Reading Journal

Beyond Body Image: The Integration of Feminist and Transcultural Theories in the Understanding

of Self Starvation

Melanie A. Katzman1 and Sing Lee2

1Department of Psychiatry, Cornell Medical College, New York, New York 2Department of Psychiatry, The Chinese University of Hong Kong

Accepted 23 June 1996

Abstract: Objective: The present study represents an intersection between cross-cultural theorizing and feminist scholarship. It is an attempt to provoke as well as augment prevailing biomedical models that esteem fear of fatness as the primary motivation for voluntary star- vation in anorexic women. Method: Recent studies of eating disturbance in both Eastern and Western societies are invoked to demonstrate the ways in which women straddling two worlds, be it generational, work-family, cultural, or traditional and modern, may employ food denial as an instrumental means of negotiating the transition, disconnection, and oppression that they uniformly endure. Results: A feminist/transcultural interpretation of the literature suggests that by construing anorexia nervosa as a body image disorder or Western culture- bound syndrome, extant models miss the broader contexts and varied meanings of food refusal. Discussion: The implications of cross-disciplinary perspectives for theory building and treatment are discussed, acknowledging not only the gendered nature of eating disorders but their embodiment of power differentials as well. © 1997 by John Wiley & Sons, Inc. Int J Eat Disord 22: 385–394, 1997.

Key words: biomedical models; fear of fatness; eating disturbance; eating and body image; feminist; transcultural

INTRODUCTION

In Picasso’s cubist painting, Les Demselles D’Avignon, multiple visual perspectives converge in an effort to capture the essence of a group of women. Initially confusing and disturbing, the juxtaposition of various images results in a work of art. Likewise, in an attempt to understand disordered eating behavior in women, multiple visions have been rendered, although not all contained within the same picture frame. As a result, logical affinities and influences which may contribute to a more complete portrait of the eating- disordered woman’s experience may have been missed. For example, feminist and trans- cultural scholars—while sharing an interest in the societal contributions to the identifi-

Correspondence to: Dr. Melanie Katzman, 10 East 78th Street Suite 4A, New York, NY 10021.

© 1997 by John Wiley & Sons, Inc. CCC 0276-3478/97/040385–10

Prod. #1233

cation and treatment of disturbed eating and body image—have tended to publish in separate journals with little cross-fertilization. Positioned somewhat outside of the main- stream, these two perspectives may share a valuable vantage point that allows for the critique of existing models of diagnosis and treatment delivery.

Focusing on anorexia nervosa, this article represents an interface between a Caucasian female American psychologist with a feminist approach (M. A. K.) and a Chinese male psychiatrist living in Hong Kong with a transcultural orientation (S. L.). To capture the essence of anorexic illness, we believe that the scope of our conclusions should not be confined by the conceptual frames of our disciplines. Our hope is that the intersection of our ‘‘cultures’’ will generate a dialogue that transcends discussion of thin media ideals to include a broader analysis of self-starvation, recognizing individual efforts to assert per- sonal control and the societal factors that promote powerlessness. While no single theory will encompass all the sociocultural forces conducive to disordered eating, we attempt to concretize those that may have direct applications for recovery and prevention. In doing this, our emphasis is not on perfecting biomedical diagnosis which may ultimately have limited impact on the actual therapeutic regime (Schmidt & Treasure, 1993).

Feminists studying the interplay of pathology and culture have focused on the gen- dered nature of eating disorders (Katzman, Wooley, & Fallon, 1994) and have hypoth- esized about the ways in which women’s roles in society may result in abhorrent eating and body image distortions. Such conceptualizations have been criticized for overvaluing sexism at the exclusion of other societal systems of oppression such as poverty, immi- gration, and heterosexism, and for academic myopia as the focus of theorizing is often white, Western, middle-class women. Cross-cultural scholars, mostly men and often less sensitive to feminist issues, have similarly examined disorders of eating and body image within varying societal contexts. However, their analyses have used ‘‘westernization,’’ rather than gender, as a crude organizing schema. This has resulted in an incomplete accounting of why universally more women than men opt for morbid caloric restriction. While the notion that women’s bodies serve as a template on which cultural and political conflicts are projected is not new in the eating disorder literature (Bordo, 1990; Turner, 1984), this line of investigation has rarely been enriched by cross-cultural exegesis.

