Annals of Medicine
ISSN: 0785-3890 (Print) 1365-2060 (Online) Journal homepage: http://www.tandfonline.com/loi/iann20
Sociocultural Aspects of Eating Disorders Frances J. Raphael & J. Hubert Lacey To cite this article: Frances J. Raphael & J. Hubert Lacey (1992) Sociocultural Aspects of Eating Disorders, Annals of Medicine, 24:4, 293-296, DOI: 10.3109/07853899209149957 To link to this article: http://dx.doi.org/10.3109/07853899209149957
Published online: 08 Jul 2009.
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Sociocultural Aspects of Eating Disorders
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Frances J. Raphael and J. Hubert Lacey Eating disorders, though recognized for centuries, are increasing in prevalence. The increase in rate is particularly remarkable over the last 30-40 years. The article considers how social function stems from biological function and evolution, and how biological function may hamper social development to the detriment of individuals. Social and cultural influences relevant to this change are examined, especially the changing position of women within society as a whole and the multiplication of conflicting roles which women find themselves balancing. Reference is made to the representation of women in the arts and media. Reference is also made to the role of those external agencies which have hlstorically controlled populations (both men and women), such as religious bodies and governments, but which t o some extent have been rejected. Evidence from in-depth studies of women with eating disorders and from transcultural studies are included to support the authors’ ideas Key words: evolution; media; arts; body image; control of society; women’s roles; transcultural evidence. (Annals of Medicine 24: 293-296,1992)
Biological Factors Adult women are fattier than men. More specifically, the fat is concentrated in specific areas which carry sexual connotations: the breasts, hips, thighs and buttock and, lastly, the stomach. This gives women their characteristic pear shape. Men do not have such fat deposits which tends to emphasize broader shoulders and narrow hips. Both forms identify the individual as mature and are an aspect of the triggering of sexual attraction of a mate (1). The importance of adipose tissue in sexual development can be seen in the body changes which occur at relevant stages in a woman’s lifetime. With the pubertal linear growth spurt there is a proportionately greater increase in fatty tissue which then assumes the adult distribution described above. It has been shown that there is a critical body weight and, more specifically, body fat proportion which must be attained for normal menstrual functioning. Frisch (2) found that 22% of any body weight for height must be fat for menarche to occur. Because girls are less fatty at menarche than when they achieve stable reproductive ability she found that secondary amenorrhoea occurs when the proportion of fat drops to only 17%of the body weight for height, e.g. in anorexia nervosa Pregnancy and lactation increase the fat content of the breasts as well as the glandular From the Department of Mental Health Sciences, St George’s HosDital. Tootina. London.
tissue. At the end of a woman’s reproductive life the breasts lose their fat content. The total body distribution also changes with increased truncal fat (3).In terms of the future of the species, these menopausal changes can be seen as an indication to men that reproduction is no longer possible. In terms of evolution and maintenance of the species, these developments in the specialization of fat distribution may have uses but the connection between adipose tissue and sexuality allows some understanding of why body shape and image have become such powerfully loaded issues and can help us consider how this might produce maladaptive responses in some people.
The Media/Arts It is often asked whether the media and fashion industries determine women’s view of themselves and what is required of them, or whether the opposite mechanism applies. Equally often the question raised is whether men dictate what women look like and the body shape they strive for, or whether women themselves determine this. These questions are inseparable and best considered in terms of the development of society as a whole. The representationof women in the arts and media of Western cultures has certainly changed. Rubens is renowned for his adoration of plump and more muscular
Downloaded by [UQ Library] at 20:06 25 April 2016
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Raphael
women in the seventeenth century. Compare his works with the elongated slender women of Modigliani (4). Each artist may have different followings but both have been extremely popular in their times. The corsetry of the late nineteenth century emphasized hour-glass figures. In more popular culture, the changes in the characteristics of female film stars and models over the past 50 years is interesting. World War II pin-up Betty Grable, the actresses Marilyn Monroe and Jayne Mansfield in the late 50s and early 60s had considerable fame and popularity based on their shapeliness. Towards the late 60s the fashionable shape changed dramatically, to the advantage of slim women with small breasts such as the fashion models Twiggy and Jean Shrimpton. In the 80s the shape changed again, this time to broad shoulders and noticeable breasts grafted unnaturally and sometimes surgically onto an emaciated frame. That women have reached the position of such an impossible aim which pulls them in opposite directions is interesting in the context of arguments to follow. These anecdotal comments are supported by the work of Garner and Garfinkel et 81. (5). Their examination of data from Playboy centrefolds and Miss America Pageant contestants over a 20-year period indicated a significant trend toward a thinner, more tubular standard in the context of increasing population weight norms. Bearing in mind links between adiposity and sexuality, it is interesting that they also noted a coincident increase in the number of diet-related articles in popular women’s magazines. Later, this article will refer to mechanisms whereby dieting can lead some into the arena of eating disorders. Western attitudes to shape and size have been discussed here. The attitudes in non-Western cultures is often quite different with obesity being admired and therefore encouraged (6).
