Eating Disorders Impact People of All Ages
by: Lisa Michelson, M.A.
Eating disorders happen at every age. From preteens to older adults, eating disorders do not discriminate. Previously, there was a long-held view that eating disorders are mental illnesses that mainly affect adolescents and young adults (e.g., Bruch, 1973). Subsequently, much of the eating disorder research has focused on these age groups (Rohde et al., 2015; Allen et al., 2014). However, as instances of eating disorders in older individuals increased, which may be attributed by an increase in awareness rather than an overall increase in eating disorders in older individuals, there became a need to treat this population as well. Unfortunately, eating disorders continue to be poorly understood in middle age and older populations. The comparison between how eating disorders manifest in older adults versus younger adults is even more elusive.
As we have begun to understand more about eating disorders, we have learned that fears and symptoms manifest in a variety of ages and also in a variety of ways. For example, at the onset of menopause, women may begin to alter how they view their body, which can lead to an increase in one’s body dissatisfaction (Gupta, 1990; Peat et al., 2008). In other words, as a woman’s body begins to change due to a decrease in hormonal production, she may become dissatisfied with how she experiences her body.
Conversely, we see body dissatisfaction in younger women may result from media portrayals of the “ideal” female body and femininity (Tiggemann & Stevens, 1999). Granted, older women are also affected by media portrayal of older women, but not to the same degree as younger women. In comparing the two ages, Rand and Wright (2000) found that older women have more realistic cognitive perceptions of their bodies. This literature may provide insight as to why older women are less affected by external factors (i.e. cultural factors) compared to younger women. Thus, it seems plausible that these cognitive, biological, and cultural differences may also manifest in different core fears in eating disorders in younger versus older individuals.
So why is this important? Why is identifying the differences between ages necessary? Therapy improves health outcomes for individuals of all ages in treatment for ED behaviors and fears. Furthermore, it is crucial to understand how etiological differences in various ages may contribute to diverse therapy outcomes. In other words, to treat a younger individual with AN in the same manner as an older individual with AN may lack efficacy. Yes, they both suffer from the same disorder; however, the reasons for engaging in such behaviors may be vastly different. It would be like a mechanic expecting to fix two cars in the same way.
Age may differentially influence how fears impact eating disorder symptoms. In a recent study, we analyzed if age moderated the relationship between the eating disorder symptoms and fear of food. Yes! We found that age moderated the relationship between fear of food and eating disorder symptoms (come see us present this work at ABCT!). Specifically, we found that fear of food is more related to eating disorder symptoms in younger versus older participants.
What does this mean? Older participants and younger participants differ in how food-related anxiety impacts eating disorder symptoms. This specific type of fear (food) may be most relevant in younger adults. This means we still need to figure out what types of eating-related fears are most relevant in older age! It is advantageous for the research community to continue to identify these differences as they may illuminate the most effective way to address eating disorder symptoms and fears between individuals of different ages.
What Mindful Eating is Really About
By: Irina Vanzhula, B.A.
People who come to my mindful eating workshop often say that they want to learn to eat healthier, lose weight, and reduce emotional and stress eating. I help them see that these goals have been imposed on them by society and the diet industry. I also challenge the idea that mindful eating is just another way to diet and then introduce a new way of thinking about their relationship with food. I usually see expressions of disbelief when I announce that emotional and stress eating are not their enemy.
Dieting vs. Mindful Eating
Any diet is by definition restrictive. Dieters deny themselves certain food groups, reduce how much they eat, or both. In addition to hunger, dieting creates a sense of deprivation, which in turn may make us sad or depressed. “I so much want that cupcake, but I can’t have it” (Johnson and Wardle, 2010). Some people may be able to convince themselves that they no longer like sweets and even override their hunger signals, but that takes a lot of mental energy and we can’t sustain it for a long time. Best-case scenario, we can maintain the eating pattern for a while using sheer willpower, but it eventually fails. Worst-case scenario dieting may trigger disordered eating (Stice, 2002) or even lead to weight gain over time.
