Anorexia Nervosa: the Girl Problem
“Throughout history, people have knocked their heads against the riddle of femininity”
Anorexia was long thought to be almost exclusively an illness of young girls. This has contributed to the illness being woefully under-researched and treatment being shamefully underfunded. It has also led us dancing merrily down many a research cul-de-sac and has had a malign influence on diagnosis and treatment. It’s high time we address anorexia’s girl problem.
Medicine: a Man’s World
As a supposedly female illness, anorexia has had a hard time getting the attention it deserves. This is, in part, because women’s health has long been neglected by Western medicine.
It begins with how doctors are trained, says Caroline Criado Perez in her fabulous book Invisible Women: Exposing Data Bias in a World Designed for Men (Vintage, 2020):
Historically it’s been assumed that there wasn’t anything fundamentally different between male and female bodies other than size and reproductive function, and so for years medical education has been focused on a male ‘norm’, with everything that falls outside that designated ‘atypical’ or ‘abnormal’…
As recently as 2022, Elsevier launched what it described as the first female anatomical model to be built with this level of detail in its entirety, to represent the female — versus replacing specific areas of the male anatomy with female features.
The subordination of women’s health is everywhere you look in medicine. Menstruation has been a taboo subject in my lifetime, the word ‘menopause’ didn’t appear until 1858 and the experience, which can be debilitating, has only recently started to receive the attention it deserves. Conditions like endometriosis remain under-diagnosed, and women can be left suffering in extreme pain for years.
Women’s bodies were, and still are to some extent, a mystery. In centuries gone by, a doctor rarely set eyes on a female patient, according to Bill Bryson, in his book The Body: a Guide for Occupants (Doubleday, 2019):
Abdominal examinations were conducted rarely, vaginal examinations almost never, and any investigations below the neck usually involved the doctor feeling blindly under the bedclothes while gazing fixedly at the ceiling.
If you venture further back in time, to Ancient Greece, you’ll find the origins of the idea of that most female of ailments — hysteria. Some Ancient Greek scholars believed in the concept of the ‘wandering womb’ — the idea that the uterus could move freely about the body like a roaming animal and that a displaced womb was the cause of a multitude of problems in women.
The idea of hysteria (from the Greek ‘hustera’ meaning ‘womb’) followed on from this. In later centuries, Christians dropped the idea of a wandering womb and explained hysteria as common-or-garden satanic possession, before it was adopted by psychologists, including Sigmund Freud, and reframed as a disorder of the mind.
Over the years, hysteria has had a dazzling array of symptoms, including anxiety, shortness of breath, fainting, nervousness, sexual desire, irritability and loss of appetite. Before it was given its modern name, anorexia nervosa was often described as hysteria. Little surprise, then, that it was not given the special attention it deserved by the medical community.
The idea of hysteria, though no longer a diagnostic label, still lingers in the collective medical subconscious and is still having a serious, negative impact on the health of women and girls. To this day, women are prescribed antidepressants twice as often as men. This may be because women are more open about their mental health. But could it also be that women’s health complaints, like menopause symptoms, are still not taken seriously? Men feel pain. Women are hysterical.
It’s perhaps unsurprising that medicine has so much catching up to do in its understanding of conditions that are thought to largely affect women, like anorexia, because it was historically a profession dominated by men. In Britain, bars on women studying medicine continued until 1944 when medical schools were forced, by a government committee, to allow acceptance of a ‘reasonable’ proportion of women. (They deemed ‘one fifth’ to be a reasonable proportion.) Before the 1950s, it was rare to meet a female doctor. Today the ratio is close to 50:50. Hopefully this will eventually have a positive effect on areas of health care, like anorexia, that have been largely ignored for so long.
Research: a Man’s World
Like the practice of medicine, medical research was also dominated by men until relatively recently. I’ve lost count of the number of academic papers I’ve read that are written by men sitting in their ivory towers, pontificating about what women (mothers) have done wrong to cause anorexia in their children.
In the Minnesota Starvation Experiment (MSE), when volunteers were semi-starved in the name of science, there was never much suggestion that the psychological problems that occurred were caused by anything other than malnutrition. But energy deficit was not looked at as causal for decades when it came to anorexia nervosa. Researchers investigated the family, or society, or the effect of television, or an array of other outside influences before they started to take the biology of the condition seriously, to look at the effect of insufficient nutrition on the brains of those with the illness.
I believe researchers took this path with anorexia in part because, unlike men, adolescent girls were seen as inherently complicated, inscrutable, emotional beings. This led them to try to figure out why this particular group of girl creatures were behaving in the strange way that they were, why they were starving themselves. They never stopped to wonder if they were asking the right question.
There has been, and still is, an enormous funding problem in anorexia research. And I believe that there are two fundamental reasons for this:
Because the condition is behavioural it is still seen as some kind of choice, and
Because it is viewed as a girl problem.
