As many of you already know,Ā Vogue has recently banned models that are “too-thin” (and “too young”). It is a big step in the right direction, no, a huge step, and one deserving an applause, that’s according to an article on allvoices.com. Cue a drop in the prevalence of eating disorders, right? The logic in most articles, whether implicit or explicit,Ā seems to be: no more skinny models = no more girls aspiring to be like skinny models = no more eating disorders.
Health of models belonging to both genders has been a growing issue in the past, especially after the death of two models in 2006-2007 from what the doctors blame to their acute eating disorders. This important step by Vogue targets not just skinny models, but also the impact they have on the young minds of girls and boys by presenting an image of perfection that is neither attainable nor healthy.
The 19 editors of Vogue magazines around the world made a pact to project the image of healthy models…..Ā They agreed to “not knowingly work with models under the age of 16 or who appear to have an eating disorder,“….Ā “Vogue believes that good health is beautiful. Vogue Editors… want the magazines to reflect their commitment to the health of the models who appear on the pages… The primary fashion organizations in Italy and Spain banned catwalk models who fall below a certain Body Mass Index level.
Sounds more like a PR move to me, but OK. I do have some questions and thoughts:
What does “appear[ing] to have an eating disorder” mean?Ā Bulimics, by definition, are of normal weight or overweight. Conversely, being thin doesn’t mean having an eating disorder.
BMI above or below a certain number is not a marker of “good health”. BMI demarcations are not scientifically derived and were never meant to be applied on an individual basis.
Finally, this perpetuates the idea that looking at skinny models for too long leads to an eating disorder. It doesn’t. Okay, no one has said it explicitly, but nearly every article mentions ED-related deaths, and the impact on young impressionable girls. Images of Ā thin models may perpetuate the Ā drive for thinness in those already struggling with an eating disorder, but it certainly doesn’t cause an eating disorder. Does it influence a non-eating disordered person’s idea of beauty, their self-esteem and feelings toward their body? I don’t doubt it. But an eating disorder is not the same as an extreme diet.
One naturally arising prediction from the theory that “our thin-obsessed society causes eating disorders” is that visually impaired individuals, especially those blind from birth, will be immune to eating disorders. (There are, of course, many other predictions, I’ll save them for future posts.)
So, I was kind of excited to come across a few case reports of eating disorders in blind patients. Unfortunately, quite a few are from the early-to-mid 1980’s and are not available on-line. I thought it would be interesting to write about them, because it is not something that I’ve seen written about or discussed in the popular press (but I haven’t read everything ever published on EDs). Keep in mind, there are tons more cases I don’t have time to mention.
*** Warning: I took out all of the numbers from the quotes, BUT some of the content below may be triggering,Ā particularlyĀ for SI
Case 1: 27 year-old blind woman with AN (Yager, 1986)
Background
Completely blind by age two, she led a very troubled and unhappy childhood, encountering a lot of bullying at school. Her parents, both alcoholics, were always fighting. They divorced when she was 6, remarried at 10, and then divorced again when she was 20. From an early age, she wasĀ pressured/encouraged to eat more (“she would claim not to like certain foods, even if she did, because she didn’t like being forced to eat”). This led to aĀ strong aversion to food due to the sound of their name (even if she liked the taste), and she “rarely tried new food after the age of six”. When she learnedĀ that her father had been unfaithful to her mother, developed the idea that “men cheat and try to controlĀ you”. One of her grandparents had committed suicide and an uncle died of alcohol-related cirrhosis. Her oldest sister had periodic episodes of binge eating, was always overweight and perpetually dieting. Her other sister had run-away and at one point was addicted to drugs, but later settled down.
At 13 she began to menstruate and develop physically, andĀ became horrified by the idea that she might start to get fat…Ā Her first periods frightenedĀ her very much, and subsequently she has welcomed theĀ amenorrhea resulting from her weight loss as a boon.
At 18, She gained independence and studied at a music school, but after being abruptly discharged from the university without a reasonable explanation (“because of her blindness, the teachers didn’t know quite how to handle her”), she had a nervous breakdown and became severely depressed.Ā She began cutting her wrists, deeply enough to require sutures, and developed the idea that the wounds needed to stay open or elseĀ she would be a “bad person”.
At this hospital she first encountered women with AN, and initially thought they were “very weird”. During this period the idea that she needed toĀ lose weight first took hold [(though she had never attained a normal adult weight)….While in hospital she dieted down to xx kg, andĀ felt that she was “bad” when her weight increased…Ā Over the next fourĀ years she had five additional admissions for impulsive suicidal behaviour.
At the time she was referred for evaluation of AN:
At [a low weight] she feltĀ far too fat, and was so terrified and depressed by her weightĀ gain that she frequentlyĀ felt suicidal. She did [several] hours per day of aerobic exercises, depending on her weight;Ā she also bought a computerised talking scale that called outĀ her weight, and weighed herself several times a day…Ā Ā She used two types of diuretic tablets, manyĀ over-the-counter diet pills, and one or more enemas on aĀ daily basis for at least two years…. her daily caloric intake wasĀ [very low] – Ā primarily in theĀ form of vegetables…..
She began to experience herself as fat through tactile exploration of her arms and her legs, but her perceptions ofĀ her limbs were inconstant: “sometimes they felt thin, andĀ sometimes they didn’t, changing sometimes from minute toĀ minute or hour to hour”. She was aware that some of theĀ changes were actually related to fluid shifts rather than fat.Ā But, she said, “anything that is weight I don’t like. When IĀ feel fat I get depressed and suicidal.” During this period sheĀ was chronically depressed, and was given the DSM-IIIĀ diagnosis of atypical depression…Ā She made additional multiple suicide attempts. . .
She was treated with many different drugs (antidepressants, lithium, and many others), including 12 sessions of ECT, with no effect. She maintained a low weight and remained terrified of weight gain.
