EATING DISORDERS: History, Biology and Cultural Factors (1997)

Y. Núñez, Ph.D.

INTRODUCTION

The first documented account of anorexia nervosa in the medical field was in 1542 when a

physician, named Bucoldianus, described the case of a ten year old girl who abstained from food for

three years. In 1611, the physician, Fabricius, published an account of "a thirteen year old girl said to

have lived without food or drink for three years" (Strober, 1986; p. 232). These accounts have since

been denounced for lack of scientific credibility. In 1689, an English physician, Richard Morton,

provided the first comprehensive description of anorexia nervosa.'. He described two cases of a young

woman and a young man that displayed symptoms of what is now commonly recognized as anorexia

nervosa (Gordon, 1990; Bhanji & Mattingly, 1988). Morton described the disorder as a "wasting

disease of nervous origins". He emphasized the patients' lack of appetite, weight loss, hyperactivity and

resistance to treatment. Prior to the 17th century, documentation exists of fasting rituals among

religious medieval women that resembled the symptoms of anorexia nervosa but that were rationalized

as religious fervency. Despite the documentation of anorexia nervosa as a medical problem as far back

as the 16th century, anorexia nervosa was a rare disorder that was only known to the medical

community, and even then, only to the few physicians that happened to come across it. In the latter half

of the 19th century, anorexia nervosa became more known to the medical community as a result of

papers published by Sir William Gull in London and a prominent neurologist, Charles Lasegue in

Paris. Both physicians described "a pattern of self-starvation" that is now recognized as anorexia

nervosa, but Lasegue explained the symptoms as a variation of hysteria, which was very common in

women in the 19th century and called it 'anorexia hysterique'. Gull, on the other hand, coined the term

'anorexia nervosa' and explained it as a distinct disorder characterized by excessive hyperactivity and
an emaciated state. He agreed with Morton as to the nervous origin of the disorder by explaining it as

resulting from "a morbid mental state".

Following Gull and Lasegue's pioneering work, numerous papers on anorexia nervosa were

written but the disorder continued to be quite uncommon in the population and an enigma to the

medical field. Many etiologic explanations for the disorder were offered but few were empirically

tested. Anorexia nervosa was falsely classified as an endocrine disease during the beginning of the 20th

century and, for various decades, it was treated with thyroid extracts (Gordon,. 1990). In the middle of

the twentieth century, psychoanalytic theory explained anorexia nervosa as a result of the patients' fear of

oral impregnation or as a repression of promiscuous impulses. In 1973, Hilde Bruch made an

extraordinary breakthrough with the publication of her book titled Eating Disorders. Bruch explained

anorexia nervosa as a developmental disorder that revolved around issues of body image and personality

development. Bruch asserted that "the core psychopathology was invariably present in a specific

constellation of ego and personality deficits, consisting of inaccurate perception and cognitive labeling of

visceral and affective states, faulty perception of body boundaries, and a deeply rooted sense of

ineffectiveness and lack of autonomy" (Quoted in Strober, 1986; p. 236). Since Bruch's work, the

research and literature on anorexia nervosa has grown exponentially, as have the number of cases in the

population. With this development, bulimia nervosa and subtypes of anorexia nervosa, that were

previously clustered together in the same category, have now come to be understood and studied in their

own right. Bulimia Nervosa was first described and named as such by Russell (1979), who regarded the

disorder as a variant of anorexia nervosa. Despite the subsequent shift toward categorizing anorexia

nervosa and bulimia nervosa separately, the similarities between these disorders make their interrelation

undeniable.

Since the first documented cases of anorexia nervosa, eating disorders have become a sort of

epidemic in the 20th century, particularly in the 1990's. Shifting from obscurity, these disorders are
presently not only known to the larger population, but are reinforced by the popular culture through the

glamorization and idealization of thinness.

The present work aims to provide a general review of the issues surrounding eating disorders

beginning with a description of the categorization and diagnostic criteria. The numerous correlations

found between eating disorders and other pathologies, including depression and personality disorders,

and any causal relationships that may exist between them will be discussed. Moreover, the etiology of

eating disorders will be presented from various perspectives, including psychodynamic, cognitive-

behavioral and biological emphasis will be placed on the disorders' existence in a particular cultural

context. Within this cultural context, the relationship between the emergence (or discovery) of eating

disorders and such cultural factors as politics, the media an religion will be discussed. Furthermore, the

paper will discuss the presence of eating disorders in populations such as males and ethnic minority

groups and explain the emergence of these exceptions in a cultural contexts. Finally, a review will be

presented of the different treatments currently used for eating disorders and their effectiveness.

CATEGORIZATION AND DIAGNOSIS

Since their discovery, eating disorders have erroneously been categorized as endocrine

disorders, as pituitary disorders or as hysteria (Gordon, 1990). More recently, the question of whether

eating disorders may be manifestations of depression or of personality disorders has been explored.

