This is part II of posts on why I am highly skeptical of the argument that we need to understand the genetic basis of eating disorders in order to improve outcomes. If you would like to leave a comment, please read Part I as well.

I worry about the implications of focusing on genetics and neurobiology in identifying causes of and solutions to eating disorders in the context of a neoliberal society.

When I was an adolescent, finding out that eating disorders have a genetic component alleviated my guilt. Coming across Dr. Walter Kaye’s research into the neurobiology of eating disorders — the hypothesis that the drive to restrict may be linked to and reinforced by serotonin systems in the brain (here, here, and here) — provided me with a plausible biological explanation for why restricting made me feel calmer. It meant my eating disorder was not my fault. I wasn’t vain. I wasn’t image obsessed. Somehow, a biological explanation made my suffering seem more real. It absolved me of the guilt I felt for not being able to “just eat.”

Biomedical explanations are often seen as legitimizing mental illnesses. For a long time, people thought that biomedical models of mental illnesses would decrease stigma, but mounting evidence suggests it has actually done the opposite (good lay article here; also see this, this, this). Angermeyer et al. (2013):

Attribution to hereditary factors showed hardly any relationship with attitudes toward people with symptoms of eating disorders. Respondents who endorsed brain disease as a cause tended more to hold those afflicted responsible for their condition, they also expressed more negative emotions and a stronger preference for social distance.

(Although Bannatyne and Stapleton found slightly different results there and here.)

When Michelle Easter interviewed individuals with eating disorders, she also found that for some individuals locating “the problem in the individual body exacerbate[d] stigma by making the problem seem to be an essential and permanent aspect of the person (Phelan, 2005); rather than having a problem, the person is a problem.”(Easter, 2012). Easter (2012, blog post here) focused on stigma, but the implications of focusing on the biomedical model of mental illnesses go far beyond stigma.

To be clear, there is no doubt that eating disorders have a genetic component (see here, for example). But by focusing on genetic and neurobiological causes of eating disorders, we are more than just shifting the focus away from environmental and societal contributions to eating disorder development and maintenance, we are also sending the message that solutions to eating disorders lie within the individual and that they are likely biomedical or pharmacological in nature.

Unduly emphasizing a biomedical model of mental illnesses shifts the responsibility of recovery onto the individual while absolving society from responsibility.

The problem is in your genes. Yes, it is not your fault. But it is on you to do something about it. They are your genes after all. It is your responsibility to ensure that you are a functional and productive member of society. 

The problem with this is insidious because there is some truth to this. This is what makes it so hard, at least for me, to point out the flaws and dangers of a biomedical explanation of mental illnesses: It is not that it is wrong, it is that focusing too much on biomedical explanations without paying attention to cultural, social, and political aspects of our daily lives is one-sided. It is missing half of the story.

Above I mentioned neoliberalism. David Harvey defines neoliberalism as:

The theory takes the view that individual liberty and freedom are the high point of civilization and then goes on to argue that individual liberty and freedom can best be protected and achieved by an institutional structure, made up of strong private property rights, free markets, and free trade: a world in which individual initiative can flourish.  The implication of that is that the state should not be involved in the economy too much, but it should use its power to preserve private property rights and the institutions of the market and promote those on the global stage if necessary.

On neoliberalism, George Monbiot writes:

Neoliberalism sees competition as the defining characteristic of human relations. It redefines citizens as consumers, whose democratic choices are best exercised by buying and selling, a process that rewards merit and punishes inefficiency. It maintains that “the market” delivers benefits that could never be achieved by planning.

Never mind structural unemployment: if you don’t have a job it’s because you are unenterprising. Never mind the impossible costs of housing: if your credit card is maxed out, you’re feckless and improvident. Never mind that your children no longer have a school playing field: if they get fat, it’s your fault. In a world governed by competition, those who fall behind become defined and self-defined as losers.

Among the results, as Paul Verhaeghe documents in his book What About Me? are epidemics of self-harm, eating disorders, depression, loneliness, performance anxiety and social phobia. Perhaps it’s unsurprising that Britain, in which neoliberal ideology has been most rigorously applied, is the loneliness capital of Europe. We are all neoliberals now.

While I think the use of the word “epidemic” is a bit much, I think Monbiot’s overall point is important. I’ll say this again, by attempting to locate the problem solely within the individual, we are ignoring the cultural, social, and political forces that contribute to mental illnesses and make recovery harder. Recall the Cui et al. (2013) paper I mentioned in my previous post. I quoted parts of a news article about the study, but here’s more:

Lutter says the scientists believe this pathway, where both genes are found, works in the brain to increase a person’s desire for food when they have an increased need for calories. But when the genes are mutated, they can block a person’s ability to want to eat.

