It's Not a Feminist Thing

Anorexia nervosa has been described for hundreds of years in both historical accounts and medical literature as it has evolved as an illness category (1). Whether anorexia is borne of religious asceticism, a need for control, the infiltration of the media, genetics or a way to protest the objectification of women's bodies, starvation, and self-denial has long been a phenomenon described and experienced by women and an increasing number of men in the United States. Modifications have been made since it was first identified as a mental illness but largely the associated benchmarks of anorexia have not changed (1). It has been conceptualized in many different ways over the course of its known existence. Both the factors seen as causing anorexia and the ways in which it has been treated have varied immensely. In fact, there is no professionally recognized method of treating anorexia successfully and it continues to have the highest mortality rate of any psychiatric illness (3). The greatest schism exists, however, in the subjective experience of patients with anorexia and the explanations offered by clinicians and social scientists to explain self-imposed starvation of their patients. If the voice of the patient is not heard and not perceived as an integral component of any treatment, those afflicted are relegated to observers in their own care, as treatments are performed on them without a comprehensive understanding of the etiology of their behaviors.

The history of women, in particular, starving themselves is a long one, and includes the stories of "fasting girls," whose self-denial gained them much notoriety from the 13th century up to the 19th century. These women were the subject of tales both written and oral (1). The tradition of mythologizing the anorexic existed from the time such behaviors were documented and continues today. Anorexia, once categorized as a mental illness, continued to engage the popular imagination. In part, the disbelief that anyone could systematically deny herself nourishment defied both early understandings of human physiology and social convention of the day. While medical journals often published articles about anorexia, so did newspapers that appealed to a wider audience. The anorexic was not so much seen as a pariah but an object of curiosity (4). In 1954 the first photograph of an anorexic was published in a medical journal, and was then reprinted for the general population to bear witness to anorexia. The picture of a young woman emaciated to such an extent that her bones threatened to pierce through her skin, shocked audiences. The voices, however, of patients were not often heard and when they were, it was through the writings of their physicians who were attempting to treat them (5). This, of course, affected the nature of treatment and the willingness of physicians and mental health workers to commit resources, both time and energy, to women who so often relapsed or perished. Thus the history of anorexia is rooted in the exclusion of the patient from a dialogue about treatment.

The role of the Diagnostic Statistical Manual (DSM) as a pillar of good science may be partly responsible. Starting in 1980 with the publication of the DSM III, criteria for anorexia, while having remained virtually the same over time, began to be more widely employed (5). The DSM III-R (revised) published in 1987 as well as the most recent DSM IV have kept intact virtually the same criteria for the diagnosis of anorexia (6, Appendix A).

Genetics studies have uncovered a possible heritability in the case of anorexia. In monozygotic twins, a study showed that fifty-five per cent of twins with anorexia had a twin with anorexia. This evidence suggests that if anorexia is, in fact, genetic, there are also other factors that contribute to its onset (5). Biological indicators alone have not proven to be a sufficient explanation for anorexia. It was not until the 1930's that the medical profession shifted its conceptualization about anorexia. The effects of the original medical shaping of anorexia as a diagnostic category proved damaging long after the tides in the medical profession had shifted. The legacy of the late 19th and early 20th century conceptualization of anorexia came about because of a fixed consensus among clinicians without relying on patient experience or even empirical studies and little has changed since (7). The issue of "disturbed eating" became the focus of understanding anorexia, thus treatment, and was seen as causal, not just symptomatic. This resulted in a "one-sided" approach to anorexia that was inevitably constrained by the narrowness of the definition (8). The use of psychoanalysis to understand and treat anorexia became commonplace and replaced the myriad of other treatments that had been attempted for anorexia, including confinement and forced feeding. Bordo writes of psychoanalysis' claim to mental illness, "Freud enabled psychoanalysis to rationalize and make clear meanings of hysteria and to bring the hysterical body under the proprietorship of the scientist/analyst" (9). Professional interests in establishing claim to anorexia have long served to shape views about anorexia within the medical arena, thus delineating the context of the illness experience for patients. The imposition of a diagnostic structure onto the patient experience of the illness resulted in a dynamism between the two that yield authority to the professional assessment of anorexia, thereby usurping the validity of the patient experience (10).