Herzog (1984) found that in a sample of 82 female outpatients with anorexia or bulimia nervosa,

55.6% of the anorexic patients and 23.6% of the bulimic patients met the Research Diagnostic Criteria

for major depressive disorder. Grubb (1993) and Swift et al. (1986) also supported the conclusion that

there is a strong correlation between eating disorders and depression. Swift et al. found that

antidepressant medication, such as phenelzine, tranylcypromine and imipramin produced dramatic

improvements in bulimic patients but noted that "response to medication alone is not an adequate basis
for inclusion in one or another" (p. 296). These findings proved the high correlation between

depression and eating disorders but the researchers cautioned against concluding that eating disorders

were a manifestation of depression. They suggested that further research be conducted to differentiate

between state and trait depressive symptoms. Swift et al. proposed "an interactive, multi-determined

understanding [of the relationship between eating disorders and depression] as the most appropriate

model (p. 290).

Eating disorders have also been linked to personality disorders or specific personality traits that

predispose women to becoming anorexic or bulimic. Vitousek & Manke (1994) found that eating

disordered patients scored high on the neuroticism and introversion scales of the Eysenck Personality

Inventory. Furthermore, data from the MMPI revealed deep personality disturbance in this group.

Anorexics yielded profiles suggesting depression, anxiety and social isolation while bulimics yielded

profiles suggesting "an expressive-dramatic characterological disturbance" (p. 140) including

borderline and obsessive-compulsive tendencies. Additionally, Garfinkel et al. (1980) found a high

frequency of impulsive and reckless behaviors amongst bulimics including drug abuse, stealing, self-

mutilation, suicide attempts and sexual diagnostic class promiscuity. Garfinkel concluded that bulimic

women tended to have "personality characteristics and ego deficits" (p. 1039) that made them vulnerable

to bulimia. Finally, Heilbrun & Flodin (1989) proposed that stress, generated from certain predisposing,

maladaptive personality characteristics and from other developmental demands, played a functional role

in the development of eating disorders. Evidently, the expression of eating disorders is affected by

personality variables, but it is unlikely that these variables alone are responsible for the development of

these disorders or that the eating disorders are,a form of personality pathology.

The issue of categorization is critical in the understanding of the understanding of eating

disorders in particular. of research has been devoted to establishing better categorization of eating

disorders. As discussed by Vitousek and Manke (1994), the categorization of eating disorders is made

difficult by the finding that "movement across categories is quite common" and that "the pool of subjects
fitting a particular subgroup will consist of some who have reached their terminal eating disorder

classification and some who are merely passing through a symptom phase on their way to a different

category"(p. 138). Vitousek and Manke recognize the differences that exist between bulimic and

anorexic patients, particularly in terms of their personality variables, but they caution against viewing

bulimia and anorexia as distinct categories rather than as disorders that exists on a continuum. In fact, the

term 'bulimia' has acquired two meanings. Originally, the term was used to refer to a symptom

characterized by the consumption of large amounts of food in a short period of time. Bulimia was

considered to be a symptom experienced by some anorexic patients at their most chronic phase.

Szmukler et al. (1986) found that bulimic symptoms were a poor prognostic sign in anorexia nervosa.

These findings suggested that bulimia may be "an end stage of chronic anorexia nervosa rather than a

distinct subcategory" (Garfinkel et al., 1980; p.1037). Garfinkel et al. (1980) later suggested that bulimia

may be a distinct subgroup of anorexia nervosa rather than a sign of aggravation. More recently, "bulimia

has been employed to describe a syndrome, of which bingeing is only one component" (Bhanji &

Mattingly, 1988; p. 127). Contemporary findings supporting the clinical differentiation of anorexia

nervosa and bulimia nervosa have resulted in the classification of bulimia nervosa and anorexia nervosa

as two distinct categories within the eating disorders rather than as subgroups of one another.

Now that a basic summary of the issues affecting the categorization of eating disorders illness at

large and has been presented, an explanation of the diagnostic features of each category follows. The

diagnostic criteria for anorexia nervosa provided by the American Psychiatric Association in the newest

revision of the DSM (the DSM-I) includes a "refusal to maintain body weight at or above a minimally

normal body weight for age and height" (p. 544), an intense fear of gaining weight, amenorrhea, and a

disturbed perception of body image or the way in which body weight is experienced. Symptoms that are

also very common in women suffering from anorexia nervosa include a heightened emphasis on body

weight as a criteria for self-evaluation and a denial of the seriousness of their condition. Anorexia is

divided into two subtypes including the restricting type and the binge-eating/purging type.
 The latter subtype of anorexia nervosa involves symptoms that closely resemble the symptoms

associated with bulimia in the DSM-IV criteria for Bulimia Nervosa, which includes "recurrent episodes

of binge eating" and "recurrent inappropriate compensatory behavior in order to prevent weight gain"

(e.g. self-induced vomiting, use of laxatives and diuretics, excessive exercise, etc.)(p. 549). These

binge/purge cycles must occur at least twice a week for a period of three months and must be

accompanied by an excessive emphasis on body weight and shape in order to meet the criteria for

bulimia. Bulimia Nervosa is also divided into two subtypes including the purging type and the

nonpurging type.