Cycles of Eating
Many who attempt to forcefully regulate their eating get stuck in a cycle of dieting, overeating, and feeling guilty. Restricting our food intake overall and denying ourselves food we enjoy leads to hunger and intensified sense of craving. As a result, we may end up overeating and eating more of those foods we were trying to avoid in the first place. It is not all about willpower too, in fact, it has very little to do with willpower. When we are very hungry, our bodies are designed to crave fatty and sugary foods because it is a sure way to stock up on enough energy in case there is a shortage of food in the future again (Heshmat, 2011). Overeating is often associated with guilt or what we call “I have blown it” effect. We feel guilty for “breaking the rules” and decide to start all over tomorrow, and the cycle continues. Alternatively, overeating may make us feel depressed and bad about ourselves, which can trigger more emotional eating.
What is the solution? In my workshop, I suggest that my participants abandon food rules and adopt a new set of goals: learn to eat intuitively by recognizing their hunger and fullness signals and satiate their body and mind. The key to achieving those goals is mindfulness. Mindfulness has many definitions and applications, but the one we focus on is awareness. Recent research is discovering that awareness may be the key to successful mindfulness-based interventions for disordered eating (Sala & Levinson, in press). Mindful awareness is paying attention to present moment experiences and is opposite of running on automatic pilot. Many of our eating experiences are indeed automatic. Our eating is a response to multiple environmental cues, such as smells, bowl of candy in the office, snacking while watching television, eating out of boredom or at the social event, and more. Overwhelmed by these stimuli, we lose touch with the true sensations of hunger and fullness, and true taste satisfaction.
Practicing mindful awareness can help us disengage the automatic processes and really tune into our bodies. General meditation practice can help build the skill of paying attention, but mindful eating can be simply slowing down and paying attention to your meal. Next time you are about to eat, pause and take a breath. Notice how you are feeling and what you are thinking. Notice any attitude you have towards this meal you are about to eat. Notice the smell, the colors and shapes on your plate. Also notice sensations of your physical hunger. Hunger may feel different for each person, but in general we get hungry when our energy level is depleted and we need to refill our bodies. Physical hunger may be associated with lower blood sugar, fatigue, stomach empty and growling, and mouthwatering. This is how your body lets you know you need to eat, but how do we know when we are full?
Most people see hunger and fullness as opposite ends of the same scale. If you are no longer hungry, you are full, and vice versa, right? In fact, body fullness and satiety are more complicated concepts. If you were to drink 20 oz of water, your stomach will feel very full, but you will likely still be hungry. Many people describe physical sensations of fullness as feeling bloated, having an extended stomach, feeling heavy, clothes getting tight, and even a lump in the throat. Have you ever eaten very fast when you are hungry and your stomach is full but you still feel hungry? These examples suggest that hunger and fullness are their own concepts and each can be measured on a separate scale. In general, physical hunger is about blood sugar levels, and physical fullness is about filling up the space of your stomach.
Psychological hunger refers to wanting to eat for reasons such as boredom, sadness, food proximity, stress, and habit. You may snack at a party when you are not physically hungry or crave chocolate ice-cream at the end of a difficult day at work. Although we perceive emotional eating negatively, psychological hunger also needs to be satisfied. We call this body satiety. Consider this example: you eat a large portion of bland boiled chicken and rice. Your hunger is down, your fullness is up, but you are still craving dessert. That is because the meal did not satisfy you and you are still low on body satiety. Mindful eating proposes that instead of fighting these feelings, you satisfy them in a mindful way without overeating.
What are you truly hungry for?
The good news is that we don’t need to consume a lot of food to be satisfied. Out taste buds get tired very quickly: third, fourth and later bites won’t taste as good as the first one. This means, that we can satisfy that psychological hunger by having only a small amount of craved food. In addition, it is helpful to ask ourselves: what are we truly hungry for? If we are about to eat out of boredom, maybe we are really hungry for some good company and friendship? And last but not the least is self-compassion. If you do make a choice to satisfy your psychological hunger by eating our favorite food, don’t blame yourself. Be kind to yourself and recognize that this is what you need at that moment.