The discussion in this and other case reports is quite interesting. There is usually an implicit suggestion that bad mother or troubled family life is a huge/main factor in leading to the ED (which may be true in these cases, but certainly not true for all ED cases). While no discussion seems to mention genetic factors, most state quite explicitly that continuous visual exposure to the “thin-ideal” is not necessary for the development of an ED.
…Ā the meticulous records she keptĀ regarding her intake. Her fussiness with food, use ofĀ food in control struggles with her parents duringĀ childhood, and weight preoccupation during earlyĀ adolescence all provided a background of vulnerability. Her subsequent AN coalesced during a timeĀ when she was without a sense of direction or purpose – when her sense of self, always shaky at best,Ā was lowest since she was no longer a musician orĀ university student; AN then provided her with anĀ identity, at a time when she desperately needed one…
The perfectionistic strivings she had as a studentĀ and musician, the presence of binge eating episodesĀ in one sister, and the harsh, critical nature of herĀ father are all possible contributing factors.
Case 2: Rita (Vandereycken, 1986)Ā
Background
Rita was visual impairment since birth (myopia and congenital nystagmus withĀ distant vision of 1/20 after correction). Her parents had a “problematic” marriage, with her father in continuous psychiatric treatment due to chronic depression. Rita excelled at school and was described as a “perfectionistic girl with a strong fear of failure”. She wasĀ admitted to hospital for anorexia nervosa at the age of 17 (in 1978).
She started losing weight I year before through a severe diet. The parents ascribed the weight loss to RitaāsĀ unusual efforts at school. During the summer holidays, the family physician intervened and Rita gainedĀ weight… but apparently because of binge eating [that is more common than you may think].Ā As soon as school resumed, she beganĀ dieting again and also vomiting after her mother tried to feed her. She was physically hyperactive andĀ had more and more difficulties in studying since she became obsessed by food and body shape. Because ofĀ progressive weight loss and increasing conflicts atĀ home, she was hospitalized in our special unit..
She was extremelyĀ dependent upon her mother without whom she felt completely helpless. But, at the same time, sheĀ became more often irritated by her motherās overprotectiveness towards her…
The author concludes, with seemingly very little thought on the matter, with:
So, after all, it was the anorexia nervosa that appeared to express the inescapableĀ attachment-autonomy conflict …
And while that conclusion doesn’t seem wholly justifiable, and ignores the Ā genetic and biological factors, these case studies illustrate the fact that there’s more to eating disorders than wanting to be thinĀ like a model. Actually, in most cases, it has nothing to do with wanting to be like a model.
Case 3: Claire (Vandereyhen, 1986)
Background
Claire was born blind. She was “a model child”, very intelligent and accomplished. However, at 14, shortly after starting menarche, she was told by a physician that she was “a bit too heavy” (she was overweight). This prompted dieting, and like all the other tasks she undertook, she was quite successful. She was initially praised for it, but soon those around her began to express concern. This, however, fuelled her drive to lose more weight. She became hyperactive and very pre-occupied with food and weight (to the point of it severely interfering with school work).
At the moment she showed amenorrhea, the parents went to the family physician who referred her to a psychiatrist. AnĀ outpatient treatment, including a weight restoration program, was tried but Claire refused to cooperateĀ (she felt āhealthy and happyā with her appearance). The weight loss continued until she went below xxĀ kg at which time she suddenly became afraid that something could go wrong with her body.
At that point, she was admitted to a hospital. Initially, she acted as autonomously as possible, but felt self-conscious and depressed about her handicap. She showed no improvement.
…until a dramatic family session wherein the parents, encouragedĀ by the therapist, overtly expressed their strong guilt feelings about her handicap in Claireās presence.Ā From that moment on, Claire recovered remarkably. She is 16 now and left the hospital 6 months ago….. Both Claire and her parents, though facingĀ the problems far more realistically, are still uncertain as to the future and prefer to have regular familyĀ sessions with us.
In the discussion, Vandereycken states that although the idea that “body image distortion and cultural valuation of thinness” are very important in leading to AN, it “starts from unjustified premises.”
First, the assumption that overestimation of body width is a typical andĀ pathognomonic [characteristic of a disease] sign of anorexia nervosa has never been proven. Since it also occursĀ in females other than anorexics, Hsuā even suggested to delete disturbance of bodyĀ image from the diagnostic criteria for anorexia nervosa.
But then another mistake isĀ made (by Hsu as well as by Quigley and Doane), notably to equate body image withĀ body estimation. All experimental studies on body image in anorexia nervosa largelyĀ rely upon the external or visual perception (exteroception) of oneās own body orĀ bodily appearance while ignoring other factors such as interception, proprioception, and cognition.Ā When an anorexic claims to āfeel fatā even when emaciated, thisĀ phenomenon is far more complex than simply misjudging bodily dimensions.
Another false premise is to consider body image disturbance as an etiological factorĀ in anorexia nervosa; we still donāt know whether it is a primary or secondaryĀ phenomenon (e.g., a consequence of self-starvation).
It is equally simplistic to assume that cultural influences, such as the overvaluation of thinness, causes serious eating disorders like bulimia and anorexia nervosa:Ā āCulture is mediated by the psychology of the individual as well as the moreĀ immediate social context of the familyāā (p. 81). But it does make sense to presume that the current culture of slenderness has contributed to an increase of eatingĀ disorders.8
Anorexia nervosa, however, can only be understood from a multidimensional,Ā biopsychosocial viewpoint. It is the final common pathway of a number ofĀ predisposing, precipitating, and perpetuating factors. Looking for the āadolescent-Ā at-riskā,ā any kind of dieting behavior might be suspicious for being potentially the first step in the downward spiralling of a pursuit of thinness when some combinationĀ of the following factors is present: accentuated weight sensitivity, adolescentĀ attachment-autonomy conflicts, interpersonal problems, stress and failure experiences, and perfectionist tendencies.ā
I really like the point they make about body image disturbance not necessarily being an etiological factor.
Personally, I never had body image distortions, felt “fat” or wanted to lose weight until I was deep in anorexia. It was only when I realized that I might have a problem, and decided to get help, that it hit me. The fear of weight gain, the inability to eat more, and the deterioration of my body image.