Body Image Currently, in Western society it appears that women believe themselves to be more attractive to men if they are slender (7-9). Despite changes in the representation of women there is no evidence to support the notion that any particular body shape or size is more appealing to men in general (10) than any other shape, and certainly no evidence that men are selectively drawn to women who are thin (11, 12). Body image has been seen as a crucial aspect of eating disorders for many years and was incorporated in the DSM ill diagnostic criteria for anorexia nervosa (13). Several authors have elaborated this. It is interesting to note that people without eating disorders also misperceive body shape (14). Fallon & Rozin (15) studied a cohort of psychology undergraduates of both sexes. For men, the current weight, ideal weight and weight they thought would be most attractive to women, were almost identical. Women assessed their current weight to be heavier than the weight they thought would be the most attractive to men, which in turn was heavier than the weight they held to be ideal. The men’s stated preference of female weight was significantly greater than the women’s assessment of themselves. The women under-
Lacey cut the men’s view of their most attractive weight In summary, the men were relatively content with their weight while the women placed pressure on themselves to lose weight. It is unclear why women should hit upon this out of the blue. That these subjects were non-eating disordered illustrates that all individuals may be under the same pressures but only a proportion develop eating disorders.
Controlling Agencies Historically, control has been imposed by men either directly, in the interactions between men and women, or indirectly through almost exclusively male institutions such as the Church (or equivalent religious bodies), monarchies and civil governments. From the male perspective, there are several possible unconscious motives for promoting such an ideal. It might be advantageous to men for women to focus on weight and eating. A woman who is underweight or simply preoccupied with food could be seen as weaker, more dependent, less able to dominate and less likely to leave the home, family or relationship. This does not stand alone as an explanation. It is necessary to include the topic of risk. If women are strong, independent and able to dominate, men as a group might feel significantly more vulnerable. It is also possible that body size and shape generate powerful unconscious associations and are relevant for their symbolism. A thin woman might represent a ‘little girl’ figure, someone dependent in a child-like way and biddable. The aspect of dependency reminds us that parents set limits on what their children do. However this ‘little girl’ is in fact a grown woman, and putting these features in a sexual context makes it interesting that the issue of control should appear in relation to an image of women. The alternative, fuller figure suggests a sexually mature fertile woman with hips suitable for childbirth and breasts capable of providing adequate milk. It is likely that neither fantasy exists alone in any individual but that different ones apply at different times. Acting out these fantasies has practical difficulties for a woman. While a man can move between female partners of different shapes the individual woman cannot change her size at a moment’s notice. The conflict for her is clear and the oscillating weight and shape seen in those with eating disorders may be explained as the nearest these woman can get to resolving the problem. Striving for equality has lead to inevitable competition with men and produced conflict over the priority of roles open to women. Women have found it extremely difficult to find equality while maintaining traditional feminine traits and have been forced to adopt more masculine traits instead. This involves suppression or denial of female characteristics. These social changes therefore add to the perceived need for women to control themselves. Many aspects of a persons life are open to control, but some women conclude (unconsciously) that the most controllable aspect which supports their aims of independence and society’s need for them to conlrol or even deny their sexuality is their body-shape and weight.
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Sociocultural Aspects Attempts at weight loss through dietary restriction begin giving a transient sense of achievement. Denial of conflict is comfortable and therefore the drive to lose weight is reinforced. However, the physiological drives of the body will not tolerate starvation indefinitely leading to binge-eating and the return of conflict. Through this battle a woman moves into the vicious cycle of starvation leading to craving and binge-eating, then to devices aimed at counteracting the effects of food ingested (16). Self-induced vomiting does reduce the amount of food absorbed but laxatives (17), diuretics and appetite suppressants are quite ineffective. As described above these restrictions can physiologically lead back to bingeeating.