Mindful eating introduces a completely different relationship with food and navigates you away from food rules. Mindful eating is based on building awareness of external and internal processes that dictate our eating behaviors. Developing eating awareness skills can help you end your battle with food and achieve your behavioral and health goals.
To join our mindful eating group contact us here: http://www.louisvilleeatlab.com/eat.html
To hear more about the negative impact of dieting, watch this TED talk:
From Media to Science: What Do We Get Wrong and Right about Men and Eating Disorders?
By Leigh C. Brosof
For a long time, there was a belief in mainstream society that “boys don’t get eating disorders” and that eating disorders were a “girls’” issue. Fortunately, this view is changing with both research and the media becoming more inclusive in conversations around eating disorders. Researchers have shown that eating disorders and disordered eating are still highly prevalent among men. In fact, men suffer from some eating disorder symptoms (such as binge eating) just as much as women. While we are making great strides towards lessening the stigma around men and eating disorders, some misperceptions still abound, such as: 1) that you must be underweight to have an eating disorder, and 2) that there must be something “wrong” with men who get eating disorders. These misperceptions reflect general myths around eating disorders.
Misperception 1: You must be underweight in order to have an eating disorder.
Whereas this is untrue for every gender (eating disorders can affect individuals of any size!), it may make it particularly difficult for men to seek help, especially because symptoms such as binge eating, may not fit one’s “typical” view of an eating disorder. In addition, when men do start losing weight or become underweight, individuals may not think about an eating disorder as the problem. This misperception makes it more difficult for men to accept they have symptoms of an eating disorder or for medical professionals to spot these symptoms in men.
Misperception 2: There is something “wrong” with men who get eating disorders.
Despite societal stereotypes surrounding eating disorders, men are more similar than different in comparison to women when it comes to eating disorders. This means that there is a complex interplay of biological, psychological, and social factors that lead to the development of a disorder. Therefore, men’s eating disorder are not a “choice,” and it’s not anyone’s “fault” if they develop eating disorders. Rather, it is a serious mental health disorder. Men may also experience some types of eating disorder symptoms, such as muscle dysphoria, at higher rates than women. Muscle dysmorphia is when an individual has a drive to become more muscular and has insecurities around not being muscular enough. For men, this desire for muscularity may be coupled with a desire to be thinner or leaner. Men may also have concerns about different areas of their bodies than women. These similarities mean that, in general, treatments that have been developed for women should also work for men; however, it also means that certain aspects of these treatments should be tailored specifically for men.
It’s also essential to remember that eating disorders affect people of ALL genders. In fact, some research suggests that individuals who are transgender or non-binary have eating disorders at higher rates than individuals who identify as cis-gender. Although the exact reason for this higher prevalence is not well-understood, it may have something to do with the stressors (and discrimination) that society puts on these individuals for not adhering to the gender binary. Research and treatments are slowly starting to include not only males, but also individuals of all genders; however, more effort still needs to be devoted in order to best serve individuals across the gender spectrum. For instance, right now, a comprehensive assessment of gender identity does not exist – something that our lab is trying to change. The most important thing that society and research can do is to acknowledge that eating disorders do not discriminate – we need to include individuals of all genders in the conversation to decrease stigma and increase the likelihood that men and individuals of other genders will seek treatment.
If you are a man who is suffering from an eating disorder, to learn more about men and eating disorders or for resources for treatment: http://namedinc.org/
Reflections from the NEDA walk
By: Cheri A. Levinson, Ph.D.
I was fortunate to join over 200 fellow walkers on Saturday to fight against eating disorders and bring awareness to the psychiatric disorder with the highest rates of mortality. I left the walk feeling extremely inspired. Inspired to continue the hard work that my team at the University of Louisville (www.louisvilleeatlab.com) and at the Behavioral Wellness Clinic (http://bewellproviders.com/) spend our lives on.
Perhaps the most inspiring part of the walk was the community of people coming together showing our state and the city of Louisville how many people are impacted and that we are not alone. As I said in my speech (read full transcript here) ‘…every day I have conversations with people, many of you who are here, many who are across the globe, but all who care about changing society and the treatment of EDs for the better. This inspires me.’ It was inspirational to see so many people come together to bring about change. It made me feel not alone, as I am sure it did to most all who attended the walk.