I wanted to gain weight. I wanted to be normal.Ā To eat like a normal person.Ā I couldn’t, and I kept losing weight.
My body image (my sense of my body, how I saw myself in the mirror, the accuracy of my self-perception compared to my actual size, etc) was never as bad as it was when I first lost weight due to anorexia. I never had body image issues, felt “too fat” or wanted consciously to lose weight UNTIL I was already anorexic (by DSM-IV criteria).
Case 4: anorexia nervosa in a 19 year old woman totally blind since birth (Touyz, 1988)
Background
Also blind at birth, she was first admitted to hospital after drug overdose, following argument with parents about her eating behaviours. As a child, she had eating problems, refusing to eat solid foods until about the age of 6 or 7. Like others, she had above average intelligence. And although she initially denied any serious problems, she later opened up and blamed herĀ father’s alcohol abuse and mother’s interest in her food intake as reasons for her dieting. SheĀ limited herself to a very, veryĀ low number of calories a day and partook inĀ excessive exercise which followed a tightly scheduled regimen. Moreover, sheĀ abused laxatives and engaged in self-inducedĀ vomiting.
A comment by her mother that she looked “a bitĀ overweight” was given as the original cause for her dieting.Ā She stated that “Mum can see me, I can’t see myself”. AĀ cousin who also had a diagnosis of anorexia nervosa wasĀ said to have “put me on the right track” and she was veryĀ satisfied that she won a bet with her cousin that she couldĀ lose xx kg in 4 weeks.
She became “terrified that she might lose control of any weightĀ gain if she changed her habits, and increasingly depressed”.
Shortly after her menarche at age 14, she was sexuallyĀ molested by a male teacherĀ at the blind school who would “touch her” and she refused to attend school for someĀ months. Eventually she confided the information to aĀ trusted head teacher, who dismissed the man involved. ToĀ her great embarrassment and humiliation, she found thatĀ her parents and the whole school had come to learn of theĀ event. She had had no sexual experience since, and wasĀ discouraged by her parents from going-out with any of herĀ friends…. She continued to be repelled by herĀ menstruation...Ā She “did not want to get too deep and meaningful,Ā it could be dangerous”. When asked to explain, she said,Ā “I’ve trusted people before and I’ve got hurt. If someoneĀ knows your deepest secrets you’ve got no control” . . .
The discussion in this case study is limited, with the authors essentially blaming family dynamics:
The patient’s weight loss began in the context of herĀ striving for autonomy and individuation. HerĀ mother’s overprotectiveness had intensified during herĀ late adolescence….
Case 5: Blindness and Bulimia (Fernandez-Aranda, 2006)
We report a single diagnosedĀ and treated case of BN in a blind, 47-year-old Spanish woman. This case presentedĀ as its main characteristics the lateĀ onset of the ED, restrictive dieting, bingeing,Ā and consequent purging behaviorĀ characterized by vomiting and great difficulties of coping with stress. From theĀ beginning, the womanās body image wasĀ not essential..
Since the age of 43 years (onsetĀ of the ED), the patient described the presence ofĀ … Ā bingeing and vomiting episodes,Ā which were frequently triggered by psychosocialĀ stressors.Ā In addition, due to psychosocialĀ stressors, anxious and depressive symptoms wereĀ constantly present. During the last 4 years, theĀ patient had gained >xx kg. Before this weight gain,Ā the patient had exhibited a lower weightĀ and revealed that during the time when sheĀ was thinner, she neither exhibited any body imageĀ concerns nor wanted to lose weight.
What do Fernandez-Aranda et alĀ conclude?
In the current case, the ED seems to be a consequenceĀ of inappropriate coping skills with stress. ..Ā in many cases, the ED is not due to an overemphasis on physical attractiveness, but toĀ a personal difficulty to cope with stress… Ā the onset of the patientās ED was notĀ associated with her body shape dissatisfaction…
I have my own thoughts on these case studies and the discussions in the papers, but, I’m wondering what do you guys think about these cases? Is there anything that is surprising in these cases and the authors’Ā interpretations? Share any thoughts you have!
References
FernƔndez-Aranda F, Crespo JM, JimƩnez-Murcia S, Krug I, & Vallejo-Ruiloba J (2006). Blindness and bulimia nervosa: a description of a case report and its treatment. The International Journal of Eating Disorders, 39 (3), 263-5 PMID: 16498584
Touyz, S., O’Sullivan, B., Gertler, R., & Beumont, P. (1988). Anorexia nervosa in a woman totally blind since birth The British Journal of Psychiatry, 153 (2), 248-250 DOI: 10.1192/bjp.153.2.248
Vandereycken, W. (1986). Anorexia nervosa and visual impairment Comprehensive Psychiatry, 27 (6), 545-548 DOI: 10.1016/0010-440X(86)90058-1
Yager, J., Hatton, C., & Ma, L. (1986). Anorexia nervosa in a woman totally blind since the age of two The British Journal of Psychiatry, 149 (4), 506-509 DOI: 10.1192/bjp.149.4.506
Also, take a look at “Disordered eating and religious observance: a focus on ultra-Orthodox Jews in an adult community study.” (PMID: 21312205) It’s a study comparing different communities in Israel.
The ultra-Orthodox women are isolated from Western society, with no exposure to magazine, television, etc. Yet they have similar rates of body dissatisfaction and disordered eating behaviors.
Great lead, thanks! I’ll check it out. There was an article in NYTimes about ED’s in the ultra-Orthodox communities in NY, here. (But, these isolated communities have way more problems, and I’d argue, way bigger problems, than eating disorders.. why don’t they sound alarms about that?.. anyway, off topic.)
Thanks Missie!
http://www.medpagetoday.com/Genetics/GeneralGenetics/2800
This may lead to a help study re exposure to fashion magazines and anorexia.
