Becoming Anorexic

A sociological study

Muriel Darmon

• Publisher: Routledge
• Year: 2016
• Topic: Social Sciences
• eBook ISBN:
  9781317175834
• Subtopic: Sociology
• Index: Social Sciences

Anorexia tends to be studied within health disciplines, such as medicine, psychoanalysis or psychology. When the condition is discussed in relation to society more broadly, focus is commonly restricted to considerations about the demise of the traditional family meal or the all-pervading obsession with thinness and media representations of 'size zero' models. But what can sociology tell us about anorexia and how a person becomes anorexic? This book draws on empirical research – both interviews and observation – conducted in and outside medical settings with anorexic girls, medical staff, teachers and other teenagers of the same age. As such, it offers the first fully sociological treatment of the condition, taking the reader closer to the actual experiences of people living with anorexia. It retraces the behaviours, practices and processes that create what is patterned as an anorexic 'career' and reveals the cultural and social characteristics of the people who engage on this path taking them from a simple diet to hospitalization or recovery. Richly illustrated with qualitative research, Becoming Anorexic: A Sociological Approach demonstrates that anorexia can be viewed as a very particular work of self-transformation, which requires specific – and social – 'dispositions'. As such, it will appeal to scholars of sociology and anthropology with an interest in health and illness, the body, social class and gender.

Part I
Beginning with a diagnosis

1 A detour via the nineteenth century

Historical issues at stake

It seems logical that an object with a history should owe at least part of its existence to its social conditions. When it comes to addressing mental illness, the historical method has often seemed to be the social sciences’ tool par excellence, to some extent a reflex reaction to the question ‘What can social science say about mental illness?’ While debates surrounding the notion of the ‘historical and social construction of illnesses’ do draw attention to the possible limitations, deviations and misconceptions of this issue,¹ they have nonetheless contributed to underscoring the value of historical contextualization: the benefits of looking at how, at a given place and time, it was possible for a diagnosis to be established (or invented, manufactured or discovered, depending on how provocative one wishes to be).

In this chapter, I draw on history’s power to ‘objectivate’ things. It is especially useful in this case, because my investigation was based on a diagnosis and that diagnosis therefore has to be put in context, and particularly in historical context.² The history of the medical diagnosis of anorexia has been subject to much study, particularly in the United States. In addition to books solely devoted to retracing this history, almost all recent books on anorexia in the social sciences and humanities give substantial space to its history. On the basis of these studies – among which Joan Jacobs Brumberg’s works deserve particular mention, as they are still the main reference in the field – it is possible to outline the historical and social configuration in which the first formulations of the diagnosis of anorexia emerged in France and in England, at the end of the nineteenth century.

Illness and diagnosis

The ‘anorexic saints’

Even when these studies refer back to older attempts at establishing the diagnosis, they all agree on the fact that its modern formulations appeared at the end of the nineteenth century. They differ, however, in how they frame the links between the history of the diagnosis and the history of the illness itself. The question of historicizing anorexia is at the heart of lively debate in the social sciences and humanities (and not only in medicine): Did the diagnosis and the illness both appear relatively recently or did the diagnosis of a very old illness simply appear very late in the day? Discussion has centred on the question of the ‘anorexic saints’.

This debate is not unrelated to internal debates taking place in the medical sphere, which also draw oppositions between different ways of calling on history.³ But it has taken on a certain autonomy within the social sciences and humanities, where historians argue about the pathological labelling of certain medieval pious practices and ask how old ‘anorexia’ is as an illness. Were the medieval saints anorexic? In other words, did the illness exist before the diagnosis did?

In medieval Europe, particularly in the years between 1200 and 1500, many women refused their food and prolonged fasting was considered a female miracle. The chronicles and hagiographies of this period tell numerous stories of women saints who ate almost nothing or claimed to be incapable of eating normal healthy fare . . . . Women who were reputed to live without eating – that is, without eating anything except the Eucharist – were particularly numerous in the thirteenth through fifteenth centuries . . . . By the seventeenth and eighteenth centuries, however, scientifically minded physicians began to pay close attention to food abstinence, so common among women of the High Middle Ages. They called it both inedia prodigiosa . . . and anorexia mirabilis (miraculously inspired loss of appetite). Some medical writers and historians claim that anorexia mirabilis and anorexia nervosa are really one and the same.