The personal narratives of anorexics began to infiltrate popular culture with the writings of Hilde Bruch, a psychiatrist, who attempted to demystify the anorexic condition by publishing detailed accounts of her patients' trials and triumphs. Bruch's books likely did de-stigmatize the plight of the women about whom she wrote, while also serving to denigrate their upbringings, fault their families and portray the young female anorexics as privileged and attention seeking (8). The anorexic continues to be portrayed as a perfectionist, obsessive and intent on exercising control over her eating as a proxy for the control she cannot have on her external circumstances. She is often portrayed as being a product of a family that simultaneously shelters and pressures her to perform (5). "I don't think doctors know what they're doing," wrote Michael Krasnow, a male sufferer of anorexia, who wrote a memoir based upon his experiences and died shortly after its publication. Krasnow also writes, "Perhaps I'm scared to get better or don't even want to. I've been this way for so long and don't know of any other way to live. It's as though for some reason, I'm holding onto the anorexia and don't want to let go. The anorexia is my shield, protecting me from something" (11). There was some fundamental lack of understanding that existed between Krasnow and his doctors that seems characteristic of the plight of many anorexics: a discord between patient experience and professional characterization and understanding of that experience. Certainly, Krasnow's writings were not those of one who feels privileged, rather of one who felt trapped and oppressed by his illness. There is a disconnect between the desire of the anorexic to be understood and the desire of the anorexic to hold onto the internal framework that is created within the brain as with any repetitive pattern of behavior. Certainly the need for "protection" echoes throughout patient accounts, but does not have a direct corollary in the literature evaluation of anorexic behavior, although there may be some merit in an argument for controlling food as a means of coming to grips with the external. And, yet, this too is limited for there is frequent reference in the writings of anorexics to a loss of control (12). Clearly behaviors associated with anorexia cannot simply be explained by a desire to be thin.

Bruch addresses some of these issues in her writings, "The patient needs to be instructed, and also the family, that in spite of outer appearances this is not an illness of weight and appetite-the essential problem relates to inner doubts and lack of self-confidence" (8). While this may, yet, be a limited understanding of the genesis of anorexia, Bruch did highlight the necessity for understanding anorexia beyond its outward manifestations and dangerous physical consequences, which are the most visible and treatable components of the illness. Krasnow writes at once about hiding food while he was in the hospital and in the next breath pleads for greater vigilance on behalf of the hospital staff to monitor such behaviors. It is as though he desired outside intervention because he could not override the drive to deny himself of nourishment and could not ask for help directly (11). It is to this that Bruch touches on in her work, but that seems lacking in much of the existing literature about anorexia.

Anorexia, in the late 1980's and early 1990's become more visible than ever before. Other physicians who had treated anorexic patients began to publish books on their interactions for broad audiences. And also anorexics themselves published memoirs of their experiences, sometimes criticizing the dearth of efficacious treatments available to them. Marya Hornbacher published one such book Wasted. Hornbacher is quite critical of her treatment and sees herself in constant battle with the medical team that is trying to help her (12). In describing her experience of anorexia, Hornbacher struggles to come to grips with the genesis of the illness. She writes, "A victim, primarily, of myself, which makes victim status very uneasy and ultimately ridiculous. My family messy, but hardly psychotic. The specifics of my diagnosable disorder, beyond the obvious eating, unclear. I appeared to be some sort of depressive..." (12). Hornbacher's struggle to understand herself within the confines of her diagnosis is typical of the writings of anorexics. As is characteristic of much of the writings done by anorexics, Hornbacher could not herself rationalize why she would systematically starve herself. However, she realized the explanation for her behavior was not as one-dimensional as being singly attributable to family, or other external variables.

The feminist movement in its various incarnations has also voiced opinions on the subject of anorexia, using the rhetoric of female oppression to understand the rise of anorexia within the socio-political arena of America. Some feminists argued that attitudes about women's bodies were to blame for anorexia. Women are seen as being intimately tied to their bodies for reproductive reasons and as a form of social capital. Anorexia in this framework is viewed as an unconscious protest against the politicization of the female body (9). Feminists also argued that the reductionist approach of the medical model, treating anorexia as strictly pathological, failed to address the underlying cultural issues that contribute to the experience of the body (9). The argument provided by feminists to explain anorexia is in part, also, an attack on the ideals promoted by society about the "ideal woman" (4). The notion that women must fit a certain mold, both physically and emotionally, results in a crisis of identity for women, some of whom develop anorexia as a result. The pressures of society, conflict with the individual desire to live unfettered by social constructions of women, which serve to constrain freedoms (13). Susan Bordo views anorexia as the "crystallization of culture". Rather than see anorexia as a set of aberrant behaviors, she purports that anorexics have internalized society's messages, thus reflecting a symptom of social ills (9). There is little evidence of protest, silent or not, of societal messages, though there is likely some evidence for this explanation in the anorexics need to "protect" herself from the outside world (11) .