Hello, I’ve noticed that when people argue that anorexia nervosa exists regardless of whether the culture idealizes thinness, they cite people like Catherine of Siena and the school girls studied in rural Ghana who have AN symptoms, but in those circumstances the motivation behind the behaviour appears to be to do with religion, which has a long history of being oppressive to women. Naomi Wolf even argued in The Beauty Myth that the fall of religiosity in the West had led to the construction of diet culture, a modern day equivalent to religion where skinny models are goddesses. Being a reader of your site, I’m aware that anorexia is a polygenic disease (forgive me if I’m wrong, I’m nowhere near as scientifically literate as you are!), but the feminist social constructionist viewpoint is somewhat appealing as well (although The Beauty Myth’s lack of mention of biology and ridiculous exaggeration of ED statistics displeased me), and while beauty standards were not the same in the Victorian times as they are today, the stigma of fatness did not begin post 1901. I’m just curious on your thoughts because I’m trying to figure out the nature/nurture thing in my head, not sure if I’ll ever get anywhere because of how tied together they are.
[Comment moved from the “Articles” page to this post by Tetyana]
Tetyana, you make good arguments. I’m just used to being surrounded by people who are tbh… Very uneducated about things. But I doubt my own knowledge/understanding and think yeah, maybe eating disorders are caused from being stupid, or whatever. I do identify as a feminist, but its handling of eating disorders is one of my main bugbears with feminism. I try to be an individualist but it’s very difficult when there are so many people saying different things (more often that not, things which disagree with my own ideas). š I quite enjoy sociology but ‘social constructionism’/the ‘blank slate’ model wrt mental illness (a la Thomas Szasz) and other things that clearly have biological components are annoying. My geographical knowledge is awful but Wolf does say ‘West’ in her book, which I have on my computer if you’re interested in looking. Wrt religion + AN being related, perhaps not but that is the explanation I have seen- anorexia mirabilis, this study- http://bjp.rcpsych.org/content/185/4/312.full. ‘Of the 668 students who were screened for BMI, 10 with a BMI <17.5 kg/m2 appeared to have self-starvation as the only cause of their low weight. All 10 viewed their food restriction positively and in religious terms. The beliefs of these individuals included ideas of self-control and denial of hunger, without the typical anorexic concerns about weight or shape. In 10 of the 29, even after detailed clinical assessment, morbid self-starvation was the only detectable cause for their low weight. These individuals all attributed their food restriction to religious fasting. They expressed āanorexia-likeā attitudes of self-control, enjoying feeling hungry, denial of hunger, self-punishment and religious motivations to explain their food restriction (Table 1). They also showed perfectionist traits in striving for high academic standards and moral asceticism. These young women described a sense of control and achievement from self-induced starvation, while struggling with other aspects of their life that seemed beyond their control, such as pressure to do well at school.' …
Just a quick comment, I’ll add more maybe tonight, but my initial thought: feminism to me as about women’s rights, equal opportunity, freedom. Not ascribing biological phenomena to some vague socio-cultural pressures that contradict or at least don’t bode well with empirical data that’s consistent with a lot of what we know about other neuropsychiatric diseases. I don’t really understand what feminism has to do with eating disorders, frankly. Just like schizophrenia is more prevalent in men, EDs are more prevalent in women, but it doesn’t make it a women’s issue or a men’s issue. There can be lots of different explanations for the gender ratios, I’ll probably touch on that too. It is not that I’m discounting that looks and the pressure to be thinner, or look a certain way, isn’t important. It can play a role. I’m sure for many, it can trigger dieting and that leads to an ED. I know that’s the case for many. But it is also NOT the case for many. What I’m interested in, is what predisposes those people to KEEP GOING. Most people diet and give up, quit, or realize it is not worth it. Or think it sucks. Nothing about it becomes addicting, or rewarding, or calming. I think there is a physiological explanation for this, likely, due to genetics and perhaps early environmental interactions. Thin ideal might trigger dieting, but why is it that, like Bulik says, out of 100 girls that diet and hate it, 1 finds relief from her dysphoric state? It is hard for me to believe that THAT is because of religious oppression, or “skinny models being goddesses”. It doesn’t explain SO MUCH other data. For one, it doesn’t explain a whole 1/10th of the ED population: men.
I could’ve attributed wanting to lose weight and losing it to wanting to be thinner because I did long-distance running. Because I wanted to look like the typical marathoner. Sure, that’s fine. But, again, that does not explain why restriction became so, compulsive, so addictive, why nothing felt as good as knowing I ate less than the day before, even though I didn’t want to lose weight! I’m also sure a LOT changes once you start resricting and losing weight, and some of those physiological changes may not change post weight-restoration, or at least soon after. You know how people say you are never recovered from alcoholism, just always in remission. Well, those people weren’t born alcoholics (discounting cases where mothers drank, of course) but yet, now, they are at a higher risk of relapse. I think same is true here, things may change and be long-lasting changes, but still.. few would starve themselves to death. And anorexics often do, unfortunately.
The blank slate idea is ridiculous notion in this day and age. My thesis project is looking at how genes (err, a gene in my case) regulates neural circuit development and function and how it guides adult behaviours (in worms), but it is a clear example that GENES are important. Those worms are not blank slates, the way they behave, the way their neurons are wired, is due to genetics. And just in case someone thinks it is irrelevant. C. elegans has around 20,000 genes, and humans it is around 20,000-25,000.
Regardless of the initial reasons, those traits that are mentioned in that article as the reasons, or I suppose rather, feelings and current motivations girls mention for their restriction are so remarkably similar, that, to me, that signals something very biologically rooted. In short, there are people, for whatever reason, who are at risk of finding starving themselves, well, addictive, for a lack of a better word. Maybe compulsive is a better word.
Wolf’s idea is that beauty standards are a socially constructed attack on women, restricting their freedom by diverting their attentions to shaving their legs, dieting/eating disorders, etc.
While I think things to do w/ dieting/body image are relevant to feminism, ‘The Beauty Myth’ reads a bit like a rambley, mediocre college essay- I already know that women are expected to look a certain way, but Wolf extrapolates that to ‘it’s easy to develop anorexia’ and ‘80% of college girls are anorexic/bulimic’.