Umm. Wow. Okay. Later, Leslie Sim (whose papers I’ve blogged about before in these posts) says:

“We’re really starting to see this as a true biological illness, where essentially we’re seeing these kids sharing these temperament predispositions that likely places them at risk,” says Sim, who serves as the clinical director of the Mayo Clinic’s eating disorders program. “So often parents are really looking for what they did to cause the eating disorder. And I think now we can pretty much definitively say the only thing they did was provide their genetic contributions.”

While the news article author says that the researchers do say that “30 percent to 50 percent of the risk is considered environmental”, this is buried at the end of the news piece. The message that genes are the culprit is reinforced by another US News article published earlier with this title: “Same Genes May Cause Alcohol Abuse and Eating Disorders.” “Cause” is a strong word.

To reiterate what I wrote above, the underlying message here is this: The problem is in your genes. Yes, it is not your fault. Yes, it is not your parents’ fault. But it is on you to do something about it. They are your genes after all. It is your responsibility to ensure that you are a functional and productive member of society. 

There is no questioning of the society within which individuals are supposed to “function”, nor is there a questioning of how we are defining “mental health” and “functioning.” The implicit argument is that if you are really anxious or depressed, it is because there’s something wrong with your brain. You are not adapting well to your circumstances. But don’t question the circumstances. 

On this a Tumblr user writes,

And it’s not only that treatment is individualistic and obscures the structural causes for ‘mental illness,’ it’s also that the idea of “good mental and physical health” is mediated and arranged by those same neoliberal forces. A return to “mental health” or “functioning” is generally defined more by what you are able to do and how useful you are to neoliberal society. Oh, you can go back to work and keep an apartment and can tell the anxious thoughts in your head to shut up long enough to convince me that you’re normal now? Cured. There’s no room in the neoliberal discourse on ‘mental health’ for a variety of definitions of healthy, ones that don’t depend on being “functional.”

This is problematic. Writing in the context of depression, Brijnath and colleagues (2016) note,

… when depression is seen as an individual problem requiring self-labour and self-transformation, socio-structural factors such as poverty, class, and work inequities are ignored and the state is absolved from acting in these areas (Gattuso et al., 2005; Peacock et al., 2014a; Teghtsoonian, 2009).

I want to be very, very clear here: I am not arguing eating disorders are caused by socio-structural factors, but they are not caused by genes either. Any argument that fails to take into account the complexity of our thoughts, cognitions, and behaviours is flawed and dangerous. When people try to make such arguments, we should be asking, “Who stands to profit from making these arguments?” 

Who benefits from making the argument that the problem is in individuals’ ability to adapt to their environment and not at all with the environment within which they are supposed to “function”?

Joanna Montcrief (2006) provides one answer,

The pharmaceutical industry has popularised the idea that many problems are caused by imbalances in brain chemicals. This message helps to further the aims of neoliberal economic and social policies by breeding feelings of inadequacy and anxiety. These feelings in turn drive increasing consumption, encourage people to accept more pressured working conditions and inhibit social and political responses.

She expands:

Critics of psychiatry have long pointed out that locating the source of problems in individual biology – ‘blaming the brain’ – impedes exploration of social and political issues.

It prevents serious consideration of the way in which economic imperatives, such as the need to tolerate poor working conditions and the discipline of the school system, help to define certain behaviours as pathological. It also obscures the effects of social factors, such as overwork and increased competition, on mental well-being.

…

The widening application of psychiatric disease theory by the pharmaceutical industry therefore not only helps to expand markets for psychotropic drugs but also helps to create conditions in which neoliberal policies can thrive and in which resistance to them is curtailed.

In “Neoliberalism and the commodification of mental health,” Esposito and Perez (2014) write,

During this time, drugs became the primary treatment for presumably pathological behaviors and conditions that were sought in fixed biological properties within the individual. As a result, the psychopharmacological revolution largely ignored the social dimension of what is defined as ‘‘mental illness.’ Consequently, most current psychiatric treatments merge with neoliberal ideology, as the individual becomes the focus of attention while the larger market society in which they live is largely ignored … 

As medicine’s pharmacological ability to create specific pills for specific conditions improves, a market solution for life’s troubles, in the form of drug consumption, is greatly advanced.

There is nothing inherently wrong with pharmacological solutions, and I am certainly not against pharmaceutical drugs (I have taken them myself and found them helpful). On an individual level, taking psychotropic medication may be the most rational decision.

But when, as Montcrief writes (in 2006), the use of antidepressants (as just one example) increased by 234% in 10 years leading up to 2002 in the UK and by 400% between 1988 and 2008 in the US (source), and 11% of Americans are taking antidepressants (source), perhaps asking what genes are causing these and not those people to become depressed or anxious or develop eating disorders is the wrong question.

Perhaps we should be asking, is there something about the environment in which we live in that is making so many people anxious and depressed?

Even the IMF has recently admitted that neoliberalism has increased economic inequality. Economic inequality does not cause mental health issues, but perhaps it is one of the “triggers” that pulls the gun loaded by genetic predispositions to anxiety, depression, eating disorders, and so on. Moreover, widening economic inequality means that a certain population will have less access to healthcare services, while at the same time being blamed for their ill health.