And while feminists continue to argue for a cultural understanding of anorexia, some also directly challenge the legitimacy of the medical model to address anorexia. Susie Orbach writes, "Because medics are trained to see the body in its component parts and to thus treat the anorexic patient as being symptomatic and hence, in need of treatment at a physiological level, a medical perspective may offer false hope or orientate treatment in unpromising ways" (13). The feminist arguments do not adequately account for the self-destruction, fear and desperation expressed by anorexics and seem only to root their behaviors in a gender struggle that does not have bearing on the lives of many (12). The conversation between proponents of cultural explanations and those with a biological orientation is tense and limited. In the meantime, the anorexic patient is left at the center of a battle between biological and various cultural arguments about their illness, none of which, likely, offers a complete explanation of their behaviors. The limitations of either explanation exclusively are apparent in the outcomes of the patients. However, compromise of the "experts" in evaluating a possible coalescence of factors that lead to anorexia are uncommon and instead the various cultural explanations are usually offered to the exclusion of other explanations and the same can be said of biological explanations (5).

Many anorexics express a sense of being misunderstood by family and physicians. Indeed, there is great emphasis placed, even by the anorexic herself, on understanding why she would starve herself when food is plentiful and do so to the brink of death, when she does not, in fact, wish to die. As Jennifer Hendricks wrote, "I know now that I'm also not strong enough to beat anorexia with others helping me. Although I stopped eating, maybe I really didn't want to die then... Maybe I just accepted the inevitable and quit fighting to live" (14). This mindset reflects that of one who has desire to live, but not the means. It does not seem to be the mind of one fighting a feminist battle or one oppressed by media representations of women. This is the mind of someone desperate to hold on, despite ambivalence as to her own reasons for starving. This is the mind of someone who feels that even with professional help, supposed allies, she cannot hope to emerge from the throes of anorexia. About her experiences in the hospital, her reasons for feeling alone even in light of receiving treatment, Hendricks wrote (14),
Mental hospitals and doctors are afraid of me... I'm a big risk because they don't know what to do. They can't help me and they make me feel like a prisoner.. They take away my right, my privacy, make me feel like I'm unworthy, and not a real person., like I don't have a life or future outside of my illness. All they're interested in is forcing food into me... They bury my thoughts in anorexia, Ignore my feelings about eating. They don't know how to treat bad feelings. I'm done with them.

The despair underlying Hendricks' words appear to mirror the feelings of many sufferers of anorexia, who cannot understand their predicaments entirely, perhaps because they are steeped in their illness; however, who have the presence of mind to recognize their physicians do not understand them either, leaving them scared, hopeless and alone. There is no mention of media images driving one to a thin "ideal" or to the need for perfection. There is only fear and longing. And in the age of the Internet, this fear and longing has given rise to a network of online communities geared towards those with eating disorders. The forums, such as http: / /www. somethingfishy.org serve as an outlet for those with eating disorders and for many, as members of an often misunderstood minority, the support of the group serves as tool for survival, for shared empathy exists among those who are afflicted. Many express dismay at the medicalization of anorexia that has them cycling in and out of hospitals in order to gain weight, only to return home and revert back to starvation. There is hope for the future mixed with fear of continued torment (15). And in a society that does not listen to their desperation, in large part, the online community is a life-line where their voices are heard and received without judgment.

The more recent acknowledgment of a growing population of male anorexics has confounded both health care professionals and social scientists who cast anorexia as a female disease. Because an increasing number of males are afflicted with anorexia, it is forcing a change in conceptualization and treatment of anorexia. Krasnow's tale is consistent with the expressions of guilt, hopelessness and worthlessness that female anorexics describe. And his narrative is somewhat critical of the treatment he received in hospitals, which was largely about weight gain (5). There is still much left unearthed about the experience of the male anorexic and how it fits into the larger schema of the understanding and treatment of anorexia. Between five and ten per cent of cases of anorexia are males. The feminist cultural perspective has not adequately addressed this issue but to suggest that anorexia in men takes different form than in women (2). This is as dissatisfying an explanation as can exist and seems to be a case of the ends justifying the means.