It bothers me when people who talk about the importance of good body image (because it IS important), airbrushing use ~eating disorder epidemic~ as a reason- the reason should be that dieting and having poor body image are harmful to everyone, not just people who have eating disorders (which aren’t necessarily triggered by body dissatisfaction/dieting).
I would be interested in learning more about the idea that anorexia and autism are linked. People with autism (especially Asperger’s syndrome) are primarily male, as I’m sure you know, and the ratio of female:male sufferers of anorexia is like the autism one reversed. I’ve read that girls with Asperger’s function differently to males and are thus less likely to be diagnosed accurately. When I was in hospital w/ AN I was tested for Asperger’s and they said I didn’t have it, but I’m wondering if that might have been because of the test being biased towards male presentations of the syndrome. Idk, I’m just ~self discovering~ and while people warn of the dangers of, for example, looking through an ab psych textbook and diagnosing yourself with things, but self awareness is really important to me.
Right, I don’t think that one can equate shaving legs with eating disorders. My anorexia was never about looking more attractive; it was about looking LESS attractive. And I know this is the case for many, but not I would never assume that’s true for all. It is probably not, of course. But you also have to delineate what people say their reasons are, and what’s actually going on. 80%? That’s false. Is her book sourced?
It is odd to me, to equate things like shaving your legs/armpits, doing your eyebrows, etc.. with eating disorders. That would lead you to assume that most people with EDs are hyper conscious of these things. I don’t know whether that’s true. I know I’m not, but I’m just one person, and it is possible I’m a complete outlier for being totally okay with being in public and not shaving my legs. I get very uncomfortable with these gender-normative ideas of beauty and beauty standards, personally, as well. But, I don’t think this has much to do with eating disorders. Dieting, sure. EDs, I’m not sure. Can dieting lead to EDs? Yes. But, like I’ve said, most people who diet don’t get an ED.
The autism and anorexia is an interesting idea. I do wonder whether it applies particularly to the subset of anorexics that are chronically ill and/or never binge and purge, though. Thoughts?
It is sourced, yeah. But I think she used dodgy studies. http://www.tandfonline.com/doi/abs/10.1080/10640260490444619 I know a girl who is on the autism spectrum who is anorexic/bulimic, but I don’t know if she’s ‘chronic’.
Oh, fantastic link! Did you read it? This is gold, a definite future post!! Why do they write about this stuff in academic journals when the public, not the academics, need to know this!
Re: autism and anorexia, I’ve honestly not looked into that research in-depth myself. But it is a great idea for future posts, and what I mentioned on that is purely my own guess.
Echoing Tetyana – that looks like a fascinating article, definitely going to bookmark for future reference & reading. Thanks, Sarah!
Yes, the abstract- I don’t have access to the full text. š Thinking of the people I was IP with, there were two girls who were what you’d probably call more severe- neither of them wore makeup or dyed their hair, used fake tan, I’m not even sure whether they shaved given that you had to hand in your sharps. And there were two guys, one of whom showered, like, once a week and wore the same clothes all the time, which I think was to keep people at a distance since he took pride in his appearance at home. And the other guy was fairly into body lotions and stuff. It’s hard though because the symptoms associated with starvation such as depression can decrease your interest in your appearance. I’m personally not conformist in terms of physical appearance, although I do worry about how I look a lot.
Tetyana, how did you do the full text link? Is it to do with being at uni or did I overlook something obvious. 0_o
I downloaded it via my access through the University, and then just posted it on my public Dropbox folder so that you can have access to it. I haven’t read it yet, just glanced at some of the numbers, and it is both crazy and hilarious.
Not sure if this is relevant to the thread at all, but I’m reading a book called Sex For Sale: Prostitution, Pornography and the Sex Industry- I think you can gather what it’s about- and the chapter on sex trafficking made me think of the way Naomi Wolf writes about anorexia in The Beauty Myth.
(The following text is an extract)
‘Claim 4: Sex trafficking is prevalent and increasing, now at epidemic levels.
The size of a social problem matters in attracting media coverage, donor funding, and attention from policymakers. Moral crusades therefore have an interest in inflating the magnitude of a problem, and their figures are typically unverifiable and/or very elastic. The antitrafficking crusade claims that there are “hundreds of thousands” of victims, and that trafficking has reached “epidemic” proportions worldwide. Shared Hope International, for example, claims that trafficking is “a huge problem, and it’s continuing to grow.” SAGE director Norma Hotaling recently claimed that “there are thousands of trafficked women in San Franciscoā—a vague figure presented with no documentation.
When concrete numbers are presented, they vary and fluctuate dramatically. Although a report by a CIA analyst acknowledged that “no one U.S. or international agency is compiling accurate statistics,” the report then claimed that “700,000 to 2 million women and children are trafficked globally each year.” In 2003, State’s maximum figure had grown to 4 million, but 2 years later it inexplicably fell to 600,000-800,000 victims of all types of trafficking, of which āhundreds of thousandsā were said to be trafficked into prostitution. No explanation has been given for the huge fluctuations from year to year in the official figures. Similarly, it is frequently asserted by several agencies that 80% of all trafficking victims are women and 50% childrenāfigures that are, again, unverifiable given the clandestine nature of the trade.
It is also claimed that the sex industry is expanding at an unprecedented rate, increasing the market for trafficked workers, and that the number of victims is steadily increasing. The director of the evangelical International Justice Mission, for example, refers to āthe growing trafficking nightmare,ā and CATW proclaims that ālocal and global sex industries are systematically violating womenās rights on an ever-increasing scale.ā
Internationally, it is clear that sex trafficking has increased in some parts of the world, especially from the former Soviet Union and eastern Europe. The breakup of the Soviet empire and the declining living standards of many of its inhabitants has made such migration both much easier and more compelling than in the past. But an increase in trafficking since the demise of the Soviet Union does not mean that trafficking is growing now. Instead, it may have levelled off A report by the International Organization for Migration points to this very possibility: the number of trafficked persons in south-eastern Europe that were identified and assisted remained virtually the same (declining slightly) between 2003 and 2004.