Binge-Eating Disorder, a relatively "new" eating disorder, has been included under the "Criteria

Sets and Axes for Further Study" section of the DSM-IV, suggesting new findings and forthcoming

discoveries associated with eating disorders and their categorization.

PREVALENCE

According to the DSM-IV, the onset of anorexia and bulimia occurs during adolescence and early

adulthood, with a mean age of onset at 17 years for anorexia nervosa. The prevalence of anorexia has

been found to range from 0.5 to 1.0 percent while bulimia has been found to range from 1.0 to 3.0

percent, suggesting that there is a higher prevalence of bulimia nervosa in the population. Furthermore,

approximately 90 percent of individuals suffering from eating disorders are females, suggesting that

particular gender variables may affect the development of these disorders.

It is stated in the DSM-IV that eating disorders are "most common in the United States, Canada,

Europe, Australia, Japan, New Zealand and South Africa" (p. 542) and that their occurrence "appears to

be far more prevalent in industrialized societies in which there is an abundance of food and in which,

especially for females, being considered attractive is linked to being thin" (p. 543). These findings

implicate culture in the development and/or expression of eating disorders.

ETIOLOGY

Due to the increased number of cases presenting with anorexia or bulimia nervosa, much research

has been focused on understanding the etiologic nature of eating disorders. A description of the origin of

eating disorders as it is explained by different theoretical approaches follows.

The psychodynamic approach views eating disorders as an internal character dysfunction in the

patient. Despite the fact that medication has been proven to work in alleviating bulimic symptoms and

that research has shown that certain family dysfunction tends to affect the development of eating

disorders, Schwartz (1987) stated that "for the areas of personality dysfunction from which the eating

disorder[s] arise, however,"(p. 59) these factors are of no particular importance. Schwartz, in his writing

on bulimia nervosa, points out that despite the influence of the family in the development of the disorder,

"by mid-adolescence, however, external influences, transformed by inner fantasy, have already become

internalized and exist independent of the original outside influences" (p. 60). Schwartz described three

personality patterns that are often found among bulimic patients. These include a strong disdain for

femininity, an idealization of masculinity and resulting sadomasochistic sexual fantasies. Schwartz

suggested that eating disorder symptoms are an expression of unconscious fantasies that are laden with

conflicted affects and wishes. Some of the common underlying fantasies among bulimics and their

transformation into bulimic symptoms include the linkage of erotic fantasy and arousal with a forbidden

partner that lead to feelings of guilt and anxiety. In other words - sadomasochistic fantasies. These

negative emotions create a shift in the patient's attention to a "safer" object of desire and obsession,

namely food. These patients suffer from such an intense degree of conflict surrounding their sexual

fantasy because of their internalized rejection of femininity. This disdain of femininity is believed to be a

result of "the passage of a defective feminine ego ideal from mother to daughter (p. 66). By focusing on

food, the bulimic patient's sadomasochistic sexual fantasies are played out in the form of bingeing and

purging. She engages in secretive and unrestricted overeating that provides her with pleasure and often

culminates in a stupor. This behavior leads to feelings of guilt, anxiety and shame and precipitate
compensatory behavior such as self-induced vomiting. Other commonly encountered unconscious

fantasies of bulimic patients involve "displaced masturbation, fellation, oral castration, oral

impregnation and biting rage" (p. 62).

Boskind-Lodahl (1976) contradicted the standard psychoanalytic theory of eating disorders.

She argued that "women have never questioned their assumptions that wifehood, motherhood, and

intimacy with men are the fundamental components of femininity" (p. 346). She states that women

have actually demonstrated "a disproportionate concern with pleasing others, particularly men" and

that " they have devoted their lives to fulfilling the feminine role rather than the individual person.

None has developed a basic sense of personal power or of self worth" (p. 347) therefore, "fear of

rejection then became a crucial motivating force in their behavior" (p. 349).

Another psychodynamic explanation for eating disorders suggests that "anorexia and bulimia

nervosa implicate object-relations disturbances and problems around separationindividuation,

specifically around the stage of transitional object use. The result is believed to be a narcissistic

fixation on one's own body" (Steiger, 1989; p. 229). Steiger suggests that style of parenting and

disturbance in family functioning affect the patient's problems. Consequently, anorexic patients, who

tend to experience overprotective and overinvolved parenting, organize their personality and defenses

around avoiding the effects of outside forces and tend to assume an avoidant stance. This attitude,

along with their fixation on body image and the thinness ideal, result in the avoidance of food. Bulimic

patients, on the other hand, tend to experience parental neglect and have parents that project their needs

for perfection and their own insecurities and dissatisfaction upon the patient, thus requiring them to

separate too early and to develop bulimic symptoms to compensate for feelings of emptiness and for

self-regulation problems. Steiger suggested that bulimics and anorexics rely on defenses for the

"discharge of affects through maladaptive action, and on reality-distorting operations like projection

and splitting" (p. 230).

 Standard psychodynamic theory focuses on early childhood as the source of later pathology and

attributes the disorder to symptom formation and the use of maladaptive defense mechanisms. Eating

disordered patients, particularly anorexics, tend to be resistant to treatment and thus, any form of

therapy must tackle the patient's resistance.