But I also left the walk feeling that a few messages still need to be communicated. A WDRB article (http://www.wdrb.com/story/36382951/hundreds-take-part-in-walk-at-bellarmine-university-to-raise-awareness-of-eating-disorders) covered the walk and highlighted two points. First, more treatment centers are needed locally. Second, there is very little research funding allocated to eating disorders. These messages need to be out there. But I also think that a word of caution is needed when putting these messages to the public.
More treatment centers are needed locally. Yes! This is a given. Our community needs a treatment center. We are a city of 1 million people, meaning at least 70,000 people in our community have an eating disorder. We need more access to empirically-validated treatments in Louisville. Key words here are empirically-validated treatments. We need to be careful about recruiting an eating disorder center to our community. Treatment centers vary in the quality of treatment provided. I can say from experience (and from research) that there is often a huge gap in the type of treatment that is provided and the type of treatment that *could* be provided. We need a treatment center in Louisville, but we need more than a ‘status quo’ treatment center that will provide sub-optimal care.
More funding for research is needed. Figures from the National Institute of Health show a huge discrepancy in the funding allocated to eating disorders versus other mental and physical health problems given the societal and personal costs. In plain language, research in the eating disorders is extremely underfunded. I am in the process of applying for three national grants. Two from NEDA and one from the National Institute of Health that would establish UofL as the primary site in a network of seven treatment development centers. In my opinion (which is of course, obviously biased) these grants hold the power to transform eating disorder treatment. Unfortunately, the stark reality is that the likelihood of receiving these grants are low, not because they shouldn’t be funded, but because there are not enough research dollars.
I do not see either of these issues as separable. The ideal treatment center is grounded in research and good research that has real impact is grounded in actual treatment. We stand at the cusp of an opportunity to create a world-renowned, state of the art, treatment, research, and training facility right here in Louisville that will provide treatment, development of novel treatments, and training, that our state (and nation) desperately needs. We are working hard at UofL and at the Behavioral Wellness Clinic to make these goals happen, but the more support, both financial and physical we receive, (which can only happen through awareness) the faster we can make this a reality, so that we can decrease the extreme amount of suffering and impairment that eating disorders cause.
Anorexia Nervosa in Russia
By: Irina Vanzhula
I grew up in the city of Saint-Petersburg, Russia and moved to the United States 10 years ago. I have noticed many differences, including how women’s sizes are perceived in each country. A woman wearing dress size 8-10 in the US would be considered by most to be of normal weight, but in Russia, she would be called overweight. Most clothing stores do not even carry sizes higher than 10, and Plus size starts with 12. The “normal” clothing size in Russia is 0-4, and women go to considerable lengths to obtain this size at all costs. The thin-ideal is pervasive in Russian culture with its famous ballerinas and supermodels.
My 14-year old brother Vasya is a student at the world famous Vaganova Academy of Russian Ballet. He spends about 6 out of his 12-hour day dancing and only eats once a day. He is underweight, but is repeatedly told that if he gains weight he will be kicked out of the Academy. Vasya is not the only one. Although media’s focus on thin bodies is ubiquitous across countries, Russian women experience additional pressures to look “perfect.” Russia has approximately 85 men for 100 women, and considering very high rates of substance abuse in men, the number of ‘quality bachelors’ is even lower. To be competitive, Russian women pay extreme attention to their looks, including body weight and shape. It is considered necessary to dress up and do hair and make-up just to go to a grocery store, and wearing sweatpants in public is unthinkable. Much of woman’s value is based on looks, and being thin is a sign of having strong willpower and being successful.
Based on these observations, I suspect that prevalence of eating disorders and especially anorexia nervosa (AN) in Russia would be higher than in the US. Thus, I decided to do some research. My search revealed that no epidemiological studies have been done and no official statistic of eating disorders exists in Russia. Prevalence rates reported range from 0.5% (Bobrov, 2015) to 20% (Anorexia in Russia, n.d.). Since Russians don’t believe in mental illness and most people don’t seek treatment, the rates are likely underreported. A large population with subclinical AN symptoms may account for the large discrepancy in prevalence rates.