Patton, Johnson-Sabine, Wood, Mann, and Wakeling (1990) argued that the study of non-Western groups is ‘‘likely to offer the greatest insight into the cultural determinants of eating disorders’’ (p. 392). If this is so, we must attend to recent reports in the Asian literature indicating that eating disorders do exist among females in transforming cities in the People’s Republic of China such as Beijing, Shanghai, and Nanjing (Song & Fang, 1990; Zhu, Sheng, Li, Fu, & Zhai, 1994), Hong Kong (Lee, Ho, & Hsu, 1993), Malaysia (Goh, Ong, & Subramanian, 1993), and the Indian subcontinent (Khandelwal, Sharan, & Saxena, 1995)—albeit not always accompanied by the expected rejection of body size (American Psychiatric Association [APA], 1994). In a recent review of the epidemiology of eating disorders, Patton and Szmukler (1995) assert that an overreliance on a fear of fatness as a diagnostic feature may result in a failure to recognize anorexia nervosa in broader cultural settings. The Study Group on Anorexia Nervosa (1995), in proposing directions for further research, likewise recommends that ‘‘it is important to take a wide view and not to focus specifically on identifying cases defined on narrowly based Western criteria,’’ and that ‘‘there is a need to develop appropriate local instruments in the first instance’’ (p. 240).

More significantly, a detailed examination of the presentations and permutations of anorexia nervosa in different societies may highlight the pressures placed upon women globally and provide an alternative laboratory in which to examine the impact of societal changes and stresses on women’s sense of their self and body. By examining the grounded

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meanings of self starvation, one may also break through the contraints of current ‘‘bodily obsessed analyses’’ in which fat phobia and body image distortion are esteemed as the universal driving force behind food refusal. The importance of promoting subjective expressions and assuring anorexic patients that their afflictions ‘‘make sense’’ was dem- onstrated in one of the few studies that asked patients to evaluate their treatment expe- rience. Previously anorexic women reported that ‘‘being understood’’ was one of the most important factors for recovery to occur (Hsu, Crisp, & Callender, 1992).

THE TWO-WORLD HYPOTHESIS

For the past decade, feminist writers have delineated ways in which attempts to straddle two worlds give rise to disordered eating. The lines of these ‘‘cultural’’ worlds are often drawn between generations (Perlick & Silverstein, 1994), gender (Wooley, 1991), and the movement from childhood to adolescence (Steiner-Adair, 1991). The impossibility of satisfying all previous expectations of women while simultaneously subscribing to new images of womanhood is often underscored (Katzman, 1993a).

Pressures to conform to these conflicting ideals and the frustrations resulting from false opportunity are echoed in the transcultural literature, in which globalization and en- hanced mobility have paralleled increased identification of eating disturbances in numer- ous Western and non-Western countries as well as in ethnic and socioeconomic groups previously thought to be immune to such disturbances (Thompson, 1994; Littlewood, 1995). Similar issues of role transition, culture clash, and generational disparity have been raised in studies where women juggling two cultural worlds exposed to ‘‘Western ideals’’ in their home countries or emigrating to new lands (see Dolan, 1991, for a review) show an increase in disordered eating.

THE PROBLEM OF VALUES

The growing cross-cultural literature has repeatedly pointed to Westernization or ac- culturation as a major risk factor for eating disorders. While confirming some cultural toxin, most of the studies have engaged in a single binary analysis, viz., are eating disorders in a given country the same or different from the United States or England? Little effort is made to deconstruct the local meaning of food refusal, let alone the nature of gender roles within a society. Instead the overinclusive concept of Westernization has been invoked to capture the impact of some nonspecific cultural process or employed interchangeably with exposure to media influences (Waller & Shaw, 1994; Rather et al., 1995). Rather than examining cultural forces other than a drive for thinness, attention is often sidetracked to debates as to whether or not the criteria for culture-bound syndrome are met in Western and non-Western countries (Steiger, 1993).