The cognitive-behavioral approach describes eating disorders as resulting from abnormal

attitudes about body shape and weight and from a distorted perception of the effects of food upon the

body. Patients tend to believe that their shape and weight are of extreme importance to their identity

and well-being and thus, they become obsessed with keeping their weight under control (Wilson &

Fairburn, 1993). These patients believe that they will gain weight if they eat small amounts of food,

therefore, they engage in behaviors, such as more restricted fasting (in the case of anorexia) and

purging (in the case of bulimia) that relieve the anxiety associated with the prospects of weight gain.

There are numerous explanations as to why these patients develop maladaptive believes and behaviors

to begin with. As discussed previously, Vitousek & Manke (1994) found that certain dispositional

traits make individuals vulnerable to eating disorders. Secondly, the value that culture places on

thinness and its association with attractiveness and individual worth greatly influence the cognitive

beliefs and behaviors of young women. The role of cultural influences in the development of

maladaptive beliefs and behaviors associated with eating disorders will be discussed further later on. A

third factor influencing the development of beliefs about body weight, body shape and food is the

family system - particularly the mother-daughter interaction. Pike & Rodin (1991) found that "mothers

whose daughters were eating disordered were themselves more eating disordered and differed in their

dieting history compared with mothers of the girls who were not eating disordered" (p. 198). These

findings suggest that mothers may pass on to their daughters certain attitudes and beliefs about body

weight and appearance that, in turn, shape the daughters cognition about their own bodies. In part, the

daughters may be modeling the mothers' disordered eating. Pike & Rodin also found that mothers of

eating disordered girls may affect the girls' behavior by exerting direct pressure on their daughters to
lose weight. They found that "mothers of girls with disordered eating thought their daughters should

lose more weight than mothers of girls who were not eating disordered. They also thought that their

daughters were less attractive than the girls judged themselves" (p. 198).

Pike & Rodin found that both eating disordered patients and their mothers "wished their

families were more cohesive than they currently experience" (p. 202) despite the fact that their families

were not found to be less cohesive than those of non- eating disordered girls. Disordered eating may be

used to compensate for feelings of emptiness and loneliness that the patients experience in family life.

The bulimic patient may binge in order to feel fulfilled and comforted and may subsequently purge to

rid of the feelings of guilt and anxiety associated with overeating and possible weight gain. The

anorexic patient may fast in order to gain some control of her surroundings. Furthermore, both the

anorexic and the bulimic patients may feel rewarded for their maladaptive behavior when their disorder

becomes the focus of family life.

While allowing for the influence of many external factors and inner conflicts in the expression

of eating disorders, the biological approach has presented evidence to support an organic explanation

of eating disorders. Studies with rats have shown that "bilateral lesions of the lateral hypothalamus

could result in life-threatening avoidance of food" (Bhanji & Mattingly, 1988; p. 9). Multiple cases of

persons diagnosed with eating disorders and having hypothalamic damage are cited by Bhanji &

Mattingly. For example, at autopsy, a 25 year old nurse that had suffered from anorexia nervosa was

found by Lewin, Mattingly & Millis (1972) to have a small hypothalamic astrocytoma. Additionally,

Rhohmer, Ebtinger and Bronstern (1975), described the case of a 15 year old girl whose neurological

examination was normal upon admission but who, five months later, showed evidence of raised

intracranial pressure.

This later case raises the question of causality. Undoubtedly, extreme emaciation produces an

array of physical deregulation and disorders that include: 1) cardiovascular abnormalities such as

crocyanosis, bradycardia, hypotension, decreased heart size and possible cardiac arrhythmia (Bhanji &
Mattingly, 1988); 2) neurological manifestations such as nonspecific EEG changes and dilation of the

third and lateral ventricles (Datlof et al., 1986); 3) damage to the alimentary tract including enlarged

salivary glands, constipation and pancreatic disorders; and 4) endocrine disorders including

amenorrhea, which often precedes any significant weight loss, decreased levels of plasma testosterone

in males, hypothalamic dysfunction involving an overactivity of dopamine, abnormal growth hormone

secretion (Bhanji & Mattingly, 1988) and low concentrations of the serotonin metabolite, 5-HIAA

(Kaye et al., 1984), but it is unclear whether these deregulations existed prior to weight or whether they

were caused by the onset of eating disorder symptoms.