I continued my search to uncover how AN is portrayed in both internet and the scientific community. Most internet articles accurately described the disorder and emphasized fear of fat, perfectionism, and disturbed body image. Health complications were usually mentioned, but I did not find anything about high levels of suicide, which is likely due to the topic of suicide being a social taboo in Russia. One disturbing discovery was that the webpages that described the dangers of AN were full of advertisements of various diets. For example, next to the article “Anorexia – severe disease statistics” you can find “how to lose weight and keep it off forever” and advertisements of various diets (www.http://www.on-diet.ru).
Most internet articles recommended the help of a professional, but after reviewing treatment options, I lost most of my optimism. I did not find any specialized eating disorder clinics in the entire country, and help with AN was offered at general medical or psychiatric hospitals. One gastrointestinal clinic advertised AN treatment, but the treatment team consisted most of the dietitians and only one psychologist. Even the clinics that offer any kind of treatment for eating disorders are few and spread thin. Most clinics are located in Moscow and Saint-Petersburg. Considering size and population of the country, the majority of Russians don’t have access to any eating disorder treatment or even a therapist. Thousands of small Russian towns are lucky to have one general practitioner, and the closest psychologist is usually hundreds of miles away.
Next, I turned to scientific journals. Most of the information was consistent with that in US journals. I came across one surprising trend strongly linking AN with psychotic disorders. Bobrov (2015) describes AN as having inaccurate cognitive perceptions of reality and empathizes its high comorbidity with schizophrenia. Further, Artemyev & Vasiliev (2012) explain that some researchers see AN as a schizophrenia syndrome, citing an article from 1932, and report that schizophrenia precedes AN in 25% cases. In another study, out of 101 women with AN on inpatient psychiatric unit, 81 were diagnosed with schizophrenia (Artemyeva & Arsenyev, 2010).
Patients with AN often report that their family and friends find their eating disorder related beliefs strange and unusual, and refusing to eat despite life-threatening complications may be perceived as particularly strange. This interpretation may have led to over-diagnosis of schizophrenia in those with AN. However, recent studies report that prevalence of psychotic in those with AN is no higher than in general population (Seeman, 2014). Russian psychologists, however, may still over-diagnose schizophrenia, or these statistics are a result of a biased sample. They mostly studied patients in psychiatric hospitals, where comorbidity of severe mental disorders is high. On the other hand, new research revealed a genetic link between AN and psychosis (Duncan et al., 2017), so there may be some connection there after all.
One major implication of connecting AN with schizophrenia in the literature is increased stigma. If seeking treatment for AN means the high probability of being diagnosed with a psychotic disorder and likely prescribed anti-psychotic medication, it is not surprising that people would avoid it at all costs.
In conclusion, the amount of social pressure on all Russian women to be thin is incredible, and the standards are impossible to achieve. People who have symptoms of AN are admired and praised for their strong wills and dedication. The scientific community is lagging behind in proper diagnosis and further contributes to already high stigma of mental illness. Although rates of AN may be high in Russia, treatment options are almost non-existent. Epidemiological studies that bring attention to prevalence of AN in Russia and lack of treatment options are needed. While the research field is catching up, all of us can help increase awareness by making translated US articles available on the Russian web.
The Importance of SEEING your Weight in Eating Disorder Treatment
By Cheri A. Levinson, Ph.D.
One question I hear a lot from parents, eating disorder providers, and patients themselves, is about weighing. Do I have to be weighed? Should I see my weight? Should I show my patient their weight? But if they do see their weight it causes them distress- isn’t this bad? I’m going to talk a bit about why it is SO IMPORTANT to see your weight when you are in treatment for an eating disorder.