In addition to factors like economic inequality, academic competition, poor job prospects for many graduates, rising student debt, and stagnant wages — factors that are arguably worsened by neoliberal policies and that increase stress and illness (as one example) — when it comes to eating disorders, we also have to take into consideration neoliberal discourse regarding dietary choices and body work.

What we eat and how we look — the size and shape of our bodies — is increasingly linked to notions of self-control and self-worth. For women, thinness and dietary control is highly valorized, but, of course, having too much dietary control and being too thin is pathologized.

Perhaps we will find gene variants that enable people to exercise that high level of dietary control and for whom that high level of dietary control serves certain psychological functions, but it won’t answer why those individuals sought to gain dietary control and alter their bodies in the first place.

Perhaps it is the incessant messages that thinness is equal to success? Or maybe it is the message that controlling our dietary intake is evidence of individual responsibility?

In “Neoliberalism, Pro-ana/mia Websites, and Pathologizing Women: Using Performance Ethnography to Challenge Psychocentrism,” Nicole Schott and colleagues (2016) write,

Brumberg (2000, p. 245) traces how, starting in the 19th century, the medical concern for obesity grew and “many internalized the notion that the size and shape of the body was a measure of self-worth.” The body became “an instrument of competition, a way to demonstrate one’s mettle” (Brumberg, 2000, p. 252), spawning an explosion of the diet industry that continues today. Within this context, anorexia has come to be understood as a “condition involving the control of appetite rather than loss of it” (Brumberg, 2000, p. 228).

They continue,

The critical scholarly literature rejects the dominant approach based on the individualization of eating disorders, and attends to the broader social contexts in which these occur. Blaming pro-ana/mia websites is seen to deflect accountability from the mainstream messages of socially acceptable media and advertising outlets (Boero & Pascoe, 2012) that promulgate “Western beliefs that thinness is a desirable, beneficial and value enhancing attribute for women” (Knapton, 2013, p. 467). As Walters, Adams, Broer and Bal (2015, p. 10) note, eating disorders represent a self-care “tool” for furthering self-actualization and self-surveillance, laudable goals within a “self-improvement culture.”

In “Choosing health: embodied neoliberalism, postfeminism, and the do-diet,” (an amazing, amazing article that everyone should read) Kate Cairns and Josée Johnston write,

Numerous scholars have connected embodied neoliberalism and fat-phobia, noting how thinness is idealized as an indicator of healthfulness, a corporeal expression of individual responsibility and self-control (LeBesco 2011; Metzl 2010; Guthman 2009).

They continue,

Even as neoliberal discourse promotes the acquisition of expert health knowledge to control one’s diet, the feminine subject who is too informed, and too controlling in her eating habits is pathologized as health obsessed. The need to avoid the penalty of the positive extreme was striking, and a theme we believe should be incorporated into theoretical understandings of femininity. At the same time, the feminine subject who is too relaxed about her eating habits runs the risk of being perceived as ignorant, self-indulgent, and—perhaps worst of all—fat. The process of calibration is analytically and politically significant because it reveals the sharp boundaries surrounding successful food femininities and the persistent gendered social pressures around women’s food practices.

Most importantly, eating disorders occur in this context; they are not removed from it. Anorexia nervosa is often seen as that former extreme — too controlling, too obsessed. Binge eating disorder and bulimia nervosa are often seen as the latter extreme — too self-indulgent. Our notions of health and recovery are shaped by these rhetorics.

Perhaps this is why I see so many treatment centers offer eating disorder treatment AND obesity treatment at the same time. (This boggles my mind, but from a maximizing profit perspective, it makes the most sense).

Yes, understanding the genetic contributors of eating disorders may help explain why some people but not others find restricting eases their anxiety. Yes, it may help us predict which individuals are at risk of developing eating disorders. It may even help us predict which individuals will benefit from this drug or that drug, this treatment or that treatment. 

It may help explain why some people have the personality traits and temperament that predisposes them to develop eating disorders. Perhaps we will identify the genes that predispose individuals to what we term a “Type A” personality — the people we view are being highly competitive and ambitious, but also more anxious, more rigid, and more self-critical. And maybe we will develop drugs so that these individuals can continue being highly competitive and ambitious but without the concomitant anxiety and self-criticism (that decreases their productivity). (And we will make lots of business owners, governments, and pharmaceutical company executives very happy!)

But are these the right questions? The right goals? 

Should we be looking for those gene variants that predispose certain individuals to eating disorders and developing drugs so that these individuals can become “functional” members of society or should we instead focus on the bigger picture?

Perhaps we should focus instead on creating healthier societies? Perhaps we should focus on improving access to affordable and timely treatment (as I wrote about in my last post). No, this will not eliminate eating disorders, but I think it will make all of us a little bit healthier. A truly holistic approach.

And yes, this battle is political.