Treatment for eating disorders must pay attention to the cultural contexts for eating problems, such as gender, according to new research from the University of East Anglia (UEA).
Although EDs affect people across different genders, ethnicities and ages, women and girls are disproportionately affected by eating problems.
But this quite obvious connection between eating disorders and cultural expectations surrounding femininity is woefully neglected in much treatment, said lead researcher Dr Su Holmes.
Dr Holmes said that although there is now extensive evidence on how EDs are bound up with cultural ideas surrounding gender, the contemporary focus on evidence-based treatment, and particularly the rise of cognitive behavioural therapy (CBT), has all but forced these issues off the agenda.
If cultural elements are addressed, it is through a limited focus on 'body image' work, which often invokes the significance of the media in perpetuating unattainable images of the body.
The paper said more culturally-focused perspectives on eating problems have argued that 'disordered eating may not necessarily be motivated by the drive for pursuit of thinness or any "distortion" of body image, but rather by wider experiences' of gender expectations and pressures.'
Dr Holmes' previous research with people who had received treatment for an ED showed that even when a patient specifically asks to talk about questions of gender, their request may be ignored - either because such issues are seen as a low priority, or because health professionals have little training in this sphere.
In response to this, Dr Holmes and Sarah Drake, an occupational therapist and lecturer in the School of Health and Social Care at UEA, devised and ran a new treatment intervention at an inpatient clinic that specialises in the treatment of EDs.
The group, which was run over 10 weeks at Newmarket House clinic Norwich, was called 'Cultural Approaches to Eating Disorders', and included all the patients who were resident in the clinic at the time. These were all female, with a diagnosis of anorexia, and their ages ranged from 19-51.
Each week, the programme examined what role culture might play in EDs, including:
- Gendered constructions of appetite
- Cultural expectations surrounding female emotion and anger
- 'Reading' the starved body in relation to cultural prescriptions of femininity
- The dynamics of 'healthy' eating/living and fitness cultures' aimed at women
The group used media, such as television adverts, Disney films, press articles, image bank photography to social media, to stimulate debate about the particular issue being explored.
But the media were not consistently positioned as the 'cause' of anorexia, as so often happens in suggestions of how society influences eating problems. The study found that people living with EDs find that the tendency to portray women with anorexia as the passive victims of media influence is often seen as patronising and simplistic by those living with the illness.
One patient said that suggesting seeing "a skinny model in a magazine" influenced the development of EDs "completely trivialises" the many reasons people develop body- and eating distress.
Looking at the wider contexts that shape ideas about gender in society - such as beliefs about 'appetite' - was seen as helpful by the participants. This focus took in food advertising aimed at women as well as wider ideas about 'appetite', such as the ways in which girls and women are still expected to exercise more restraint in sexual appetite than boys and men - and are sex- or slut-shamed if they don't.
Participants in the group said they found it useful to situate their problem within society, thus moving away from the more individualised focus of medical perspectives that may encourage self-blame - but it also raised questions about recovery.
One patient said: "But then, as the groups went on it's like OK, maybe this society's norms are quite disordered. But then it's like ... if society's norms are disordered ... then ... I don't know, how am I meant to change kind of things?"
Dr Holmes said: "The medical framework may offer the patient a greater sense of personal agency when it comes to feelings of control in recovery. Given that anorexia in particular is seen to be tightly intertwined with issues of control, this is clearly worth some thought."
Dr Holmes said: "It is important to stress that the study does not work on the assumption that issues concerning gender identity are only relevant to the experience and treatment of eating disorders in girls and women. The focus on how eating- and body distress may be used to negotiate dominant ideas about gender and sexuality is similarly applicable to male patients, as well as gender minorities, even whilst the cultural constructions at stake may be different."
Indeed, she said, given that recent research indicates how transgender individuals may be particularly at risk from developing eating problems, this arguably adds credence to the idea that EDs may be bound up with the pressures and difficulties posed by dominant gender norms.
Dr Holmes said: "The bottom line is that, although eating disorders are now widely recognised as being shaped by biological, psychological and social factors, the social aspect of the equation is poorly served."
The research is published in the journal Eating Disorders.