One of the scariest parts of eating disorder treatment is gaining weight. In fact, there is growing evidence supporting the idea that fear of weight gain plays a central role in maintaining eating disorders (e.g., Levinson et al., 2017; Murray et al., 2016). What this means is that being afraid of gaining weight may actually be what keeps an eating disorder going. That means that to get rid of the eating disorder – we need to get rid of (or reduce) this fear!!
So what do we do about this? How do we minimize fears of potential weight gain? This question is so important to us that we are currently working on developing a treatment specifically for fear of weight gain here in the EAT lab. In the meantime, the good news is- there are other treatments out there that work! And part of the reason they are thought to work is because of a practice called open weighing (seeing your weight in treatment). In these treatments patients see their weight once (or twice) a week when they meet with their therapist. Their therapist then plots out their weights across time and then uses this chart in treatment with the patient.
So what are these treatments? Cognitive Behavior Therapy (CBT) and Family Based Therapy (FBT) both use open weighing. These are the treatments we know work best for eating disorders. In fact, FBT is the type of treatment with the most support for adolescents with anorexia nervosa and weekly, open weighing is a non-negotiable part of treatment.
But I still don’t understand why seeing my weight is so important? Let’s do a thought exercise. If I tell you to not think about the purple elephant, what are you going to do? DON’T THINK ABOUT THE PURPLE ELEPHANT….you are going to think about the purple elephant. If I tell you, not only don’t think about the purple elephant, but avoid elephants and anything purple at all costs, what is going to happen? You are going to think more and more and MORE about the purple elephant, elephants in general, and anything purple, and purple elephants are going to become a bigger and bigger deal in your mind.
What do purple elephants have to do with fear of weight gain? The same principle applies to seeing your weight. Our goal in eating disorder therapy is to help patients become less afraid of gaining weight, to realize that gaining weight is not catastrophic, and to put less over-evaluation on weight and shape. The only way that patients can learn that weight is really not as big of a deal is for them to regularly see their weight!!! Patients then learn that just because they have gained weight (or maybe they really haven’t even gained weight like they predicted they would!) the terrible things that they imagined would happen from gaining weight (or seeing their weight) do not happen. After all, your weight is just a number – it does not define who you are as a person!
Perhaps the biggest complaint I hear about this practice is: But if I let my patient see their weight they get really upset, anxious, and it triggers their eating disorder! I get it, it’s tempting to not let patients see their weight. Anxiety is uncomfortable and it’s really hard to see someone who is already in distress get more distressed. Let’s take a deep breath...
I truly believe that the job of the therapist is to help patients learn that they can tolerate uncomfortable emotions. And this is not just me! There is mounds and mounds of literature that shows that learning to tolerate anxiety and distress is actually what makes the anxiety go away and gives you better control of your life. This is what we call exposure therapy and this is how we treat anxiety disorders. By letting patients with eating disorders continue to avoid seeing their weight, we are interfering with learning, we are teaching them that yes, seeing your weight is scary and you SHOULD avoid it. In fact, this is the opposite of what we want them to learn. We want them to learn that they CAN see their weight, it is just a number, and THEY CAN TOLERATE THEIR DISTRESS when they see their weight. The take-away here is this: LETTING PATIENTS SEE THEIR WEIGHT IS ACTUALLY HOW WE REDUCE ANXIETY IN THE LONG TERM.
When I see someone for eating disorder treatment, weekly, open weighing is a non-negotiable part of treatment. In our first session, I take weights and let them know that starting in the following session they will begin seeing their weight, once a week, when they come to treatment. They shouldn’t weigh themselves in between sessions, but they will see their weight and we will talk about their reactions until weighing becomes ‘no big deal.’ I’ve found that the most common reaction to seeing a weight is “oh that wasn’t really as bad as I thought it was going to be.”
So what does this mean for someone with an eating disorder? For a parent? For eating disorder providers? The evidence suggests that we need to be practicing open-weighing. If you are a parent or a patient with an eating disorder and your provider/treatment center does not practice open-weighing- ask them why not? Unfortunately, most eating disorder providers do not practice open weighing, in spite of the evidence (Forbush et al., 2015). If you are a provider or treatment center, it’s up to us to teach our clients that they CAN tolerate being anxious and that their weight is really no big deal. That means we need to make it a point to include open-weighing in our practice.