Downloaded by [UQ Library] at 20:06 25 April 2016
Demographic Data Some demographic information lends support to the notion that eating disorders arise as a counter-productive solution to intolerable conflict. Lacey et al. (18) found their group of patients with bulimia nervosa unified by a poor relationship with one or other parent, This often stemmed from marital difficulties. There was an interaction with personal emotional problems, focusing particularly on doubts about attractiveness towards men as well as peer group relationships and striving for academic achievement. They suggested that women with such characteristics who also dieted were susceptible to specific life-events triggering bulimia nervosa. The beginning or end of the first major emotional relationship, especially if sexual intercourse first occurred during it, was seen as the most relevant event. Environmental changes, including change of job, moving out from home and losing a parent, were also important. The first major relationship is highly significant for the acceptance and development of a person's sexuality and self-confidence, regardless of their sex. In a woman susceptible as described, any hiccough or rejection at this stage could fuel her beliefs that sexuality is dangerous and to be avoided. Relating rejection to body appearance could clearly lead to manipulation of food, leading into the cycle established above (19). Kramers et al (20) have attempted to examine whether the characteristics of bulimia nervosa have changed alongside the changes in prevalence. They found that they have not. The characteristics of bulimia nervosa in their sample of women appear to be constant.
Historical Evidence There are two ways of looking for further evidence to support or refute these ideas. The first is the evidence put forward to suggest that eating disorders are new conditions. The existence of fasting cults and legends of women who may have had eating disorders have been known for a long time. Lacey (21) writes of the legend of Wilgefortis from the tenth century but more importantly comments on the multiplicity of smaller legends across Europe at that time. Richard Morton (22) described anorexia in 1694 but there is little mention again until the late nineteenth cen-
tury when Gull (23) and Lasegue (24) separately took up the picture. It was not until early this century that bulimia was reported in any form. Reported cases of anorexia took off more significantly in the 1960s.Bulimia nervosa was not formally described and defined until Russell's work in 1979 (16). The time-scale of this relative explosion of eating disorders has tended to parallel the sociocultural changes described above. This pattern would seem to support the ideas in this paper.
Transcultural Evidence Secondly, it is possible to examine the ideas by studying the relative incidence of eating disorders between societies in different stages of development. Differences in body shapes and attitudes towards them between Western and non-Western cultures have been raised. If the ideas here are correct it would be appropriate to expect lower prevalence rates of eating disorders in societies where external controls of populations, particularly women, are in operation. There is not an extensive current literature on this area. El Sarrag (25) and Okasha et al (26) both found anorexia nervosa to be a rarity in Arabic cultures. In a comparison of female Egyptian student groups in London and Cairo, Nasser (27) found that, although both groups had abnormal eating attitudes, there were only cases of bulimia nervosa in the group studied in Britain, i.e. those exposed to Western attitudes lacking the external controls more familiar in Cairo. The second author has seen two cases in his clinical practice of woman who display symptoms of bulimia nervosa only when staying in Britain. The symptoms of both disappeared on returning to their native countries (Peru and Pakistan) where external controls are much more significant.
Case 1 An 18-year-old woman, the eldest of five children was born in Pakistan but emigrated to the U.K. with her strict Muslim family at the age of 2 years. There was childhood sexual abuse by her father during her mother's absence with depression. Her weight. increased to 21 0% MMP weight at this time. Vomiting began at 16 years while living in England with her maternal grandparents and in connection with the eating rituals of Ramadan. Bland English food gave no difficulty. Binge-eating and laxative abuse started 2 years later with a proposal for a traditional arranged marriage. Admission to a specialist unit allowed minor improvement. Dramatic improvement followed her return to Pakistan based on a family decision. There she lives as an unmarried aunt being chaperoned wherever she goes. Her symptoms have settled. There is no binge-eating or laxative abuse.