(Brumberg 1989, 41–2)

Two authors stand out in this debate opposing those who believe that anorexia mirabilis and anorexia nervosa are two separate phenomena and those who believe in continuity between the two. In Holy Anorexia, historian Rudolph Bell retrospectively applies modern psychological theories to explain the case of medieval fasting and talks about an ‘analogy’ between the medieval and modern women who abstain from food: in his view, the medieval saints had ‘anorexic behaviour patterns’ (Bell 1985). Even though he does not claim that modern anorexics and medieval saints were the same – he describes them as ‘anorexic saints’ – he does present them as ‘analogous’, psychologically motivated by the same search for identity and autonomy in societies that oppress women: ‘In this sense the anorexic response is timeless’ (Bell 1985, 56). For medieval scholar Caroline Walker Bynum, however, renouncing food made sense within a much broader system of religious practices, which modern authors tend to forget when they give fasting such a predominant place (Bynum 1985). In her view, equivalence with anorexia is a historical misinterpretation and applying this diagnosis retrospectively is a mistake. She believes it is not even possible to talk about a single type of fasting behaviour that was simply viewed differently at different periods (as a pious act in the Middle Ages and an illness in the twentieth century): ‘Medieval people did not see all refusal to eat as “fasting” (i.e. asceticism) or all extended abstinence as miraculous’ (Bynum 1987, 195).

To take up Catherine Garrett’s terms (1998, 112–16), this debate therefore opposes proponents of ‘continuity’⁴ (for whom there is a form of continuity between medieval religious anorexia and modern anorexia nervosa) and proponents of ‘discontinuity’ (for whom there is no sense in applying a modern diagnosis to medieval practices).⁵ The discontinuity argument seems to be in the majority within the social sciences, whereas the continuity stance is much more visible in works in medicine or psychology. Discontinuity is mainly defended in the name of the principles of historical methodology, and in particular the problems inherent in applying a diagnosis retroactively, but also in order to avoid being too quick to assert the existence of an eternal feminine: ‘The underlying assumption here [in Bell’s text] is that the psychology of women is fixed in time and that past and present are the same’ (Brumberg 1989, 43). For both these reasons, it is reasonable to follow the lead of the social historians advocating discontinuity and consider that the history of the illness and its diagnosis coincide.

From this perspective, anorexia can therefore appear as one of the ‘transient mental illnesses’ analysed by Ian Hacking: an illness ‘that appears at a time, in a place, and later fades away’ or ‘reappear[s] from time to time’ (Hacking 1998, 1). Using Hacking’s terms, one might suggest that an initial ‘niche’, ‘stable home’ or ‘habitat’ for the medical diagnosis of anorexia emerged in France and in England at the end of the nineteenth century and that this niche then crumbled in the early twentieth century before being reconstructed, with some changes, from the 1960s onwards.⁶ Showing how the diagnosis emerges requires looking in detail at its different constituents. I will give particular emphasis to three points: how the diagnosis slotted into medical taxonomies; what kinds of conditions of possibility were necessary to identify the practices covered by this diagnosis; and how representations of the female body were reconfigured when it was first formulated.

The diagnosis within medical taxonomies

Two distinct processes led to anorexia appearing in medical taxonomies: fasting practices were included in the sphere of medical competence, and fasting was recognized not as one of several symptoms of certain illnesses (particularly organic illnesses) but rather as a separate diagnostic entity in itself (in England) or an autonomous symptomatic group related to hysteria (in France).

Secularizing and medicalizing female fasting

After the miraculous fasting of the thirteenth to sixteenth century, cases arose that were more problematic for contemporary observers. Beginning in the seventeenth century, women who fasted became the subject of a classification quarrel between doctors and priests over who had the right to account for their practices. During the seventeenth and eighteenth centuries, prolonged abstinence from food was increasingly related to organic causes and considered the symptom of an illness rather than the sign of supernatural intervention. Losing appetite and fasting were progressively enrolled in the medical sphere, although not without some difficulty (Brumberg 1989, ch. 2). Finally, during the last third of the nineteenth century, this ‘long transition from sainthood to patienthood’ (60) once again created a very visible opposition between priests and doctors on the topic of the ‘fasting girls’ of the Victorian era. This term, used at the time by both the British and the Americans, served to designate cases of prolonged abstinence from food without specifying whether this fasting was of a religious or medical nature. In the case of one young woman, Sarah Jacob, she ‘literally was killed by empirical design’ (67) after medical observation was organized to verify her claims that she no longer ate: this surveillance was so efficient that the young woman died on the tenth day of observation.