It is sadly the case for many conditions that affect women, like premenstrual syndrome or period pain, or endometriosis. Today, compared to other mental illnesses, anorexia research receives a pitiful amount of cash. In the UK in 2021 the annual mental health research budget totalled £124.2 million. A mere 1 per cent was spent on all eating disorders, while depression received 9 per cent and schizophrenia 8.3 per cent.
Anti-Female Public Health Messaging
On average, women naturally have a higher body-fat percentage than men. We are not straight lines. Our bodies go in and out. They are often rounded and curved, and it is perfectly healthy and perfectly natural to be wonderfully wobbly. Yet ‘health’ messaging nowadays is often around the idea that fat is bad and must be lost, that smaller is always better, and this can create the conditions for anorexia to thrive in a susceptible person.
Fat on women is not wrong. It’s normal. And women and girls come in all shapes and sizes, reflecting the fantastic diversity and beauty of our species. But if women and girls are constantly bombarded with messages that fat is unhealthy, is it any wonder that so many try to eliminate it?
For someone with a predisposition to anorexia nervosa, this can be catastrophic.
Biased Treatment
Because of the anti-fat health messaging that is so prevalent, in treatment women are often encouraged to put on weight — just not too much. There often seems to be an expectation that girls should look a certain way, and this drives treatment providers to set low target weights. Fear of getting fat runs deep throughout society, and this sometimes extends to anorexia treatment. This is, of course, extremely unhelpful — disastrous even, for many. All it does is keep people unwell. Anorexia will not go into retreat until the person who is ill stops suppressing their natural body weight and reaches the weight that is healthy for them. And if treatment providers perpetuate the idea that fat is bad and wrong by suggesting that anything over a certain BMI is unhealthy, how are they to help someone for whom this fear has become destructive?
Most of the men in the MSE experienced extreme hunger when they were in the rehabilitation phase of the study. Many people in recovery from anorexia also experience extreme hunger. The natural response to this feeling is to eat — a lot. This has historically been pathologised and called bingeing — and discouraged, ostensibly because of the fear that they will develop another eating disorder. I suspect there is also an underlying fear that if they ate too much they might get fat. The horror! And what message is it sending to someone who is in recovery from an illness which is about controlling food intake to the very calorie to be told that it is wrong to eat with abandon, to just let go and listen to their bodies? It is confusing, to say the least.
But I wonder also if something else underlies this discouragement of doing exactly what the body is telling them to do, and exactly what the men in the MSE did: that eating a lot of food is just not considered, well, feminine? A woman or girl having a voracious appetite, either for food, sex, or anything else, has historically not sat well with society. Women and girls are supposed to be dainty, to be small, to be delicate. Eating uncontrollably is just not what girls and women do, is it? So it must be stopped. It must be wrong — even if it is the most natural thing in the world, and what they absolutely need to do in recovery from malnutrition.
Even if it is right.
Punishment
Punitive treatments for anorexia rode on the back of centuries of punishment of women who just didn’t do as they were told — women who didn’t conform to societal norms, or expectations of how they should behave: libidinous women, women who became pregnant out of wedlock, women who wanted to heal others or help them have babies. Caroline Criado Perez illuminates this:
Women who had often done little more than manifest behaviours that were out of feminine bounds (such as having a libido) were incarcerated for years in asylums. They were given hysterectomies and clitoridectomies. Women were locked up for having even mild post-natal depression; the grandmother of a friend of mine spent her life in an asylum for throwing a scourer at her mother-in-law. At least one US psychiatric textbook, still widely in use during the 1970s, recommended lobotomies for women in abusive relationships.
Women have historically been punished in psychiatric treatment for simply being women. Is it any surprise then that, in treatment for anorexia, considered for so long a female illness, women and girls were, and sadly still are, mistreated in quite horrible ways?
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None of this helps people with anorexia nervosa — including men and boys, who have been neglected for decades because of the perception that anorexia is a girls’ illness. Men have historically not sought treatment because they didn’t recognise themselves in descriptions of the illness, or they have often not been diagnosed promptly because they just don’t fit the stereotype. They have suffered, and in some cases died, in silence. Unheard, uncared for, their suffering unacknowledged.
We still don’t know the true ratio of males to females with the illness. Many now believe that the figures are far higher than has been traditionally thought — possibly as high as 50 per cent of all cases. If that is true, anorexia is still being dramatically underdiagnosed in males. And this needs to be rectified urgently.
It’s essential that we move beyond the stereotype if we are to understand this illness fully and if we are to build treatments that are effective for everyone.
Anorexia nervosa is not just a girl problem, but our culture’s problem with girls has affected people who have the illness in extraordinary, far-reaching ways.
It’s time to put that right.