However, simply viewing eating disorders as a Western culture-bound syndrome ‘‘rooted in Western cultural values and conflicts’’ (Prince, 1985, p. 300) has three obvious problems. First, it begs the question of which cultural values and conflicts are evoked in Western contexts and leaves intact the assumption that cultural preoccupation with thin- ness and dieting is the primary cultural value ‘‘ingested’’ in this syndrome. Second, culture is often simply used to reflect geographic boundaries without any effort to dis- mantle societal constraints on behaviors and their constructed meaning regardless of their

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locale. Last, the meaning of self starvation for individuals in Eastern and Western coun- tries who report no fat phobia is left unaccounted for (Steiger, 1995).

Specifically, in a study of 70 anorexic patients in Hong Kong, Lee et al. (1993) reported that 58.6% displayed no conscious fear of becoming fat, and in large-scale surveys in Singapore, anorexic respondents usually related no fat phobia (Kok & Tian, 1994). Instead, these non-fat phobic patients used epigastric bloating, no hunger, or simply ‘‘don’t know’’ as legitimations for food refusal. These embodied rationales, Lee and co-workers argue, may represent a more efficient vehicle for the negotiation of change in the Chinese inter- personal nexus than complaints of fatness. In a thorough discussion of psychopathology and personal agency, psychiatrist and anthropologist Littlewood (1995) asserts that South and East Asian women, in the absence of a fear of fatness, engage in self-starvation to instrumentally achieve self-determination when confronted with ambivalent cultural de- mands. In the Western literature, a series of reports also describe ‘‘atypical cases’’ in which self-imposed starvation was not prompted by bodily dissatisfaction (Van- dereycken, 1993; Mitchell, Pyle, Hatsukami, & Eckert, 1986). These findings parallel West- ern reports of anorexia nervosa at the turn of the century in which fat phobia was not stated as the precipitant for morbid food restriction. Prior to the medicalization of an- orexia nervosa in this century, the religious and political nature of food refusal was a starting point for understanding eating disturbance, not a caboose to a genetic- pharmacological train. Historical accounts of asceticism certainly suggest that both the onset and reduction of self starvation mirror changes in oppressed individuals’ opportu- nity for overt recognition and advancement (Vandereycken & van Deth, 1993).

Lee (1996) invoked Murphy’s (1973) concept of changes in symptomatology of mental disorder as a ‘‘by product of social problem solving’’ (p. 51) to explain how anorexic behavior may reflect the ills of a culture absorbed in dieting. However, the problem to be solved by modern-day waif protesters may not directly relate to body morphology or even fat phobia. For example, in the case of Miss W., a Chinese non-fat phobic anorexic patient with a familial history of distance and abuse, Lee (1995) describes her loss of interest in eating as ‘‘symbolizing a loss of voice in a social world perceived to be solely oppressive’’ (p. 31)—a quote which out of context could surely be attributed to a white female feminist.

Another patient seen by M. A. K., a married orthodox Jewish woman employed outside the home, articulated a keen awareness of her diminishing body size but denied any fear of becoming fat. She was just ‘‘unable to eat’’ and refused the weight restoration necessary for healthy functioning and the return of menses. In the course of treatment, it became clear that in a subculture that emphasizes progeniture, the client’s infertility—readily attributed to her anorexia—was in fact a means of protesting proscriptions of vocational motherhood and of concealing her husband’s sexual impotence. Thinness and fashion never entered the discussion.

Theoretical efforts to interpret eating disorders outside of individual pathology—as a product of calculated hedonism (Turner, 1984), cultural narcissism (Lasch, 1979), or meta- morphosis (DiNicola, 1990)—similarly continue to maintain the focus on the body and its appearance as the ultimate end point. This may easily replicate the dilemma of ‘‘woman as body’’ (Greenspan, 1983), without clarifying the meaning of body image distortions as they are created in the context of relationships, or in the societal roles one plays. Medical anthropologists (Scheper-Hughes & Lock, 1987) and sociologists (Schilling, 1993; Turner, 1984) speak to the importance of examining the way in which society contributes not only to the way we construct the body but gender as well. These theorists have dismantled ‘‘Westernization’’ into the changes pursuant to industrialization, such as the organization

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of public and private life, the freedom afforded women, the importance of the individual as a competitive product, the disappearance of traditional cultural idioms for articulating personal distress, and the medicalization of indignation through which active protest is transformed into passive breakdown. In so doing, these scholars have broadened the meaning of disturbed eating during periods of culture change.