Whether physiological complications and irregularities precipitate the development of eating

disorders or are, in fact, a result of starvation is questionable. Vitousek & Manke (1994) described

various studies that explored the effects of starvation on personality variables and suggested that

despite significant differences found between eating disordered patients and controls, most of the

variation in personality characteristics could be attributable to starvation. Similarly, physiological

problems may be associated with starvation. Much research continues to be produced in this area. In

support of the dopamine theory of eating disorders, Biedermann et al. (1984) found that a number of

patients suffering from anorexia nervosa had a significantly lower mean platelet MAO activity than

matched normal control subjects. Unfortunately, these subjects also met the Research Diagnostic

Criteria for a major depressive disorders. Subjects diagnosed with anorexia but who did not meet the

criteria for major depression did not differ from controls, suggesting that the lowered platelet MAO

activity was associated with depression and not eating disorders. Other studies included the study by

Pike and Rodin (1991) previously discussed, that showed that mothers of eating disordered girls tended

to be more eating disordered themselves. These findings can be interpreted as a model of social

learning, where girls learn maladaptive beliefs and behaviors from their mothers, or it can be

interpreted as a genetic model where both mothers and daughters are genetically predisposed to
acquiring eating disorders. Unfortunately, it is practically impossible to conduct the ideal study that

would assess the patient's physical state prior to weight loss in order to establish causality.

Explaining eating disorders as a function of one particular factor or through one specific

approach, blurs the true nature of the disorders. Eating disorders can be more clearly explained and

treated by an integrative method that takes into account the findings and theories of psychodynamic,

cognitive-behavioral and biological approaches. Most importantly, this explanation must not neglect

the reality that these findings and theories exist in a cultural context that affects both the development

and expression of eating disorders.

Research has shown that despite the fact that psychoanalysis, cognitive-behavioral therapy and

medication are equally effective in the treatment of bulimia nervosa, the treatment times required for

them to be effective varies (Wilson & Fairburn, 1993). For example, cognitive-behavioral therapy was

found produce improvement in areas such as reduced bingeing and purging earlier in treatment than

did interpersonal psychotherapy. Both treatments "produced marked and lasting reductions in binge

eating and purging" (p. 264) in the long run. Wilson & Fairburn also discussed three studies - Mitchell

et al. (1990), Agras et al. (1992) and Leitenberg (1991) - that compared the effectiveness of medication

and of cognitivebehavioral therapy in bulimia nervosa. They concluded that medication alone is more

effective than no treatment but that medication and cognitive-behavioral therapy combined provided

the best results. Anorexic patients, on the other hand, are unresponsive to medication and unreceptive

to cognitive-behavioral therapy. Wilson & Fairburn paraphrased Vitousek's (1991) hypothesis that

cognitive-behavioral therapy was ineffective with anorexic patients because "patients with this disorder

are far more likely than those with bulimia nervosa to resist attempts to change their eating behavior

and weight" (p. 262). Anorexic patients are very opposed to intervention in general and, therefore, an

approach that deals with their defenses (such as psychoanalysis) tends to be more effective. Another

consideration in evaluating treatment effectiveness is the fact that certain patients, regardless of

whether they are anorexic or bulimic, tend to be more receptive to a particular type of intervention,
therefore, the form of intervention should be chosen on an individual basis. An integrative approach

would undoubtedly provide the patient with the best of all treatments.

CULTURAL FACTORS

The shift that has taken place in society from communities of primary relationships, where

"appearance is only one of the many dimensions that define people" (Pipher, 1994; p. 183), to cities of

secondary relationships, where appearance is "the only dimension available for the rapid assessment of

others" (p. 183), has made appearance an incredibly important criteria in defining value.

Despite the prevalence of anorexia nervosa ranging from 0.5 to 1.0 percent and that of bulimia

nervosa ranging from 1.0 to 3.0 percent, "milder subsyndromal variants of anorexia nervosa may be

present in some 5 to 10 percent of this age group" (Strober, 1986; p. 241) and milder forms of bulimia

may be present in as many as 15 percent of college-age women (Wooley & Kearney-Cooke, 1986). In

fact, Pike & Rodin (1991) stated that "rather than being a discrete group with unique concerns, women

who develop eating disorders are thought to be those who fall at the extreme end of the continuum of

eating and weight concerns" (p. 198). Siever (1994) stated that "although there are undeniably many

important individual psychological factors in the development of eating disorders, these occur in a

sociocultural context that places inflated value on youth and beauty and encourages the obsession with

dieting and weight loss that is the hallmark of anorexia and bulimia" (p. 259).

Gordon (1990) explored the sociocultural factors associated with anorexia and bulimia and

concluded that eating disorders may be viewed as 'ethnic disorders' in that they are 'socially patterned'.

Gordon presented a host of sociocultural factors that provide the framework for the development of

eating disorders. Primarily, these factors included a changing female role within society, where women

struggle to develop an identity while attempting to maintain a balance between new ideals and

traditional expectations; and a preoccupation with appearance and body image that is magnified by
modern technology and consumerism. He claims that anorexia nervosa "expresses symptomatically the

contractions of female identity at the present" (p. 11).

The sexual revolution and the feminist movement of the 1960's signified a changed in the role

of women in society. Women were encouraged to enter the work force and to procure power within the

public sphere. Prior to this movement, women that worked and participated in the public sphere did not

attempt to gain power. Their roles were predominantly in lowincome jobs, such as teachers, nurses and

secretaries, that required qualities usually attributed to females, such as nurturance and passivity. After

the feminist movement of the 1960's, in order to advance and procure power in the public sphere,

women were expected to simulate the traditional male role by acquiring qualities such as

competitiveness and independence and by ridding themselves of all signs of femininity and sexuality.