For more discussion and research on how to best implement open weighing, please see the following two articles:
Waller & Mountfold (2015). Weighing Patients Within Cognitive Behavioral Therapy for Eating Disorders: How, When, and Why.
Forbush et al., (2015). Clinicians Practice Regarding Blind Versus Open Weighing among Patients With Eating Disorders.
Developing a Measure of Non-Binary Gender (Genderqueer) Assessment
by: Lisa Michelson, B.A.
Classifications of gender identity, gender expression, and biological sex have become prevalent topics within contemporary healthcare conversations. These topics were once understood as a binary of options (i.e. male/female, masculine/feminine), but now these topics are viewed as a part of a spectrum (i.e. an individual can vary in how much they identify as “male” and “female”/”masculine” and “feminine”). However, the healthcare system has not yet been able to adapt its treatment plans, insurance plans, and other types of documentation within healthcare to this new ideology of gender and sex. This causes individuals who do not associate or perform as the stereotypical “male” or “female” (at the very least) to be misunderstood, and (at most) to receive inadequate healthcare.
Before we move on, let’s define some terms. Performing gender is “performing” one’s gender in alignment with societal expectations of that gender (i.e. a woman would be performing gender if she were to wear a dress). Non-performing gender is deviating from what culture depicts as an individual’s “authentic self,” or the individual’s identity that society is most comfortable with. Examples of non-performing gender are cross-dressing or identifying as transgendered. Heteronormativitiy are policies, beliefs, norms, and disciplinary mechanisms that reinforce the sex/gender system; for example, heteronormative culture endorses “female” and “male” sex designations on birth certificates. Cisnormativity is the expectation that all people are cissexual, that those assigned male at birth always grow up to be men and those assigned female at birth always grow up to be women. Not performing gender (i.e. cross-dressing or being transgendered) can cause a variety of negative outcomes, such as bullying and teasing, to be elicited. It is this performativity of being a “man” and being a “woman,” that has affected how individuals are treated within the healthcare system.
There are issues if an individual does not perform his/her/their gender identity. For example, Trans* individuals are poorly understood and medicated by healthcare professionals, who mostly lack training in Trans* healthcare. Because physicians are not trained in the treatment of Trans* individuals and because important healthcare documents force individuals to designate their sex as “male” or “female,” Trans* individuals experience systematic violence by the healthcare system; for example, they do not have the option of identifying as two genders on medical documents, if they feel their identity is a blend of male and female. If one does not follow the gender binary system, then one’s identity undergoes erasure and is not viewed as legitimate. There are serious ethical issues with forcing Trans*, inter-sexed, or non-binary individuals to associate with one of two genders if they view their identity as either a mixture of male and female, or one outside of the binary scale.
Because there are currently no assessments that attempt to understand gender separate from performativity, I, along with the EAT lab, have developed the Non-Binary Gender Assessment (NBGA). This assessment asks individuals questions about how they view themselves rather than through performativity questions. Traditional performativity questions assess items such as “I like guns.” In scoring, this individual would be described as “masculine.” However, this is based off of stereotypical analysis of gender performativity within a heteronromative, cisnormative culture. In other words, it is unfair to attach masculinity to the “I like guns” statement. In fact, a female who considers herself feminine may like guns as well.
Instead, we are trying to develop a measure that does not rely on these stereotypes. In the Non-binary Gender Assessment (NBGA) individuals are asked questions regarding how they view their identity. For example, individuals have the opportunity to quantify their gender identity on a scale from 1 to 10 in three categories “Female,” “Male,” and “Other.” Allowing individuals to quantify their own gender rather than assigning them a gender based off performativity aids in the individual’s agency, which is defined as one’s ability to make an autonomous decision for himself/herself. Through this 62-item survey, individuals answer a series of questions regarding ones’ gender identity, gender expression, and biological sex; for example “I am afraid to not wear clothes in public because people will look at my body (i.e. at a swimming pool or sauna).” The individual is not marginalized by a series of “yes” or “no” questions, but rather have the opportunity to scale one’s answer and provide clarification for answers if desired.