Building on these themes, other sociologists and anthropologists (Banks, 1992; Thomp- son, 1994) argue that the image of anorexia as a transitory, self-inflicted problem devel- oped by young women lost in their world of fashion and calorie restricting is a belittling stereotype that may mask women’s real worries. By emphasizing slenderness, the dom- inant imagery about eating concerns misnames as much as it discounts real biases against women and their limited access to other forms of power of self-expression beyond cor- poreal power. As Thompson (1994) writes, ‘‘in countries [celebrating] glorified images of youth, whiteness, thinness and wealth, it makes painful sense that dissatisfaction with appearance often serves as a stand-in for topics that are still invisible’’ (p. 10).

In a review of three transcultural studies that challenge the causal role of Western beauty ideals, Steiger (1995) argues that an overreliance on weight preoccupation as an etiologic variable in anorexia nervosa risks being unduly ethnocentric and misses the universal power of food refusal as an attempt to free oneself from the control of others. He asserts that as the meaning of self-starvation ‘‘transcends its local sociocultural con- text, it cannot so easily be separated from gender’’ (p. 68). From this vantage point the worldwide recognition of eating disorders as a predominantly female malady may not simply reflect a disorder resulting from the internalization of popular media messages, but rather a fairly universal difference for males and females in the task of establishing self-definition and self-control - a ‘‘disorder that may be linked more to power imbalances than gender’’ (p. 68).

For certain, other disciplines and areas of psychology have not clearly separated the impact of gender from the analyses of power differentials. For example, in the sociolin- guistic field, modes of communicating attributed to female styles of relating (Tannen, 1990) have been reanalyzed as expressions of subordinate status (Lakoff, 1995). Carol Gilligan’s often glorified work (Gilligan, 1982) has similarly been reinterpreted not as a uniquely feminine psychology, but rather as a nongender-specific means of adapting to a disempowered status (Hare-Mustin, 1989). Studying matriarchal aboriginal tribes in Tai- wan, Cheng and Hsu (1993) revealed more minor psychiatric morbidity in males which they believed reflected one’s status in the family rather than gender per se. It would, therefore, be valuable to examine both the presentation and ascribed meaning of male food denial in a matriarchal society.

IMPLICATIONS FOR TREATMENT

As a song sung in unison, a resounding chorus emerges, conceptualizations focused solely on the body size of the individual may lose the message embodied in the struggle between eating and noneating. The proliferative literature addressing historical transfor- mations (Bemporad, 1996) and societal contaminants (Littlewood, 1995) to eating disor- ders notwithstanding, the integration of these observations into diagnostic formulations and treatment plans has lagged noticeably. As a result, a ‘‘respectful nod’’ is offered to culture while an undue emphasis on individual pathology has persisted. Mainstream eating disorder research and its focus on the individual without integrating society even when studying ‘‘cultural influences’’ may reflect a legacy of dichotomizing the individual

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and society. In their recent review of the cultural basis of cognitive psychology, Rogoff and Chavajay (1995) argue that traditional approaches to ‘‘understanding individual and sociocultural processes dissected them apart and settled them within the boundaries of disciplines, making it difficult to address questions of sociocultural and individual de- velopment in an integrated manner’’ (p. 871). As the field of psychology in general is struggling to overcome ‘‘the limitations of concepts derived from the dichotomy between the individual and society’’ (Rogoff & Chavajay, 1995, p. 871), it behoves the eating disorder community to do the same.

A SEARCH FOR MEANING

Embedded in public and medical perceptions of health and disease are metaphors created to explain, engage, and sometimes dismiss illness (Thompson, 1994, p. 2). To the extent that ‘‘looking fat’’ defines the dialogue between clinician and patient, the concerns of ‘‘typical’’ patients are sorted along bodily dimensions while other concerns are poten- tially erased. Meanwhile, the concerns of non-fat phobic women, which, potentially over- lap with the definition of an eating-disordered patient as outlined in the 4th ed. of the Diagnostic and statistical manual of mental disorders (DSM-IV; APA, 1994), are marginalized and silenced as they do not count as ‘‘real cases.’’ What if instead of fat phobia the illness negotiations centered on female issues of powerlessness? Would we find more ubiquitous presentation of powerlessness than we would fatness across women in different cultures? In case studies of rural Chinese women (Lee, 1995), feelings of powerlessness, oppression, and experience of sexual abuse are reported, but fat phobia is not. The descriptions ‘‘sound’’ reminiscent of Western eating disorder subjects, but are considered inauthentic diagnostically. If ‘‘no control phobia’’ was substituted for fat fears, how would case presentations, studies, and treatment be organized? How would this impact our efforts at prevention? Historian Micale (1995) makes the point that rewriting the meaning of gen- dered illnesses impacts not only their treatment, but results in an increased understanding of ourselves and our social world.