Case 2 A 20-year-old woman of Peruvian origin was living with her divorced mother and younger sister in London. The mother's own ballet career had been thwarted by severe injury in a road traffic accident. She tended to pursue her
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own ambitions through her daughters. To that end, having bsen brought up in a highly structured and protected environment, chaperoned wherever she went outside the family home, at the age of 13 years she was sent to a London ballet school. Within 2 years, while in the care of a family friend with liberal views and in the context of puberty she developed bulimia nervosa. Inand out-patient treatments were unhelpful except for a few months, However, during visits to Peru when, as an unmarried woman, she was expected to return to the custody of her grandmother, there was no disordered eating. She described life there as restricted but reassuring. Returning to London, the binge-eating would rapidly recur, as indeed did a social and sexual life which would have been utterly unacceptable in Peru. Wlodarczyck-Bisarga’s as yet unpublished work in Poland presents an intermediate picture. Despite the rigid controls on both men and women by the state and Catholicism, bulimia nervosa does exist in Poland. The caution with this statement must be that the sample was of students who may be exposed to more Western, liberaf ideas and influences. These studies are not of rigidly demarcated cultures. That they find women with bulimia nervosa in Egyptian and Polish women may confound the arguments here but may simply represent cultures in transition. A clear culture in transition is the Asian population in Britain. A group of young girls has been studied in England in the town of Bradford, which has a very high proportion of Asians (28). The prevalence of bulimia nervosa amongst the Asian girls was almost as high as that of the white girls. Comparing this with the Egyptian and Polish studies, it would seem that the effects of removing external controls are even greater when the population is suddenly immersed in a society with those new vaiues than when a society gradually acquires new values from outside. In summary, although our ideas are sometimes speculative they do not exclude the possibility that direct genetic family and social factars might influence individuals in a personal sense as well as acting on whole populations. The arguments of this attide hinge on the principle that interactional and interpersonal aspects of any society can only have developed and continue to develop from a fundamental biofogical basis which is subject to evolution. For millennia, man has been ruled by external entities for the good of the whole. The relatively recent rejection of such external controls has produced internal drives to maintain society in the broadest possible sense. In a developing society the particular forces acting on women concerning reproductivity act in such a way as to create a confuslon of roles for women and intolerable conflict. Some women attempt to resolve this conflict through manipulation of their body shape, hence the rise of eating disorders.
References 1. Morris D. The Naked Ape, Chs 2 and 3, Grafton Books. 2. Frlsch RE. Menstrual cycles; fatness as a determinant of
minimum weight tor height necessary for their maintenance or onset. Science 1974; 185: 949-51.
Lacey 3. Kaye SA, Folsom AR et al. Associations of body mass and fat distribution with sox hormone concentrations in postmenopausal women. Int 3 Epidemiall991; 20,151 -6. 4. Kenneth, C. The Nude. Penguin Books, London, 1956. 5. Gamer DM, Garflnkul PE, Schwartz D, Thompson M. Cultural expectations of thinness in women. Psycho/ Rep 1980; 47; 483-91 .. 6. Rudofaky 6. The Unfashionable Human Body. New York: Doubleday,1972. 7. Furnham AF, Radley S. Sex differences in the perception of male and female body shapes. Personalityand lndividual Differences 1989;Vol. 1 O(6): 653-62. 8. Freeman HR. Structure and content of gender stereotypes: effects of somatic appearance and trait formation. Psychologyof women Quarterly I 987; 11(1): 59-68. 9. Franzol Sl, Herzog ME. Judging physical attractlvensss: What body aspects do we use? Personality and Social Psychology Bulletin 1987; 13flj: 19-33. 10. Smlth JE, Waldorl VA, Trambath DL. ’Single white male looking for thin very attractive Sex-l?oles 1990; 23(11-12): 675-85. 1 1 . Horvath T. Physical attractiveness: the influence of selected torso parameters. A r c h Sex Behav 1981 : lO(1): 21 -4. 12. Kleinke CL, Staneskl RA. First impression of female breast size. J Soc Psycho/ 1980; 1 1 O(1):123-34. 13. American Psychiatric Aeaaclatlon. Diagnostic and Stafistical Manual oi Mental Disorders, 3rd ed (revised). Washington;D.C.: APA, 1984. 14. Psnnsr LE, Thompson JK, Cooveti DL. Size overestimation among anorexlcs: much ado about very little. J abnormal Psychd 1991; 100: 90-3. 15. Fallon AE, Roan P. Sex differences in perceptions of desirable body shape. J. abnorm Psycho/ 1985; 94: 102-5. 16. Russel G. Bulimia nervosa: an ominous variant of anorexia nervosa. Psycho1 Med 1979; 9: 429-48. 17. Lacey JH, Glbson E. Does laxative abuse control body weight? A comparative study of purging and vomiting bulimics. Human Nutrition: Applied Nutrition 1985; 39A: .__I
36-42. 18, Lacey JH, Coker S, #irtchnell SA. Bulimia: faclors associated with its etiology and maintenanw. Int J &ling Disorders 1986;5: 475-87. 19. Bosklnd-Lodahl M. Cinderella’s stepsisters; a feminist perspective on anorexia nervosa and bulimia Signs. Jourmf of Women in Culture and Sociefy 1976; 2: 342-56. 20 Kramers M, Evans CDH, Dolan B,Hume F, Lecey JH. The changing face of bulimia. Britlsh Review of Bulimia and Anorexia Nenrosa 1991 ; 5: 17-21, 21. Lacey JH. Anorexia nervosa and a bearded female saint. Br Med J i 982; 285: 1816-7. 22. Morton R. Phthysiologia or treatment of consumptions 11864) quoted by Sllss EL, Branch CHH. Anorexia Nervosa: Its History, Psychology and Biology. New York: Paul 6. Hoeber.