Despite this shift in female gender role, women continue to be expected to take care of the domestic

sphere as mothers and wives, and also continue to be objectified for male pleasure. These expectations

create contradictions and demands that have left modern women struggling to achieve the

"superwoman" role that encompasses the businesswoman, the homemaker and the sexual diva. It is no

wonder then, that modern adolescent girls are perplexed and uncertain about their futures as women.

Many adolescents with anorexia nervosa may develop the disorder as a means of avoiding the

impending development of their bodies from an androgynous, boyish shape to a sexualized, feminine

shape. These girls are using fasting as a passive mean of avoiding the much feared public sphere and

sexualized role. These girls believe that as long as they remain 'little girls', everything will be okay.

Bulimic girls, on the other, tend to be more sexual than anorexics, often to the point of promiscuity.

These girls fear not so much the multiple roles encompassed within the superwoman, but their own

inability to regulate, control and balance their impulses. They may fear that they will not be able to

practice the self control necessary to participate within the public sphere nor be able to balance the

multiple roles that they are expected to take on. By engaging in bulimic behavior in a secretive fashion,
these girls can feel free to lose control by bingeing and then regain it through purging without

compromising their possibilities of participating in the public sphere.

Wooley and Kearney-Cooke (1986) noted that, while "anorexia nervosa represents severe

problems surrounding the passage into adolescence, bulimia reflects problems in passage out of

adolescence and into independent adulthood" (p. 478). The authors state that "all young women [today]

arrive at the threshold of maturity, to some degree, to reject the ways of their mothers and accept those

of their fathers" (p. 479) in order to emulate the traditionally male values of autonomy, achievement

and self-discipline that will permit them to fulfill the demands of the 'superwoman' role, including the

businesswoman, in the public sphere. Bulimic women have a problem integrating these new values

with the old values, and this becomes an area of unresolved conflict.

Historical examples of women's use of fasting as a means to enter or avoid the public sphere

are provided by Bynum (1987). Bynum described the fasting rituals of religious medieval women.

Despite the fact that medieval women could not achieve high rank positions within the church,

"women's piety took on certain distinctive characteristics that powerful males, both secular and

clerical, noted, sometimes with awe and sometimes with suspicion" (p. 13). The number of women

saints increased during this era and, in fact, a women's movement within Christianity can be clearly

identified. Many of these women were sanctified because of their apparently miraculous flight from

physicality. They refused food and accepted only the Eucharist as their meal while they spent their

days serving others. Religious medieval women went far beyond conventional religious practices of

the time, which were circumscribed by an ethos of moderation. Their self-starvation, bodily suffering

and nurturing behavior served to provide women a certain spiritual autonomy, authority in the Church

and a sense of moral and spiritual perfection. Additionally, self-starvation reduced these womeri s

"bodies to an asexual and non-productive state" (Gordon, 1990; p. 120) that made them unsuitable for

marriage and relieved them from undertaking the traditional female role. Bynum suggested that "to

religious women, food was a way of controlling as well as renouncing both self and environment" (p.
5). In this same fashion, modern women suffering from eating disorders attempt to renounce their

traditional female role by maintaining an androgynous, asexual, non-productive body that

approximates that of the male body and thus, may earn them the privileges awarded to males. Pipher

(1994) discussed a study by psychologist LK. Broverman that showed that, "while people describe

healthy men and healthy adults as having the same qualities, they describe healthy women as having

quite different qualities than healthy adults" (p. 39). She concludes with derision that anorexia and

bulimic women may fear developing into women because they may have discovered that "it is

impossible to be both feminine and adult" (p. 39).

Gordon provides other examples of the use of fasting for social and political reasons. He

discussed the common Hindu practice where a "man who was owed a debt would entrench

himself in front of the tent of the debtor and fast until the debt was repaid" (p 121). Additionally,

hunger strikes have traditionally been undertaken by oppressed groups as a form of protest and in the

hopes of extracting concessions from those in power. In the 19th century, the phenomenon of the

'hunger artist' occurred. These starving artists gained a great deal of notoriety in Europe and the United

States during their time despite the fact that their behavior was devoid of any religious or moral

reasoning. Their capacity for self-control was fascinating in a time when there existed an "increasing

unease with the problem of self-control in a society in which greed, accumulation, and consumption

were already running rampant" (p. 122).

Despite the fact that many historical accounts depict the fasting behavior of anorexia nervosa,

bulimia nervosa is not as commonly traced back. Gordon presents Gerald Russell's argument that the

increased number of cases presenting with bulimia nervosa are examples of the malleability of a

disease under the influence of historical factors or altered cultural conditions such as the "increasing

availability of low-cost, calorie-rich foods, [the] tendencies towards desocialization and fragmentation

in contemporary eating patterns, and the general emergence of a cultural 'style' that includes greater

impulsivity and addictive patterns of behavior" (p. 23).

