Eating Disorders and Cultures in Transition

Mervat Nasser, Melanie Katzman, Richard Gordon, Mervat Nasser, Melanie Katzman, Richard Gordon

• Publisher: Routledge
• Year: 2003
• Print ISBN: 9780415228596
• eBook ISBN: 9781134585236
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Eating disorders: do they mark cultural transition?

Eating disorders that were once viewed as exclusive to specific class and ethnic boundaries in western culture are now spreading worldwide. This issue is fully discussed in this groundbreaking volume.

Eating Disorders and Cultures in Transition is written by an international group of authors to address the recent emergence of eating disorders in various areas of the world including countries in South America, Asia, Africa and Eastern Europe. It offers an in-depth analysis of the existing socio-cultural model arguing for the need to extend both our theoretical understanding and clinical work to account properly for this global phenomenon. Eating disorders are seen as reflecting sweeping changes in the social and political status of women in the majority of societies that are now undergoing rapid cultural transition.

This multidisciplinary, multinational volume reflects wide-ranging, intellectually stimulating and frequently provocative viewpoints. It promises to be of great interest to medical and mental health professionals, public policy experts and all those watching for the processes of cultural transformation and their impact on mental health.

Chapter 1

Eating disorders East and West: A culture-bound syndrome unbound

Richard A.Gordon

Professor of Psychology, Bard College, Annandale-on-Hudson, New York

Debate question

Eating disorders appear to be on the increase in developing countries, as is evident from case reports and research data. What are the likely mechanisms for this phenomenon? While these disorders are rising in prevalence around the globe, is it possible that their incidence could be leveling off or even declining in the West?

The sociocultural panorama

Since the early 1980s, when papers on cultural influences on eating disorders began to appear in the literature, it has been evident to many observers that eating disorders are unique among psychiatric disorders in the degree to which social and cultural factors influence their epidemiology, development and perhaps their etiology (Barlow and Durand, 1999). Hilde Bruch (1978) was one of the first to implicate cultural factors in the increasing incidence of eating disorders, citing both the fashionable emphasis on slenderness as well as the conflicting demands on contemporary young women that created severe identity confusion. The incidence of eating disorders appeared to increase sharply in the United States, the United Kingdom and many Western European countries beginning in the mid- to late 1960s and then in accelerating fashion into the 1970s and through the late 1980s (Willi and Grossman, 1982; Lucas et al., 1991, 1999; Eagles et al., 1995). This was remarkable for anorexia nervosa, which had been identified as a medical syndrome since the 1870s in Europe and the United States but had been considered a relatively obscure, almost exotic, condition over the first 100 years of its medical history (Bruch, 1973). The situation was even more startling for bulimia nervosa, which had been virtually unknown prior to the 1970s until its description by Boskind-Lodahl (1976) and Russell (1979). By the 1980s, however, it was widely agreed that bulimia nervosa was considerably more common than anorexia nervosa (Pope et al., 1984).

The rise of eating disorders in the United States and Western Europe has been described as a modern epidemic (although not without controversy—see Williams and King, 1987, and Fombonne, 1995) and has coincided with a number of sweeping changes in Western societies in the second half of the 20th century (Sours, 1980). Among these are the rise of a consumer economy, which places an enormous emphasis on the achievement of personal satisfaction at the expense of more collective goals, an increasingly fragmented family that seems beset on all sides by forces such as increasing conflicts in intergenerational relationships and upheavals in sex roles that have introduced great strain and confusion into the developmental experiences of adolescents. Some of these cultural trends seem to play a direct role in the rise of eating disorders. More specifically, because eating disorders affect mainly females and revolve around issues of identity and body image, it is not surprising that observers have linked the rise of eating disorders in the West with the crisis of female identity and the forces impinging on women that followed the cultural upheavals of the 1960s (Gordon, 2000).