In short, given the underground nature of the trade, estimates of both its current magnitude and changes over time are highly dubious, which means that claims regarding a growing worldwide epidemic cannot be confirmed.’
Hey, Tetyana!
I’m an autistic woman with a biochemistry degree, and I often blog about autism-related journal articles.
One that I came across, and blogged about a long time ago, dealt with disordered eating in adolescent girls diagnosed with Asperger’s syndrome.
They had just a small group of girls — this is often a problem with cognitive or psychological studies of autism because there are so few of us; genetic studies tend to do better because they can pull from a much wider geographic area — there were 56 in this one. (That’s 56 people in both the AS group and the control group – that’s decent sized for a psychometric profiling of people with a rare condition, but an epidemiologist would snort contemptuously at it. “That? That’s not a study, that’s a bunch of anecdotes disguised as numbers!”)
Anyway, the study author – Efrosini Kalyva – found that a lot more of the girls with AS scored above 20 on the test she used (the EAT-26, a screening tool for disordered eating), but that they did not actually diet more than their typically developing peers.
Hey Lindsay! Thanks for your comment! I read your post and I agree with your assessment that it is hard to draw conclusions from such small sample sizes. There seem to be quite a few studies similar to the one by Kalyva, I’ll write about it in the future as it seems that people find it an interesting theory. I am not sure I buy it, to be honest, but I haven’t read enough to be persuaded either way.
What do you think about it?
@Tetyana – I think I need to read the other studies similar to Kalyva’s, first. I think her idea about food obsessions maybe being one manifestation of a more general autistic tendency to obsess about things is reasonable.
I’d be interested to see if the other studies also found no difference in dieting behavior; that seems like kind of a big deal to me.
I think I am going to write a post on this, too, once I’ve rounded up and read however many other studies there are.
Yes, I definitely need to read WAY more about it.
“I think her idea about food obsessions maybe being one manifestation of a more general autistic tendency to obsess about things is reasonable.”
That definitely seems reasonable. But, then, there’s still a difference between obsessive food rituals and an eating disorder. Though, of course, these lines can be really difficult, if not impossible, to draw.
You write:
“I really like the point they make about body image disturbance not necessarily being an etiological factor.”
So do I! Neither a desire to lose weight, nor body dissatisfaction pre-dated the onset of my AN. Even when severely ill with AN, at a very low weight I could see I was too thin and disliked my physical appearance.
My personal opinion is that the Vogue move is ‘hot air’ and that images of skinny models are ‘red herrings’ in the aetiology of EDs.
Completely agree. The last that I was at a weight that would classify me as anorexic in the DSM (just last fall), I also felt too thin and disliked my appearance, though at that weight previously, like 6-7 years ago in high-school, I could barely stand it and often didn’t want to go outside out of shame of my size. And even then, there were points even then, when I would realize I’m way too thin.
I completely agree with you regarding the Vogue move. I think it is a blatant PR move on their part. As if they actually care! And as if this actually does anything! (It is not hard to water-load). And really, meeting a BMI cut-off doesn’t mean you are healthy!
I see your points about Vogue using this as a PR stunt. In one way, I agree. But at the same time, I think it is important to consider who it is giving the inforamtion to Vogue for them to make this decision. Do we think Vogue had “scientific opinion” guiding them – unlikely. More likely to be misguided public opinion. Are they aware of any scientific reserach and their outcomes regarding EDs? again probably not. Have they taken steps which they believe would do something? Quite possibly. We cannot berate them if they believe they are doing something right/to help. It is not entirely their fault for not having the correct info. Should they seek it out if they truely want to achieve something opsitive, then yes, probably. At least, some of these girls who may actually have ED will not be exposed to the high pressured world of perfectionism by being discounted from modeling – no doubt perfection within themselves is one of the things they strive for and I don’t see how that environment can help them. It is an environment after all that “lets” them be skinny – no one tells them to eat more and if they lose weight they probably get told they look “great” just reinforcing the negative behaviour.
No, I don’t work for Vogue, I don’t work in fashion either. I work in sport and have pesonal and occuational experience of dealing with this.
Maybe we could all consider this a postive step towards change in that Vogue have highlighted the issue and raised awareness. It is now the responsibility of those who are “aware” to congraulate them on trying to make a difference but to raise the rest of the world’s awareness about causes of ED so we can help people more effectively.
Tetyana- just a friendly nudge, you said you were going to respond to my comment. š Also, you have posted the same comment in response to extralongtail twice.
Oh, oops. I did. Yes, I will! I JUST finished my thesis committee meeting, so I will reply tonight!
(I just want to think about it thoroughly and say what I mean, as oppose to rushing it.)
Hi Maibukkit,
I really do believe that Anorexia is genetically predisposed. I truly believe it’s something I was born with that needed to be triggered – but was there biologically independent of any life exposure factors. I had it well before I even cared about what my body looked like and well before I even knew what anorexia was. I also wasn’t interested in models. I’ve barely glanced at them all my life.
Eating disorders DO exist in first world countries where the media is not at all widespread in terms of magazines, tv, etc. The difference in numbers is mainly attributed to lack of reporting due to lack of medical resources available. For men, recent articles (can’t quote, I read a lot but not as research so haven’t taken notes etc) put the prevalence of men to woman closer to 50-50 – again, reporting is the issue here.
Do you think that if a specific gene is isolated, it could mean a cure or at least preventative measures? And do you agree with some experts who believe it’s the same gene that might be responsible for depression?
Fiona, who is your comment directed to?
Hi Tetyana, I’m sorry, my mistake, I was told someone called Maibukkit was writing this site. But it’s a good article.