 In the 1990's, there are no longer the starving artists to fascinate society with their capacity for

self-control but there are supermodels to take their place. These women appear on television, movies,

magazines and billboards as the icons of feminine beauty and perfection despite the fact that their body

weight and size are usually drastically below normal for their height and that their faces and bodies are

airbrushed and computer-edited to perfection. These women, as we see them in the media, are in fact

not real - they are chemically and technologically improved. Small wonder, then, that women are

having such difficulty shaping themselves after these supermodels.

The overabundance of food and the cut-throat corporate competition to sell it, creates a

contradiction in the messages sent by the media. Food is presented to the public as an irresistible

luxury that must not be denied while, simultaneously, thin models are eating and offering these foods

while promising that the viewer, too, can plunge into the pleasures of eating and not suffer the

consequences of fat. This mentality is quite similar to that of the bulimic, who finds pleasure in

bingeing and then performs behaviors to avoid the repercussions of indulgence (i.e. fat). Anorexics, on

the other hand, appear to take to the extreme the frenzied trend toward dieting and exercise. This trend

resulted from and reinforced a feeling of anxiety and food aversion in the general population,

particularly in females, who have always been held to higher standards of physical attractiveness.

Anorexic women are often perceived with awe and admiration at their ability to do what other women

feel and are told they should do - avoid the many temptations of food and reduce their bodies to a

prepubertal size. On the other hand, the sight of anorexic girls' bodies are viewed with disgust and

confusion because, in them, the pathological nature of our cultural ideal of and obsession with thinness

is clearly evident.

More recently, evidence of the emergence of eating disorders in males and ethnic minority

groups have surfaced. This emergence supports the postulation that eating disorders are 'ethnic

disorders' whose expression is transformed by cultural changes. The cultural preoccupation with
thinness, and its application to measure attractiveness and individual worth, are permeating every

group within industrialized societies and, therefore, men and ethnic minorities are no longer immune.

A discussion follows of the research associated with eating disorders in males and ethnic minority

groups and what these findings reflect about cultural changes.

Ziesat & Ferguson (1984) described three cases of adult-onset primary anorexia nervosa in

males. They presented differences and similarities between male and female anorexics and state that,

while both sexes "appear to share similar underlying sexual conflicts" (p. 681) and both engage in strict

dieting and excessive exercise, males tend to "display a quasi-delusional belief that their body weight

is just right [as opposed to] too thin' (quoted in Ziezat & Ferguson, 1984; p. 681) and they tend to

develop the disorder after adolescence. Males are also less likely to seek medical help for what they

perceive as a woman's disorder and therefore, they have a poorer prognosis. Ziesat & Ferguson

postulated that the sexual conflicts experienced by eating disordered males are rooted in issues of latent

homosexuality and gender identity problems. They found that in all three cases that they studied, the

men had problems with their own sexuality. One patient "checked [the following] potentially revealing

critical item of the MMPI, 'I am very strongly attracted by members of my own sex"' as true. Herzog et

al. (1984) supported the conclusion that the onset of the disorders in males occurs in late or post-

adolescence. He also concluded that eating disordered males reported experiencing significantly more

sexual isolation, sexual inactivity, and conflicted homosexuality.

Yager et al. (1988) suggested that homosexuality predisposes males to eating disorders. They

found that, in comparison to controls, the male homosexual students that they studied "were

significantly more likely to report a present or past problem with binge eating, use of diuretics, felling

terrified of being fat, and feeling fat despite others' perceptions" (p. 496). The authors concluded that

homosexuality may predispose males to eating disorders because of "the cultural shapings of self-

identifications that for at least some homosexual males tend toward the effeminate from an early age"

(p. 497). Although Yager et al.'s findings are elucidating, their conclusion is simplistic and
controversial. They attribute male homosexual's susceptibility to eating disorders to their 'effeminate'

nature, while ignoring that the majority of male homosexuals are quite 'masculine' and that many male

heterosexuals can be 'effeminate'. Furthermore, they fail to define their criteria for 'effeminate'

behavior other than adhering to standards set in previous studies that included subjects' reports of

"preference for such activities as cooking, sewing, and other atypical traditionally defined gender role

behaviors" (p. 495) and subjects occupations including jobs that are traditionally held by women, such

as secretary and nurse. Cantrell 8i Ellis (1991) challenged theories that "view eating dysfunction as

involving only conventional stereotypic feminine identification" (p. 55). They found data that suggests

that "gender/gender role/eating pattern relationships differ in men and women" (p. 55), therefore,

person's measures on the Bern Sex Role Inventory showed that a feminine role identity in men did not

mean that they held attitudes about weight that made them particularly vulnerable to eating disorders.

Siever's (1994) findings supported those of Yager et al. He found that gay men "are [more]

dissatisfied with their bodies and [are more] vulnerable to eating disorders" (p. 252). He specified that

this is true for both heterosexual women and gay men when compared to heterosexual men and

lesbians. Rather than speculating that gay men are vulnerable to eating disorders because of an

'effeminate' nature, Siever concluded that gay men and heterosexual women have a "shared emphasis

on physical attractiveness and thinness that is based on a desire to attract and please men" (p. 252).