Because eating disorders revolve centrally around the issues of body image and weight control, it is important to focus specifically on these factors. Seminal research by Garner and his colleagues (1980) and later by Wiseman et al., (1992) confirmed that idealized representations of the female form in the wider culture have became increasingly thin and relatively less curvaceous in shape from 1960 until the late 1980s. By all accounts, it appears that these trends have continued relentlessly throughout the 1990s. Whether such media images play a causal role in eating disorders or whether they merely reflect the standards of the wider culture is a matter of some controversy (Becker and Hamburg, 1996), but there seems little doubt that there has been an increasingly stringent expectation for thinness in women. Given the centrality of drive for thinness and body image preoccupation in the psychopathology of eating disorders, it seems implausible that the relationship between the increasing demand for thinness in the wider culture and the rise of eating disorders would be accidental. It is likely, however, that only those individuals who are vulnerable to these pressures, such as those with preexisting depression or anxiety, low self-esteem in childhood, a history of weight preoccupation, and perhaps genetic predispositions will respond to these cultural demands with the symptoms of an eating disorder (Fairburn et al., 1997; see Bulik, chapter 4 of this volume).

A related factor is the sharply accelerating increases in overweight in the Western countries, particularly within the last two decades in the 20th century. In the United States, in particular, the percentage of individuals whose weight exceeded levels that are considered medically healthy increased from 25% in 1980 to 32% in 1990 and accelerated even further into the 1990s (Kuczmarski et al., 1994; Mokad et al., 1999). The trends are in evidence, albeit to a lesser degree, in most countries in Western Europe (Seidell and Flegal, 1997). Despite the apparent dramatic increases in weight in the general population, overweight and obesity continue to be highly stigmatized, particularly for women (Hebl and Heatherton, 1998). As a result, an acute tension has arisen between the drive for thinness, on the one hand, and the forces that have led to increases in weight in the general population, on the other. This contradiction is centrally related to the increase in eating disorders. Eating disorders such as anorexia nervosa and bulimia nervosa could be viewed from one perspective as pathologies of dieting, and their increasing prevalence in Western countries has risen in step with the pervasiveness of dieting. A number of research studies have clearly indicated that dieting is a particularly powerful antecedent of eating disorders, especially of bulimia nervosa (Polivy and Herman, 1985; Hsu, 1997).

The fact that eating disorders occur overwhelmingly in women, however, cannot be fully comprehended without addressing the critical transitions in female identity that have characterized the late twentieth century in industrialized or rapidly industrializing societies. As women have moved in increasing numbers into the spheres of education and work around the globe, expectations for achievement and performance have sometimes conflicted sharply with insistent demands for traditional postures of dependency and submissiveness as well as a renewed cult of physical appearance that has been fed by corporate forces (Wolf, 1991). The result of these contradictory pressures has been for many an enhanced sense of personal uncertainty and self-doubt, along with an increased sense of powerlessness (Gordon, 2000). The paradoxical character of this increased identity confusion in the face of enhanced opportunity is captured in the title of a book by Silverstein and Perlick (1995), The Cost of Competence. These authors have suggested that the thin ideal so touted in traditional sociocultural accounts of eating disorders can be understood as a body ideal that de-emphasizes traditional ‘feminine’ curvaceousness, in a society still riddled with sexist stereotypes that associate curvaceousness with low female intelligence.

In fact, it could be argued that the contradictions and transitions in female identity represent the most profound basis of eating disorders throughout history and across cultures (Bemporad, 1996; Katzman and Lee, 1997). This may account for the fact that eating disorders, as they have emerged in the newly industrialized areas of the world, do not necessarily express themselves as body image preoccupations, but rather may draw on a variety of cultural vocabularies to express some common underlying psychosocial conflicts. The fact that female identity issues are at the core of eating disorders will be evident in many of the essays in the present volume.