23. Gull Sir W. Anorexia rwrvusa (apepsia hysterics, anorexia hysterican). Transactions of the Clinical Society of London 1074; 7: 22-6. 24. Lasegue EC. De I’anorexia hysterique; Archs gen Med 1873; 2 1 : 385. 25. El Satrag ME. Psychiatry in the Northern Sudan: a study in comparative psychiatry. Br J Psychiatry; 1468; 114: 946-8. 26. Okseha A, Kernel M, Sadnk A, Lotalf F, Blshry 2. Psychiatric mcrbidlty among university students in Egypt 8 r J Psychiarfy 1977; 131; 149-54. 27. M6arer M. Comparative study of the prevalence of abnormal sating attitudes among Arab female students of both London and Cairo universities. Psycho/M e d 1986; 16; 621-6. 28. Mumford 08, Whltehause AM. Increased prevalence of bulimia nervosa among Asian schoolgirls. B M J 1988, 297:
718.
ISSN: 0785-3890 (Print) 1365-2060 (Online) Journal homepage: http://www.tandfonline.com/loi/iann20
Sociocultural Aspects of Eating Disorders Frances J. Raphael & J. Hubert Lacey To cite this article: Frances J. Raphael & J. Hubert Lacey (1992) Sociocultural Aspects of Eating Disorders, Annals of Medicine, 24:4, 293-296, DOI: 10.3109/07853899209149957 To link to this article: http://dx.doi.org/10.3109/07853899209149957
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 72
View related articles
Citing articles: 4 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iann20 Download by: [UQ Library]
Date: 25 April 2016, At: 20:06
Sociocultural Aspects of Eating Disorders
Downloaded by [UQ Library] at 20:06 25 April 2016
Frances J. Raphael and J. Hubert Lacey Eating disorders, though recognized for centuries, are increasing in prevalence. The increase in rate is particularly remarkable over the last 30-40 years. The article considers how social function stems from biological function and evolution, and how biological function may hamper social development to the detriment of individuals. Social and cultural influences relevant to this change are examined, especially the changing position of women within society as a whole and the multiplication of conflicting roles which women find themselves balancing. Reference is made to the representation of women in the arts and media. Reference is also made to the role of those external agencies which have hlstorically controlled populations (both men and women), such as religious bodies and governments, but which t o some extent have been rejected. Evidence from in-depth studies of women with eating disorders and from transcultural studies are included to support the authors’ ideas Key words: evolution; media; arts; body image; control of society; women’s roles; transcultural evidence. (Annals of Medicine 24: 293-296,1992)
Biological Factors Adult women are fattier than men. More specifically, the fat is concentrated in specific areas which carry sexual connotations: the breasts, hips, thighs and buttock and, lastly, the stomach. This gives women their characteristic pear shape. Men do not have such fat deposits which tends to emphasize broader shoulders and narrow hips. Both forms identify the individual as mature and are an aspect of the triggering of sexual attraction of a mate (1). The importance of adipose tissue in sexual development can be seen in the body changes which occur at relevant stages in a woman’s lifetime. With the pubertal linear growth spurt there is a proportionately greater increase in fatty tissue which then assumes the adult distribution described above. It has been shown that there is a critical body weight and, more specifically, body fat proportion which must be attained for normal menstrual functioning. Frisch (2) found that 22% of any body weight for height must be fat for menarche to occur. Because girls are less fatty at menarche than when they achieve stable reproductive ability she found that secondary amenorrhoea occurs when the proportion of fat drops to only 17%of the body weight for height, e.g. in anorexia nervosa Pregnancy and lactation increase the fat content of the breasts as well as the glandular From the Department of Mental Health Sciences, St George’s HosDital. Tootina. London.