The prevailing conception that anorexics are perfectionists, striving to have dominion over their social worlds and excelling at all of their endeavors, including self-denial persists. The variable of the family, too, is dramaticized in relation to anorexia. The family of the anorexic is typically seen as demanding, affluent and part of the problem, rather than the solution. This, too, is congruent with the notion of anorexic as over-achiever, pressured by her parents to strive with dire consequences. Since the early 20th century, the anorexic, like the hysteric of Freud's era, often described in light of family dynamics (5). This value judgment helped fuel the conception of the anorexic as scheming and manipulative. After all, went the popular thinking, how could anyone from a well-respected, educated family suffer emotional tumult? Indeed, the psychoanalysis of the 1930's-1960's reinforced the notion that some element of normal development in childhood had been arrested, resulting in the manifestation of anorexia, which had definite elements of deceit that were inherent. The salience of the argument rested on the convergence of deceit and the family. Increasingly in the second half of the 20th century, the anorexic came to be viewed as a victim of an oppressive mother. The anorexic as striver felt guilty for surpassing the mediocrity of her mother, thus halted her own development so as to remain an emotional child (4). Kim Chernin describes the daughter's conflict with her mother as, "...this fateful encounter between a mother whose life has not been fulfilled and a daughter now presented with the opportunity for fulfillment" (4). It is the mother-daughter struggle that many argued, in the period post-1930, which was the underlying cause of anorexia. Hornbacher astutely comments on her own struggle with anorexia (12),
... the easy excuses of low self-esteem, bad parenting, media images,
didn't seem sufficient. They were related, certainly. But the part that kept lurking, unarticulated, in the back of my head wasn't discussed.

The "part" to which Hornbacher refers can only be articulated by the patient, not the physician, sociologist or theologian.

There is no consensus as to the etiology of or best treatment for anorexia. Anorexia remains the psychiatric illness with the highest mortality rate. Though the numbers vary, approximately twenty per cent of people diagnosed with anorexia will die as a result of it. And upwards of seventy per cent will never fully recover (5). Anorexia remains in the limelight as a result of popular media images of emaciated women and a greater cultural awareness of the problem. The quest to understand anorexia continues, but will be thwarted without the inclusion of the patient in her care. The treatment of anorexia is as good as the understanding of the treating clinician and the willingness of society to listen. If one in four cases of anorexia result in death and countless others in relapse, there is more to be understood and the best place to glean information is from the people suffering with anorexia. Without their voices, as muted as they may be, there can be but limited resolution.



Appendix A
(Anorexia nervosa, as seen in the DSM IV)

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
B. Intense fear of gaining weight or becoming fat, even though underweight.
C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.) (307.1)

References

1. Brumberg, Joan Jacobs. Fasting Girls: The History of Anorexia Nervosa New York: Vintage Books, 1988.

2. http://www.anred.com/males.html, accessed 29 March, 2008

3. http://www.state.sc.us/dmh/anorexia/statistics.htm, accessed 29. March 2008

4. Chernin, Kim. Hungry Self. New York: Times Books, 1985.

5. Gordon, Richard A. Eating Disorders: Anatomy of a Social Epidemic. Oxford, England: Blackwell Publishers, 2000.

6. American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual of
Mental Disorders. Washington, D.C.: American Psychiatric Association, 1994.

7. Bergh, Cecilia and Per Sodersten. "Anorexia Nervosa: Rediscovery of a Disorder." The Lancet 351 (May 9, 1998): 1427-1429.

8. Bruch, Hilde. The Golden Cage: the Enigma of Anorexia Nervosa. Cambridge, Massachusetts: Harvard University Press, 1978.

9. Bordo, Susan. Unbearable Weight. Berkeley: University of California Press, 1993.

10. Hacking, "Making up People" in: Biagioli, Mario, ed, The Science Studies Reader. New York: Routledge, 1999.

11. Krasnow, Michael. My Life as a Male Anorexic New York: Routledge, 1996.

12. Hornbacher, Marya. Wasted. New York: Harper Perennial, 1998.

13. Orbach, Susie. Hunger Strike: The Anorectic's Struggle as a Metaphor for our Age. New York: W. W. Norton & Company, 1986.

14. Hendricks, Jennifer. Slim to None: A Journey Through the Wasteland of Anorexia Treatment. New York: McGraw-Hill, 2003.

15. http: / /www. somethingfishy.org, accessed 1, April 2008.