The global rise of eating disorders: Discussing the evidence

The apparent uniqueness of eating disorders to Western societies strongly suggested that these syndromes are culture-bound (Prince, 1983, 1985). This issue was discussed by Gordon (1989, 2000), who countered the traditional constructs of culture-bound syndromes with the notion of an ethnic disorder. The latter could better embrace the broad array of cultural forces that are shared by a large number of societies, rather than a particular geographic locale. Nasser (1997) posited that the meaning-centered approach to understanding culture may have emphasized cultural differences at the expense of similarities. She argued, based on a review of published research from around the globe, that eating disorders may no longer be unique to Western societies.

Prince (1985) had suggested that as the reach of Western cultural norms became more influential around the world, as initially illustrated in the case of Japan, that eating disorders would become more common in areas that had previously been considered immune to them. This appears to have been precisely the case since 1990. Table 1.1 shows the countries that have reported eating disorders in the literature. It is apparent that the almost all those countries that had reported eating disorders prior to 1990 were European or North American, with the exception of Japan and Chile. Countries reporting after 1990 include Hong Kong and mainland China, South Korea, Singapore, South Africa, Nigeria, Mexico, Argentina and India.

It needs to be pointed out that our knowledge of eating disorders in the areas in which they have recently emerged is based almost entirely on case histories, and in some instances there have yet to be relevant publications in the scientific literature. There are virtually no formal epidemiological studies that document these trends. It is also possible that eating disorders may have existed in at least some of these areas prior to the 1990s, but were either unidentified as such or diagnosed and treated by local healers. We have no evidence that this is the case, and yet the possibility cannot be completely discounted either. Psychiatric services in many of these areas have been sparse and not accessible to much of the population. Nevertheless, it is unlikely, given the cultural logic of eating disorders, that the appearance of these disorders in highly urbanized areas within the 1990s is merely an artifact of observation.

Table 1.1 Countries reporting eating disorders

See Table

For the remainder of this chapter, I will briefly review some of the major geographical areas in which eating disorders appear to be newly emerging, and will preview some of the issues that will be discussed in greater depth throughout this volume. My scope is not meant to be comprehensive. For example, I will not discuss here the apparent increase in eating disorders in European countries such as Spain or Italy, which appears to have intensified during the 1990s (for a discussion of the situation in Italy, see Ruggiero, chapter 7, this volume). Nor will I discuss here the phenomenon of post-communist Eastern Europe and the clash of the values of market economies and the historical transition for women in a post-communist world (see Rathner, chapter 5, this volume, and Catina and Joja, chapter 6, this volume).

1 Southern and Southeastern Asia

Outside Europe and the United States, there is only one country in which eating disorders have been as well known in the second half of the 20th century as in the West, and that is Japan. In a symposium on eating disorders held in Germany in the 1960s, Ishikawa (1965) suggested that the incidence of anorexia nervosa had been increasing since the Second World War. He attributed the increase to changes in traditional family structure in the post-war period. During the 1980s a survey of a large number of medical facilities all over the country showed that the number of patients in treatment for anorexia nervosa doubled between 1976 and 1981 (Suematsu et al., 1985). Even from 1980 to 1981 alone, the total number of patients in treatment jumped from 1080 to 1312. A later survey found that between 3500 and 4500 patients were estimated to have been treated in hospitals in Japan in 1985, whereas in 1992 the number was estimated to be a slightly larger 4500 to 4600 (Kuboki et al., 1996). In the latter study, the prevalence among females between the ages of 13 and 29 was estimated to be 25.7–30.7 per 100 000 population, a figure that is substantial but somewhat lower than comparable US estimates (Lucas et al., 1991). The increasing incidence of eating disorders was confirmed in a study of patients who sought treatment at an outpatient clinic at a University Hospital in the Yamagata Prefecture in Northern Japan, an area of approximately 1200 000 inhabitants about 350 miles north of Tokyo (Nadaoka et al., 1996). Over the period 1978–1992, the number of patients with anorexia nervosa increased sharply with even greater increases in the number of patients with bulimia nervosa.

