment and self-understanding very difficult because it doesn’t allow us to reach the real etiology of the disease. It even reinforces those negative suggestions that a woman’s worth is in the beauty standards she does or does not strive to live up to.

Instead of these things, it would be far more helpful to talk about the sexism that makes women feel inadequate no matter what they do, or the bad family systems that don’t allow for good communication or healthy emotions, or the abusive relationships that many women are in, or the trauma and depression of daily life, or the failure of our mental health system to provide us with good coping techniques for when we do start to feel over our heads. If we want to talk about cross cultural eating disorders, maybe we should talk about the different family roles that exist, the different expectations of women in different cultures, the common mental illnesses in those cultures, the differences in guilt and shame in different culture (these feelings are huge in eating disorders), and the relationship that these cultures have to food as symbolic, relational, or positive.

Eating disorders are mental illnesses. They are not an attempt to be skinny. They are not a reaction to the media. They are not the desire to look like a model. They are serious. They are life-threatening. They are painful. They come with depression, constant mental stress, trauma, self-hatred, difficulty with relationships, isolation, loneliness, feelings of guilt and inadequacy, and all sorts of things that ARE NOT simply reactions to the media, but are about how we relate to ourselves and how we relate to others. Can we please start talking about them in terms of the mental situation of the individual suffering, because that is what makes something a mental illness?