Well, I don’t think a specific gene will ever be isolated. In fact, I know it wont be, because it is a polygenic disorder. That is, a lot of genes are involved. One must remember that genes code for proteins. A lot of the time, with regard to the brain, they code for subunits of channels that are important in how neurons communicate to each other. Genes code for proteins that regulate cell-cycle, how neurons develop, migrate to the right place, form the right connections. They code for things that help cells live, like clearing up cell “debri” or junk, or generating enough energy. They don’t code for complex traits. We are very far away, in my persona opinion, from understanding complex behaviours. We barely understand simple behaviours in a 302 neuron worm. So, in short, it is a hell of a lot of genes, and perhaps one combination makes you less susceptible to depression or anorexia, or whatever else, while another one makes you more susceptible, + environment (mothers nutrition, to early up-brining, to childhood and young adult experiences.. etc). Just like in the autism spectrum disorder, you have everything from severe Autism to high functioning Aspergers. The same is true for all other complex behaviours. That probably plays a role in why some people respond better to treatment or particular treatments (this is why you know, anti-depressants don’t work for everyone, in fact, no drug works for everyone; because of genetic variation) and probably why some people are able to recover and others are not. Same is true for all other psychiatric problems. Do I think there’s an overlap in genes that may contribute to depression and AN? Probably, I think anxiety and obsessive/compulsive behaviours are more pertinent, but that’s just my hunch. It is incredibly difficult to isolate gene variants that might be important for this, for a whole slew of reasons, both theoretical and practical.
Thank you for answering and that makes sense. You are right about the complexity of the problem when it comes to isolating any specific gene. I do agree about OCD and anxiety being more likely. In fact I have heard there is an OCP personality that’s been said to relate to anorexia and quite a number of my friends agree, I myself don’t fit the traits for OCP but have a lot of OCD like problems myself that tie in with the ED. Anxiety seems to be an extremely common problem in all of us – I’ve met a lot of Ed patients because of my many admissions and not a single one of them has been exempt from anxiety – in fact, the more anxiety they are experiencing the worse their symptoms. We even got the occasional patient whom the treatment team had decided did NOT have anorexia even though they were admitted emaciated and having as much difficulty eating as the rest of us, same thoughts etc, because they didn’t see themselves as ‘fat’ and they didn’t want to lose weight, their anxiety disorder had prevented them from eating. (I call bullshit on that to be honest, I think that the weight and shape distortion really shouldn’t be a compulsory diagnostic factor as again, it varies. These women were as in denial and as sly when it came to hiding their efforts to not eat and still lose weight as we were on the whole, although they did seem to be more open to the refeeding process and not as openly dismayed by the weight they gained)
Back to the topic of this post, I truly don’t think the media images cause anorexia, no, but I do feel they can act as triggers. I also wonder if it’s because so much importance is placed on body image and eating (obviously since it’s essential to life) in our society, that’s why anorexia manifests the way it does. If the importance was placed on something different, would it manifest differently. Eg. were all our models overweight, and overweight was glorified in every magazine, on tv, etc – would we have more cases of (not sure what to call it) reverse anorexia?
Actually having asked that, I don’t think so – because anorexia existed even when the ideal woman’s body WAS larger, it exists in first world countries where fat means you are wealthier and can access food, and eating large quantities isn’t seen as something needing a lot of control, nor is it obtained through a loss of appetite or inability to eat despite appetite. I think control is a large factor too. So many emotions play out when it comes to food and avoiding it, that as well as controlling your body there is a lot of control over the other people around you. They can do anything to you in other ways but they can’t make you eat the food. (well, out of a hospital setting, but they still can’t make you eat even though they can feed you other ways).
Sorry for the tome. Usually I don’t have the cognition to really think properly but you caught me on an insomniac roll š
Fiona, when you say ‘reverse anorexia’ I assume you mean binge eating disorder/compulsive over eating, when people eat massive amounts of food as an emotional coping mechanism? Some sufferers are morbidly obese, others are ‘normal’. But ‘reverse anorexia’ is quite an offensive way of putting it, just so you know for the future. š
@Sarah: I think what Fiona meant with “reverse anorexia” is the idealization of overweight. In BED, patients still, from my understanding, idealize a slim body.
@Fiona: I think that OCD, anxiety, depression, and whatever else, need to be present prior to, or after, the eating disorder, for it to be truly co-morbid. I think that’s why family studies and twin studies are important: if parents or siblings have a higher likelihood of experiencing those, but lack an ED, it suggests there’s either biological or environmental factors that play a role and perhaps, an ED, is the result of all of those predisposing factor + stressor. Or something like it.
I was quite obsessive and anxious when I got sick initially. But, that went away when I got better, though definitely not immediately. And when I relapse, I get more obsessive and anxious, not just about food, though food and weight of course predominates, but everything else, too.
You wrote: “the more anxiety they are experiencing the worse their symptoms,” and it makes me wonder, maybe it is the reverse, the worse the ED symptoms, the worse the anxiety? I don’t have an answer, I’m sure they both feed into each other.
I do think images can act as triggers, but I think that comments and things IRL are much more important. And don’t get me wrong, I don’t think Vogue or any other fashion magazine (or whatever) should promote thinness. I just think it is idiotic to think that enforcing some BMI cut-off (waterloading, hello?) is a huge step forward in terms of promoting health. Why not truly promote health by featuring models that are thin, normal, overweight, that aren’t airbrushed? Health doesn’t mean BMI > 17.5.
Sarah, I’m sorry to have offended you. I was musing, there, about if the ideals of society were reversed (ie it was ideal to be larger instead of smaller) would women put as much effort into gaining weight as they do losing it? And if illnesses like Anorexia would manifest in the opposite way instead. I didn’t know what else to call it.
Tetyana, I do agree about truly co-morbid illness being present separate from the ED. Anxiety, OCD like behaviour, depression, etc can be caused as a symptom of ED and that’s not the true illness.
I do agree that anxiety can be caused by the ED, so it would have to be present as a problem before or after to be truly anxiety disorder rather than ED-caused anxiety. They do feed into one another, it’s a chicken-egg problem, the same way I see the ‘what comes first, anorexia or starvation’ chicken-egg question. Starvation produces behaviours and thoughts very much like anorexia does, as evidenced in the Minnesota Starvation study, but people who develop Anorexia usually are not starving at the onset (I believe).