tissue. At the end of a woman’s reproductive life the breasts lose their fat content. The total body distribution also changes with increased truncal fat (3).In terms of the future of the species, these menopausal changes can be seen as an indication to men that reproduction is no longer possible. In terms of evolution and maintenance of the species, these developments in the specialization of fat distribution may have uses but the connection between adipose tissue and sexuality allows some understanding of why body shape and image have become such powerfully loaded issues and can help us consider how this might produce maladaptive responses in some people.
The Media/Arts It is often asked whether the media and fashion industries determine women’s view of themselves and what is required of them, or whether the opposite mechanism applies. Equally often the question raised is whether men dictate what women look like and the body shape they strive for, or whether women themselves determine this. These questions are inseparable and best considered in terms of the development of society as a whole. The representationof women in the arts and media of Western cultures has certainly changed. Rubens is renowned for his adoration of plump and more muscular
Downloaded by [UQ Library] at 20:06 25 April 2016
294
Raphael
women in the seventeenth century. Compare his works with the elongated slender women of Modigliani (4). Each artist may have different followings but both have been extremely popular in their times. The corsetry of the late nineteenth century emphasized hour-glass figures. In more popular culture, the changes in the characteristics of female film stars and models over the past 50 years is interesting. World War II pin-up Betty Grable, the actresses Marilyn Monroe and Jayne Mansfield in the late 50s and early 60s had considerable fame and popularity based on their shapeliness. Towards the late 60s the fashionable shape changed dramatically, to the advantage of slim women with small breasts such as the fashion models Twiggy and Jean Shrimpton. In the 80s the shape changed again, this time to broad shoulders and noticeable breasts grafted unnaturally and sometimes surgically onto an emaciated frame. That women have reached the position of such an impossible aim which pulls them in opposite directions is interesting in the context of arguments to follow. These anecdotal comments are supported by the work of Garner and Garfinkel et 81. (5). Their examination of data from Playboy centrefolds and Miss America Pageant contestants over a 20-year period indicated a significant trend toward a thinner, more tubular standard in the context of increasing population weight norms. Bearing in mind links between adiposity and sexuality, it is interesting that they also noted a coincident increase in the number of diet-related articles in popular women’s magazines. Later, this article will refer to mechanisms whereby dieting can lead some into the arena of eating disorders. Western attitudes to shape and size have been discussed here. The attitudes in non-Western cultures is often quite different with obesity being admired and therefore encouraged (6).
Body Image Currently, in Western society it appears that women believe themselves to be more attractive to men if they are slender (7-9). Despite changes in the representation of women there is no evidence to support the notion that any particular body shape or size is more appealing to men in general (10) than any other shape, and certainly no evidence that men are selectively drawn to women who are thin (11, 12). Body image has been seen as a crucial aspect of eating disorders for many years and was incorporated in the DSM ill diagnostic criteria for anorexia nervosa (13). Several authors have elaborated this. It is interesting to note that people without eating disorders also misperceive body shape (14). Fallon & Rozin (15) studied a cohort of psychology undergraduates of both sexes. For men, the current weight, ideal weight and weight they thought would be most attractive to women, were almost identical. Women assessed their current weight to be heavier than the weight they thought would be the most attractive to men, which in turn was heavier than the weight they held to be ideal. The men’s stated preference of female weight was significantly greater than the women’s assessment of themselves. The women under-
Lacey cut the men’s view of their most attractive weight In summary, the men were relatively content with their weight while the women placed pressure on themselves to lose weight. It is unclear why women should hit upon this out of the blue. That these subjects were non-eating disordered illustrates that all individuals may be under the same pressures but only a proportion develop eating disorders.
