Why Young Women Are Prey to Eating Disorders
By Stefanie Gilbert
"Are you pregnant?" the young girl asked me suddenly. Horrified that she had discovered my secret before I'd even had the chance to tell my supervisor, I answered her with a therapeutic technique designed to keep the focus on the patient. "Well, that's an interesting question," I commented, noting the five pairs of adolescent female eyes scrutinizing my torso. "What thoughts do you have about that?"
I'm a clinical psychologist specializing in the treatment of eating disorders; the girl and four others, each a member of my weekly eating disorders therapy group, revealed their concerns about my being pregnant in a discussion that followed. How much would I have to eat, they wondered. Did I know whether I was having a girl or a boy? Which would I prefer? And, most provocative of all, if I had a girl, what would I do to ensure that she didn't develop an eating disorder?
Approximately 1 percent of adolescent girls develop anorexia nervosa, and another 2 to 3 percent are diagnosed with bulimia nervosa, according to the National Institute of Mental Health. One in 10 individuals with anorexia die as a result of their illness. Complications from bulimia, such as vomiting-induced potassium losses that can lead to cardiac arrest, also may result in death, but the institute lacks numbers.
While most girls don't develop these severe eating disorders, many are preoccupied with their weight from an astonishingly young age. As early as first grade, children express dieting and weight concerns and even engage in eating-disordered behaviors, according to a 1996 study by psychologists Ellen Flannery-Schroeder of Temple University and Joan Chrisler of Connecticut College. By the eighth or ninth grade, one out of two girls has been on a diet at some point in her life, suggests research conducted at the University of Missouri.
Girls are about 10 times more prone to developing these disorders than are boys, said J. Kevin Thompson, professor of psychology at the University of South Florida and co-author of "Exacting Beauty: Theory, Assessment and Treatment of Body Image Disturbance" (American Psychological Association, 1999). Why this discrepancy? Researchers point to the experience of adolescence, when girls' and boys' bodies undergo profound but dramatically different physical changes.
The transformations that girls experience – acquiring more fat and becoming more rounded – are condemned by America's weight-obsessed culture. In contrast, the increased muscularity that boys undergo is reinforced and heralded. "Culture collides with biology," Thompson said.
In an effort to control their developing bodies, girls may turn to dieting, a risk factor for developing an eating disorder in adolescence, according to a recent study at Stanford University. Adolescent girls in the study who dieted, who perceived greater social pressure to be thin and who were less happy with their bodies, were also more likely to engage in eating-disordered behaviors such as bingeing and purging.
Just why some girls develop eating disorders and others do not is not known. Genetics appears to play a role in the development of anorexia since the chances of both members of a pair of twins having it are higher if they are identical rather than fraternal. Researchers at Virginia Commonwealth University have reported similar findings for bulimia.
Culture also plays an important role, because eating disorders are virtually nonexistent in non-Westernized countries, and girls who immigrate to Westernized nations are more likely to develop an eating disorder than those who remain in their non-industrialized homeland.
The incidence of eating disorders increased dramatically in the 1960s, a time of great change in the roles of women, as historian Joan Jacobs Brumberg points out in her book, "Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease" (Harvard Press, 1988).
Brumberg notes that as increasing numbers of women began entering the work force and competing alongside men for the same jobs, health officials became aware that their daughters began exhibiting an increasing number of eating disorders. She and other theorists speculate that the demands to be successful professionally and to be attractive and acceptably feminine place women in a bind. The fashion industry, meanwhile, has promoted an increasingly waif-like beauty ideal.
At the same time, Ruth Striegel-Moore, professor of psychology at Wesleyan University, views the increase in disorders as a product of better epidemiological surveying and a greater awareness of such problems. Prior to the 1970s, rates of eating disorders were assessed by looking at the number of patients reporting to treatment centers, a method that may have grossly underestimated incidence rates.
Certainly, American culture plays a significant role in helping children develop the attitudes that are the crux of many eating-disordered behaviors. But it explains only a piece of this puzzle since all girls are exposed to similar societal pressures to look attractive and be successful, and most do not develop eating disorders.
Beyond biology and culture, other variables that appear to be important are ethnicity and family environment. White adolescent females, for example, are almost twice as likely to view themselves as overweight than are black adolescent females, according to a 1997 study at the University of South Carolina School of Public Health. These white teenagers are nearly four times as likely to diet and exercise in an effort to manage their weight, and six times as likely to use diet pills and vomiting as means of losing weight.
Eating disorders are still primarily a white woman's disease, although black women who are more assimilated to white culture are at risk of developing these problems, according to James Gray, professor of psychology at American University. "It's intuitive," Gray said. "Black women who are pulled toward white culture become more like white women in their tendency toward eating disorders."
The dynamics within one's family also play an important role in determining attitudes and behaviors toward weight and food. A 1997 University of Minnesota study suggests that girls with parents who make comments about their daughter's weight are more likely to be unhappy with themselves and go on diets. Compared with mothers of girls with no eating problems, mothers of girls who become bulimic tend to restrict what their daughters eat, encourage them to diet and exercise to lose weight and perceive them as overweight, according to a 1993 study at the University of Missouri. No studies have compared the relative influence of mothers' vs. fathers' weight-related attitudes and behaviors on eating disorders in their daughters.
There are also psychological issues that need to be addressed. While genetics, culture, ethnicity and family variables offer some clues as to why eating disorders develop, the experiences of the young women I have worked with may also provide another explanation.
Nearly every anorexic girl I see tells me her eating disorder makes her feel special. Nothing else in her life informs her that she stands out. If she's a straight-A student, so are lots of other girls. If she plays piano, it probably isn't so well that it will be her career. If she sings with the choir, so do others. What does she have other than her eating disorder that makes her extraordinary?
Nearly every girl battling bulimia who comes to me for help says her eating disorder gives her a feeling of control, when so much in her life – her changing pubescent body, her family situation, her future – seems chaotic and uncertain. Bingeing on doughnuts and cereal may not appear to offer a real solution, but to the young girl who wants to escape from a life of confusion, an eating extravaganza provides needed, controlled comfort and, albeit temporary, diversion.
"Anorexia is often misunderstood as being about beauty," Striegel-Moore said. "It's not about beauty. It's about being able to handle anxiety in ways other than food."
Stefanie Gilbert practices with the Metropolitan Psychiatric Group in Bethesda.
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