As for the vogue models, it’s a start – but yes, waterloading and other methods of trickery pretty much invalidate the >17.5 requirement. I also find that 17.5 is a rather low BMI cut-off requirement. If I remember correctly, when I read the article, it stated that girls below that BMI would need a doctor’s letter in order to be allowed to model, stating that they were not underweight. Yet that BMI is already very underweight so that didn’t make sense to me at all.
http://oddculture.com/weird-news-stories/the-fat-fiancees-of-africa/ You might find that interesting- it certainly seems disordered and the opposite of a culture where young girls are encouraged to diet/starve. Anorexia exists in those countries though. I think BED/bulimia is possibly more prevalent but that’s the case everywhere I think; anorexia is the rarest ED.
Wrt to the whole autism and anorexia thing, one thing I think of is the media focus on ‘health’. It’s difficult because absolutist and black and white thinking are COMMON, they’re not just autistic traits. But I personally remember back in my childhood when I would think the way I do now. I do something and I decide I should feel guilty about it and I keep thinking about it in class or whatever and it can be something so irrational like walking ONE step in the wrong direction on Pokemon, and I have to invent a reason why it was ok and I don’t deserve to die because of it, which is the same kind of thing I have to do with eating. Like the one time I ate one small strawberry ON TOP OF MY DIET PLAN when I was in hospital, from the garden. When I was about 6 (so it’s a fuzzy memory), I’d got my face painted but then I wanted a hot dog, or something. And I didn’t want to make my face paint imperfect by eating the hot dog so I wiped ALL of it off, and then people were like ‘oh what a shame’ and I felt bad. But anyway I think w/ autistic traits you’re more likely to get obsessive about avoiding food with saturated fat for example, with society being a triggering factor.
@Tetyana, I completely agree with you that eating disorders can present without significant weight concerns. In fact, that is a key research interest of mine.
I did want to add to this thread, though, that individuals who are blind can also present with significant body image disturbance. My colleagues and I published a case report in 2012 http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2010.10040555) describing some of the cognitive behavioral manifestations of body image disturbance in a young woman with anorexia nervosa who has been blind since birth:
“In addition to tactile checking and body avoidance, Ms. A also reported several cognitive-behavioral manifestations of body image disturbance that have not previously been reported in the literature on blind patients with anorexia nervosa and bulimia nervosa, including attempted mirror checking. āI like to pretend I can see a form,ā she explained, describing how she often stood very close to full-length mirrors in order to make out patterns of light and darkness that might provide insight into potential changes in her body shape. Ms. A explained that because she could typically only see āa blob,ā mirror checking usually resulted in her concluding that her body was too large. She also reported that she engaged in frequent body comparisons between herself and others.
Not only did she engage in tactile comparisons (e.g., feeling another personās arm bones during an embrace), but she also compared herself to the imagined attributes of othersā bodies, despite her inability to see them. To facilitate navigation without sight, Ms. A had been trained to use echolocation to ascertain the approximate location of nearby people and objects. As she increasingly endorsed extreme body image disturbance, she began to describe applying these techniques to the assessment of othersā shape and weight. For example, during conversations, she paid close attention to othersā voice location and pitch, which she interpreted as clues to height and weight, respectively, with higher locations indicating taller height and lower pitch indicating greater abdominal girth.”
Jenny, thank you very much for your comment! I’ll read the paper, looks very interesting!
I am not surprised that someone who is blind from birth can have body image disturbances – at all, actually. When I was sick, I used to hate the way my body felt, the way it felt when I walked and ran (and to some extent, this is still true even today, I don’t do some forms of exercise because I dislike how my body feels at certain weights). I would wake up and feel “fat” and hate the way my body felt against the bed, for example, even before seeing myself. So, I can really understand having body image disturbances without being able to visualize your body.
I think, though, or at least I have a hunch, that this disturbance is disconnected from any aesthetic ideal or a desire to be “sexy/attractive”. I don’t want to project my experiences onto others, of course, so it is just my hypothesis. But, it almost seems like it becomes a thing in and of itself (obsession with how the body looks or feels, desire for thinness), without any real rational reason as to why.
Do you have any thoughts on that?
Thanks again for your comment (and the follow on twitter).
Tetyana
As far as I am aware disorders like anorexia stem from issues like feeling unable to to control your life. It’s a serious mental disorder attributing it to seeing pictures of slender women does so much damage to our ability to address the real problem.
Correlation is not causation, being sick makes you thin not the other way. People who are naturally thin are not unhealthy. Most bulimics have a BMI above 18.5.
It’s unnecessarily punitive to women who are natural thin. It also send the message naturally slim women that there is something wrong with their bodies.
This article is cool! I’ve had AN since junior high, and I’m totally blind (since age 5). For me it did have a lot to do with looking prettier to others, but everyone is different, I think. But being blind doesn’t stop one from hearing friends talk about models or knowing models hights, weights, and BMIs.
Very true, Chloe. You are still able to hear the rhetoric even if you can’t see it!
“But being blind doesnāt stop one from hearing friends talk about models or knowing models hights, weights, and BMIs.” So true!
I resisted thinking the media was to blame for ed’s for a long time. But I think it has a part in the majority of ed’s even though for me it was never the main motivation (in fact I have had therapists note while I was in treatment centers that I was less pre-occupied with weight than other girls). I do think though that the media;s influence is a factor for many and heightens the incidence of more severe/extreme ed’s we see now compared to in times past. It somehow gets deep in our psyche. I think in past times I wouldn’t have eaten much because of my anxiety but wouldn’t have thought about food as much, probably would have just been labeled “hysterical” and became addicted to laudanum instead.
I think the media and exposure to thin models plays a role, but I often wonder if it plays the most significant role not as a causal or predisposing factor, or as a long-term maintaining factor, but somewhere more in the short-term. Once the things that can lead to the ED start to take root, but not quite when the ED is in “full force”, do you know what I mean? Basically, these factors don’t need to be “to blame” for the onset of an ED to still play a role in the ED course.