Controlling Agencies Historically, control has been imposed by men either directly, in the interactions between men and women, or indirectly through almost exclusively male institutions such as the Church (or equivalent religious bodies), monarchies and civil governments. From the male perspective, there are several possible unconscious motives for promoting such an ideal. It might be advantageous to men for women to focus on weight and eating. A woman who is underweight or simply preoccupied with food could be seen as weaker, more dependent, less able to dominate and less likely to leave the home, family or relationship. This does not stand alone as an explanation. It is necessary to include the topic of risk. If women are strong, independent and able to dominate, men as a group might feel significantly more vulnerable. It is also possible that body size and shape generate powerful unconscious associations and are relevant for their symbolism. A thin woman might represent a ‘little girl’ figure, someone dependent in a child-like way and biddable. The aspect of dependency reminds us that parents set limits on what their children do. However this ‘little girl’ is in fact a grown woman, and putting these features in a sexual context makes it interesting that the issue of control should appear in relation to an image of women. The alternative, fuller figure suggests a sexually mature fertile woman with hips suitable for childbirth and breasts capable of providing adequate milk. It is likely that neither fantasy exists alone in any individual but that different ones apply at different times. Acting out these fantasies has practical difficulties for a woman. While a man can move between female partners of different shapes the individual woman cannot change her size at a moment’s notice. The conflict for her is clear and the oscillating weight and shape seen in those with eating disorders may be explained as the nearest these woman can get to resolving the problem. Striving for equality has lead to inevitable competition with men and produced conflict over the priority of roles open to women. Women have found it extremely difficult to find equality while maintaining traditional feminine traits and have been forced to adopt more masculine traits instead. This involves suppression or denial of female characteristics. These social changes therefore add to the perceived need for women to control themselves. Many aspects of a persons life are open to control, but some women conclude (unconsciously) that the most controllable aspect which supports their aims of independence and society’s need for them to conlrol or even deny their sexuality is their body-shape and weight.
295
Sociocultural Aspects Attempts at weight loss through dietary restriction begin giving a transient sense of achievement. Denial of conflict is comfortable and therefore the drive to lose weight is reinforced. However, the physiological drives of the body will not tolerate starvation indefinitely leading to binge-eating and the return of conflict. Through this battle a woman moves into the vicious cycle of starvation leading to craving and binge-eating, then to devices aimed at counteracting the effects of food ingested (16). Self-induced vomiting does reduce the amount of food absorbed but laxatives (17), diuretics and appetite suppressants are quite ineffective. As described above these restrictions can physiologically lead back to bingeeating.
Downloaded by [UQ Library] at 20:06 25 April 2016
Demographic Data Some demographic information lends support to the notion that eating disorders arise as a counter-productive solution to intolerable conflict. Lacey et al. (18) found their group of patients with bulimia nervosa unified by a poor relationship with one or other parent, This often stemmed from marital difficulties. There was an interaction with personal emotional problems, focusing particularly on doubts about attractiveness towards men as well as peer group relationships and striving for academic achievement. They suggested that women with such characteristics who also dieted were susceptible to specific life-events triggering bulimia nervosa. The beginning or end of the first major emotional relationship, especially if sexual intercourse first occurred during it, was seen as the most relevant event. Environmental changes, including change of job, moving out from home and losing a parent, were also important. The first major relationship is highly significant for the acceptance and development of a person's sexuality and self-confidence, regardless of their sex. In a woman susceptible as described, any hiccough or rejection at this stage could fuel her beliefs that sexuality is dangerous and to be avoided. Relating rejection to body appearance could clearly lead to manipulation of food, leading into the cycle established above (19). Kramers et al (20) have attempted to examine whether the characteristics of bulimia nervosa have changed alongside the changes in prevalence. They found that they have not. The characteristics of bulimia nervosa in their sample of women appear to be constant.
Historical Evidence There are two ways of looking for further evidence to support or refute these ideas. The first is the evidence put forward to suggest that eating disorders are new conditions. The existence of fasting cults and legends of women who may have had eating disorders have been known for a long time. Lacey (21) writes of the legend of Wilgefortis from the tenth century but more importantly comments on the multiplicity of smaller legends across Europe at that time. Richard Morton (22) described anorexia in 1694 but there is little mention again until the late nineteenth cen-
tury when Gull (23) and Lasegue (24) separately took up the picture. It was not until early this century that bulimia was reported in any form. Reported cases of anorexia took off more significantly in the 1960s.Bulimia nervosa was not formally described and defined until Russell's work in 1979 (16). The time-scale of this relative explosion of eating disorders has tended to parallel the sociocultural changes described above. This pattern would seem to support the ideas in this paper.