Siever showed that, while women look for attributes such as personality and intelligence in prospective

partners, men tend to focus on physical attractiveness when judging prospective partners. Such sexual

objectification of heterosexual women and gay men leads to a high degree of body dissatisfaction. Gay

men, then, become overly concerned about their bodies because, like heterosexual women, their

physical attractiveness will dictate how they are perceived by prospective male partners. In further

support of this theory, Siever found that lesbians generally reported a lower frequency of body

dissatisfaction and attitudes associated with eating disorders than did heterosexual women and gay
men. Despite their gender, this group of women was not as vulnerable to developing eating disorders

because their prospective sexual partners would place less emphasis on physical attractiveness.

Siever warns that caution should be exercised in interpreting the findings of his study because

of the fallibility of self-reports. He points out that heterosexual men may have scored lower because of

their "tendency to downplay negative feelings or reluctance to admit to dysfunctional attitudes" (p.

258). Lesbians, on the other hand, may have been reluctant to admit to maladaptive attitudes and

behaviors because it would be incongruent with their feminist beliefs and political agenda. Even taking

these factors into account, the differences amongst these groups in attitudes and behaviors that

propagate eating disorders are undeniably significant.

Although the pressure to be physically attractive is stronger for women, the pressure on men

has been slowly increasing, therefore, it is no wonder that men are becoming more preoccupied with

their own bodies. Gay men, in particular, experience this pressure from the gay subculture that has

developed in America. This subculture, composed of only men, places a great deal of emphasis on

physical attractiveness measured in terms of weight and body shape. The lesbian subculture, on the

other hand, has rejected the patriarchal standards of beauty and women attempt to actively avoid

focusing on the superficial.

While encompassing the thinness ideals of the dominant patriarchal society creates an

obsession with physical appearance in the gay subculture and rejecting those ideals have the opposite

effect on the lesbian subculture, assimilating the ideals (including beauty ideals) of the dominant

culture may make ethnic minority groups more susceptible to eating disorders.

Lucero et al. (1992) "compared the frequencies of Asian and Caucasian women who were

classified by their responses to the EAT-26 scale as having eating problems" (p. 255) and found that

"while Caucasian women are more likely to report eating problems, the percentages of Asian and

Caucasian women who claimed to be free of any symptoms of eating problems" (p. 257) were about

the same. These findings confirm that, while Caucasian women are more susceptible to eating
disorders because of the glamorization of thinness in their culture, ethnic minority women, because of

their exposure to the dominant culture, also internalize many of these ideals and adopt some of the

maladaptive attitudes and behaviors associated with eating disorders. These findings alone may not be

generalized to all ethnic minority groups because certain Asian cultures, such as the Japanese, are quite

industrialized and therefore, they too, may hold similar attitudes about attractiveness. Snow & Harris

(1989) studied the incidence of eating disorders in South-western Pueblo Indians and Hispanics. They

found that a large number of females in both ethnic groups worry about their weight. Unfortunately,

the methods used for this study were unreliable. There was no comparison group of Anglo-American

women to test the differences between these groups, there was no measurement of the subject's level of

assimilation of the dominant culture, and the instrument used to measure the incidence of eating

disorders was a questionnaire with no proven validity that was constructed by the authors. Future

research should focus on understanding the ideals of thinness and attractiveness and the existing

gender roles of specific ethnic groups and nationalities prior to exploring how acculturation affects

these ideals and roles.

The role of cultural factors in the development of eating disorders was acknowledged by the

APA in the DSM-IV, where they stated that "immigrants from cultures in which the disorder is rare

who emigrate to cultures in which the disorder is more prevalent may develop [anorexia nervosa] as

thin-body ideals are assimilated" (p. 543) Without doubt, more research needs to be conducted that

explores the interrelation between culture, gender, sexual orientation and eating disorders.

SUMMARY

As has been presented, the history of eating disorders; particularly anorexia nervosa, can be

traced as far back as the 16th century. Many etiologic explanations have been offered by psychologists

and physicians and many theories have been formulated within the various schools of thought,

including psychodynamic, cognitive-behavioral, and biological. Personality variables and family

dysfunction have been factors commonly implicated in the development of eating disorders as have

been cultural factors that affect every facet of a person's life.

The prevalence of eating disorders has been increasing exponentially since their discovery.

Despite the undeniable role that personality variables, internal conflicts, organic deregulation and

familial disturbance play in the development and expression of eating disorders, these factors exist and

must be interpreted in a cultural and historical context. The same behavior - willful starvation to the

point of emaciation and often, death - was interpreted as a search for religious sanctity and moral

purity and was labeled as sacrificial in the medieval ages, and has been interpreted as a search for

physical attractiveness and social acceptance and has been labeled as pathological in the twentieth

century. Furthermore, a woman whose body may be perceived as 'fat' in North America may be

perceived as 'skinny' in Latin America. This difference does not necessarily result from variations in

what people may actually see, but from how they interpret it through their 'cultural lenses'. The

influence of cultural changes through time and place are clearly evident in these varying

interpretations.
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