Such events, largely publicized outside the medical sphere, gave medical science the chance to take the refusal to eat and change it from a religious act to a symptom of illness and thus to bring these women under their control. By the end of the nineteenth century, fasting behaviour was firmly enrolled in the sphere of medical competence. Behaviour was henceforth read through a secular lens and the medicalization of this behaviour contributed to professionalizing medicine – two processes that of course extended far beyond the question of female fasting.⁷

In parallel – and following the inclusion of fasting practices in the medical sphere – during the last two-thirds of the nineteenth century, fasting went from being the symptom of various illnesses, particularly organic ones, to being a diagnostic or symptomatic entity in itself (Brumberg 1989, 101–2). In 1873, a French doctor named Lasègue published an article entitled ‘Of hysterical anorexia’. That same year, an English doctor named Gull presented a paper at a Clinical Society congress that was published shortly after under the title ‘Anorexia Nervosa (Apepsia Hysterica, Anorexia Hysterica)’. Both described cases of young women from good families who limited their food intake and lost weight, sometimes to the point of emaciation, while still maintaining or even increasing their physical movement and activities and without there seeming to be any physical causes for a state that therefore had to be considered, at least partly, ‘nervous’ or ‘mental’. These two texts are traditionally defined as the first forms of medical diagnosis of anorexia and their authors as the founding fathers, discoverers or inventors of the diagnosis.⁸ The early stages of the medical diagnosis of anorexia were therefore framed by the controversy opposing ‘nervous’ and ‘hysterical’ anorexia.

I shall not go into the details of these two diagnostic formulations as they have been very widely documented.⁹ I will simply underline the fact that, as Ian Hacking has shown for ‘transient mental illnesses’, these diagnoses slotted into existing medical taxonomies without entailing any ‘scientific revolution’, in Kuhn’s sense of the term, but that they also constituted topics of discussion or even controversy within the medical community (Hacking 1998, 38, 81). Lasègue’s formulation took place within the search for the various manifestations of hysteria, while Gull’s corresponded to efforts made by high-status consultants to make diagnostic acuity the hallmark of medical competence (Brumberg 1989, 111–12). The diagnosis gave rise to an interesting debate for doctors, given that it constituted a secondary battleground for the controversy surrounding hysteria. This controversy did not oppose ‘nervous’ England and ‘hysterical’ France but rather took place within each country between proponents and opponents of the main national diagnosis. In France, Charcot himself, along with some of his students, questioned whether hysterical anorexia should be related to hysteria while, in England, Gull’s opposition to theories of hysteria was strongly debated within English medicine, and some practitioners using Gull’s term nonetheless still considered anorexia nervosa a variant of hysterical behaviour.¹⁰ This debate is still in play today (although the stakes are not the same) in the importance given to each of the founding fathers of the diagnosis. Indeed, publications on anorexia differ in terms of which doctor they consider to have ‘really’ discovered the diagnosis and which doctor they credit with the most refined and ‘modern’ formulation. This choice to call on different traditions might initially seem to be mainly due to their national character (an English and then North American tradition, on the one hand, and a French one on the other); however, the question still needs to be repositioned within the current space of scholarly discourse about anorexia. Gull’s medical approach focused on examining the symptoms of anorexia nervosa (extreme emaciation, loss of appetite, no menstrual cycles and substantial activity). Lasègue’s was more psychological and gave substantial weight to the description and clinical study of the ‘stages’ or ‘phases’ through which the patient and her close family and friends went through. When researchers choose to call upon one founding father rather than the other, this therefore depends largely on their own theoretical approach.

Under the watchful eye of medicine and the family

These initial formulations of the medical diagnosis of anorexia share the common feature of defining a very specific clientele: young girls (between sixteen and twenty three for Gull, between fifteen and twenty for Lasègue) belonging to the middle and upper classes.¹¹ At the time, these were the classes where a whole apparatus observing the bodies and eating behaviour of women and adolescent girls was put in place – an apparatus that therefore constituted a second set of historical and social conditions of possibility for establishing the diagnosis. Indeed, in order to be able to label practices as deviant, they have to be identifiable first.¹²

In general, in the nineteenth century, the observation of bourgeois adolescent behaviour increased with changes in family structure and especially in the place ascribed to the child. In particular, a network observing female eating habits developed that placed young girls’ restrictive eating habits under the watchful eye of both the medical institution and the family.

First of all, the medicalization of female conduct continued and grew stronger at the end of the century thanks to its potential to serve political interests, as Jan Goldstein has shown in the case of the medical diagnosis of hysteria:

The popularization of the hysteria diagnosis and related ‘nervous’ conditions served the anticlerical cause . . . . It helped to sever the close traditional bond between women and priests, which nineteenth-century French anticlerical republicans had always found so odious, and to repl...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Introduction
• Part I Beginning with a diagnosis
• Part II The anorexic career
• Part III The social space of the anorexic career
• References
• Index