These temporal patterns are closely parallel to the incidence patterns of anorexia nervosa in the United States and Western Europe. While the reasons for the perhaps singular incidence of eating disorders in Japan vis-à-vis other Asian nations are not clear, one possible explanation would follow from the fact that Japan could probably be characterized as the most economically developed society in Southern Asia after the Second World War. From a cultural standpoint, many of the same tensions that have exploded in the advanced industrial societies of the United States and Europe have been in evidence in Japan. These would include an increased emphasis on individualism that conflicts with traditional collective values, a conflicting female role associated with altered societal expectations, and the everexpanding impact of consumerism and media (White, 1993; Skov and Moeran, 1995). In contemporary Japan, images of thinness are glorified in the media and Japanese teenagers are extraordinarily weight conscious, despite the low levels of obesity in the society. There is considerable tension regarding gender roles and the status of women in Japan, with female aspirations for greater parity with men conflicting sharply with powerful traditions of male dominance. While it is important to recognize the unique characteristics of Japanese society and not to attribute simplistically the emergence of eating disorders to ‘Westernization’, it can at least be hypothesized that the impact of such forces are extremely pervasive. It should be pointed out, however, that Japan has extensive psychiatric facilities and many psychiatric workers who have adopted many of the concepts of American and European psychiatry. This would inevitably lead to a more ready recognition of such syndromes as anorexia nervosa. While such factors should not be discounted, it is however unlikely that such a sharp increase in disordered eating could be totally attributed to them.

Reports about eating disorders in other Asian countries began to emerge after 1990. The first of these was contained in a series of papers by Sing Lee, a Hong-Kong based psychiatrist (Lee, 1991; Lee et al., 1993). Lee was not sure as to whether these cases, which had occurred during the 1980s, represented an increase in the prevalence of the condition or perhaps a greater awareness of the syndrome by Western-trained psychiatrists. In any case, he noted a number of ways in which patients from Hong Kong differed from their Western counterparts. First, most were from the lower socio-economic levels of society. Second, patients often interpreted their inability to eat in terms of gastric distress (for example, symptoms of ‘bloating’) rather than a fear of fatness. Third, and perhaps most important, over half of these patients did not suffer from body image distortion and most did not voice body image concerns. Lee suggests that these patients resemble more those seen by physicians and psychiatrists in England and France in the late 19th century, for whom body image distortion was also not a prominent symptom. He proposed that these observations suggest that current Western diagnostic criteria for anorexia nervosa are ethnocentric, and that they should be revised accordingly (see Lee, chapter 3, this volume).

While the relative lack of body image concerns among anorexic patients in Hong Kong is intriguing, it is important to note that by the mid- to late 1990s, weight consciousness was becoming pervasive among high school students and college students in Hong Kong (Lee and Lee, 1996). This trend is in direct contradiction to the traditional value that the Chinese place on plumpness as a sign of health, and yet it is compatible with the increased influence of consumerist norms in a relatively affluent Hong Kong. It is possible that the lack of evident body image distortion found in those patients may represent an unwillingness to admit to such a culturally dissonant idea.

During the period from 1988 to 1997, Lee reported treating 68 patients with anorexia nervosa and 25 with bulimia nervosa, with the majority of these patients being seen after 1995. Thus, whereas eating disorders were extremely rare in Hong Kong as recently as the 1980s, it may well be that the finding of an intense degree of weight preoccupation that students are now evidencing will soon give rise to an increase in the prevalence of eating disorders to levels comparable to those in Europe and the United States.

Little information is available on the prevalence of clinical eating disorders on mainland China. One survey in the early 1990s of 509 first-year medical college students at universities in Shanghai and Chongqing indicated th...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Notes on contributors
• Preface
• Acknowledgements
• Chapter 1
• Chapter 2
• Chapter 3
• Chapter 4
• Chapter 5
• Chapter 6
• Chapter 7
• Chapter 8
• Chapter 9