The hope in creating this scale is to better understand an individual’s gender and sex identity. Additionally, the goal is to see if the NBGA illuminates any relationships between both gender and sex identity and eating disorders. Previous research suggests that there is a higher prevalence of eating disorders in non-binary populations when compared to the same demographic in binary populations (Feldman & Meyer, 2007; McClain & Peebles, 2016). If the NBGA is able to detect the parts of an individual’s gender and sex identity that can cause an increase prevalence in eating disorder symptoms, then this may help in better understanding why non-binary individuals engage in disordered eating behaviors in the first place. Stay tuned as the EAT lab continues to develop and validate this measure!
Culture and Eating Disorders
by: Benjamin J. Calebs, B.A.
Eating disorders have traditionally been viewed as impacting the lives of non-Hispanic White women in Western countries. Relatedly, there have been debates about the degree to which eating disorders may be culture-bound syndromes (Keel & Klump, 2003). The DSM-5 defines a cultural syndrome as “a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context” (American Psychiatric Association, 2013, p. 14). As you can imagine cultural and ethnic differences in eating disorders are a very complex topic!
Some researchers have argued that eating disorder diagnoses such as anorexia nervosa and bulimia nervosa are culture-bound syndromes motivated by Western ideals of thinness, while others have emphasized the substantial biological and genetic components to eating disorders. After a review of the evidence on eating disorders across cultures and time periods, Keel and Klump (2003) concluded that bulimia nervosa is heavily influenced by culture, while anorexia nervosa is experienced similarly across cultures. The authors suggest that bulimia nervosa may be so influenced by culture because binge eating is reliant upon an individual having access to enough available food to have a binge episode. Relatedly, purging seems to predominately occur in cultures where thinness is highly valued (Keel & Klump, 2003).
In spite of the traditional view of eating disorders outlined before (i.e., that eating disorders are predominately seen in non-Hispanic White, Western women), it is now clear that disordered eating behaviors occur across different ethnicities and cultures. Lifetime prevalence rates of eating disorders vary among ethnic groups in the United States, yet disordered eating has been found among European Americans, African Americans, Hispanic Americans, and Asian Americans (for a recent review see: Levinson & Brosof, 2016).
Our lab recently completed a review on disordered eating across ethnic groups. I will discuss a bit about what this review found. African American women tend to show lower levels of disordered eating behaviors than European American women, which may be related to the lower levels of both body dissatisfaction and thin-ideal internalization reported by African American women as compared with European American women. Hispanic American women may have higher levels of binge eating than either European American women or African American women. Asian American women show lower levels of many disordered eating behaviors than European American women. Ethnic minority groups in the United States are less likely than European Americans to seek treatment for eating disorders, suggesting a further need to examine how cultural and ethnic differences relate to differences in eating disorder symptomatology and treatment.
Both similarities and differences in disordered eating symptoms have been found across cultures as well. Researchers have found that Japanese women may have levels of body dissatisfaction that are similar to women in the United States; yet there may be different motivations behind body dissatisfaction among Japanese women. For example, body dissatisfaction is largely motivated by the thin-ideal in American culture, while body dissatisfaction may be driven more by a desire for delayed maturation in Japanese culture. In Chinese culture, fear of fatness may play a role in body dissatisfaction similar to American culture.
However, such generalizations may be limited by common definitions of cultural and ethnic groups. For example, China is inhabited by 56 different ethnic groups. As was seen when looking at the differences in disordered eating between ethnic groups in the United States, it’s likely that variability exists in levels of disordered eating across ethnic groups in China (and everywhere!). Imprecise definitions of culture or ethnicity can contribute to difficulties in examining similarities and differences across cultures.
Eating disorders are the outcome of a complex interaction between a variety of factors, including culture, environmental risk factors, individual differences in personality, and genetic factors. In order to understand how to reduce the distress and impairment that eating disorders cause, it’s important to examine the unique contribution of each of these factors. In so doing, researchers and clinicians can create interventions that best meet the needs of diverse populations.