Transcultural Evidence Secondly, it is possible to examine the ideas by studying the relative incidence of eating disorders between societies in different stages of development. Differences in body shapes and attitudes towards them between Western and non-Western cultures have been raised. If the ideas here are correct it would be appropriate to expect lower prevalence rates of eating disorders in societies where external controls of populations, particularly women, are in operation. There is not an extensive current literature on this area. El Sarrag (25) and Okasha et al (26) both found anorexia nervosa to be a rarity in Arabic cultures. In a comparison of female Egyptian student groups in London and Cairo, Nasser (27) found that, although both groups had abnormal eating attitudes, there were only cases of bulimia nervosa in the group studied in Britain, i.e. those exposed to Western attitudes lacking the external controls more familiar in Cairo. The second author has seen two cases in his clinical practice of woman who display symptoms of bulimia nervosa only when staying in Britain. The symptoms of both disappeared on returning to their native countries (Peru and Pakistan) where external controls are much more significant.
Case 1 An 18-year-old woman, the eldest of five children was born in Pakistan but emigrated to the U.K. with her strict Muslim family at the age of 2 years. There was childhood sexual abuse by her father during her mother's absence with depression. Her weight. increased to 21 0% MMP weight at this time. Vomiting began at 16 years while living in England with her maternal grandparents and in connection with the eating rituals of Ramadan. Bland English food gave no difficulty. Binge-eating and laxative abuse started 2 years later with a proposal for a traditional arranged marriage. Admission to a specialist unit allowed minor improvement. Dramatic improvement followed her return to Pakistan based on a family decision. There she lives as an unmarried aunt being chaperoned wherever she goes. Her symptoms have settled. There is no binge-eating or laxative abuse.
Case 2 A 20-year-old woman of Peruvian origin was living with her divorced mother and younger sister in London. The mother's own ballet career had been thwarted by severe injury in a road traffic accident. She tended to pursue her
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own ambitions through her daughters. To that end, having bsen brought up in a highly structured and protected environment, chaperoned wherever she went outside the family home, at the age of 13 years she was sent to a London ballet school. Within 2 years, while in the care of a family friend with liberal views and in the context of puberty she developed bulimia nervosa. Inand out-patient treatments were unhelpful except for a few months, However, during visits to Peru when, as an unmarried woman, she was expected to return to the custody of her grandmother, there was no disordered eating. She described life there as restricted but reassuring. Returning to London, the binge-eating would rapidly recur, as indeed did a social and sexual life which would have been utterly unacceptable in Peru. Wlodarczyck-Bisarga’s as yet unpublished work in Poland presents an intermediate picture. Despite the rigid controls on both men and women by the state and Catholicism, bulimia nervosa does exist in Poland. The caution with this statement must be that the sample was of students who may be exposed to more Western, liberaf ideas and influences. These studies are not of rigidly demarcated cultures. That they find women with bulimia nervosa in Egyptian and Polish women may confound the arguments here but may simply represent cultures in transition. A clear culture in transition is the Asian population in Britain. A group of young girls has been studied in England in the town of Bradford, which has a very high proportion of Asians (28). The prevalence of bulimia nervosa amongst the Asian girls was almost as high as that of the white girls. Comparing this with the Egyptian and Polish studies, it would seem that the effects of removing external controls are even greater when the population is suddenly immersed in a society with those new vaiues than when a society gradually acquires new values from outside. In summary, although our ideas are sometimes speculative they do not exclude the possibility that direct genetic family and social factars might influence individuals in a personal sense as well as acting on whole populations. The arguments of this attide hinge on the principle that interactional and interpersonal aspects of any society can only have developed and continue to develop from a fundamental biofogical basis which is subject to evolution. For millennia, man has been ruled by external entities for the good of the whole. The relatively recent rejection of such external controls has produced internal drives to maintain society in the broadest possible sense. In a developing society the particular forces acting on women concerning reproductivity act in such a way as to create a confuslon of roles for women and intolerable conflict. Some women attempt to resolve this conflict through manipulation of their body shape, hence the rise of eating disorders.
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