The level of abstraction willingly employed in diagnosing and understanding patients will clearly dictate not only specific treatment approaches, but our ability for cross- cultural comparison as well (Hui & Triandis, 1985)—a point seemingly underscored more in the cross-cultural than in the mainstream literature. Cross-cultural researchers, disen- chanted with the Western constrained paradigms such as disturbed body image and fear of obesity, have argued for more flexible criteria as well as expanded causal constructs that respect both the individual and cultural relevance of disordered eating (Lee, 1995).

In calling for such a polythetic stance to diagnosis and treatment, male cross-cultural writers are united with feminist theoreticians in urging an understanding of patients that acknowledges societal precipitants for extreme food denial beyond caricatured cosmetic compliance—the latter being the socially sanctioned coloring of distress and not the cause (Russell & Treasure, 1989). Such an approach would value the authenticity of the patients’ illness experience, not merely the validity of available experimental tools. By highlighting the need for a ‘‘shared narrative’’ in an intersubjective milieu (Miller, 1991; Lee, 1995) that respects the communicative power of anorexia nervosa, male and female clinicians and theoreticians in Eastern and Western countries are casting doubt on ‘‘fat-obsessed’’ mod- els that blind the choice of questions asked and limit the answers to be obtained. The repetitive polling of women internationally on fat and food-focused instruments such as the Eating Attitudes Test (EAT), Bulimia Investigation Test—Edinburgh (BITE), and the

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Eating Disorders Inventory (EDI) may provide a false sense of knowledge as to the motivation for women’s war with their bodies. Unexpected results, such as the low EDI scores of East Berlin anorectic patients in Steinhausen, Neumärker, Vollrath, Dudeck, and Neumärker’s (1992) study, call into question the cross-cultural validity of constructs tapped by our most frequently used instruments. Perhaps the renewed interest in quali- tative analytic tools (Streigel-Moore, 1994) will provide a mechanism by which to examine the deeper meanings of self-starvation and forge broader paths to recovery.

One such technique is to utilize the technology available to investigate the meaning- centered interpretation of anorexic symptoms. This has been advanced by feminist thera- pists examining the self in relation to others (Miller, 1991) as well as anthropologists outside of the field of psychology (Banks, 1992; Swartz, 1987). From a medical anthropo- logical perspective, efforts to understand eating disorders that do not consider etic versus emic categorizations are clearly limited (Lee, 1995). By arguing for a contextual under- standing of symptoms, one not only legitimizes the eating problem, but reduces treatment hierarchies as the patient is made expert on her problems rather than having to colonize them into biomedically established norms. The notion of empowering the patient to be the authority of her own care, to develop a vocabulary for enhancing the message conveyed in bodily terms, and to construct a narrative that captures her struggles and focuses recovery, parallels principles in feminist care (Raymond, Mitchell, Fallon, & Katzman, 1994) and the experience of cross-cultural psychiatrists (Lee, 1995). Case studies presented in both literatures speak to a loss of voice and the potential abuses of an unyielding authoritarian treatment system (Steiner-Adair, 1991; Lee, 1995). To some extent, an insen- sitivity to power issues of the provider as well as the recipient of care may account for the treatment resistance noted in professional medical settings in the United States (Sesan, 1994) as well as Hong Kong (Lee, 1995).

Whatever the ultimate metaphor or message conveyed by self-starvation, why does the fear of fatness retain such a central appeal? Why is there a seeming complacency with such a cross-culturally encapsulated organizing theme? Perhaps because the current so- cially constructed fat phobic discourse is ready-made and ‘‘user friendly’’ (Lee, 1997). As a result, it provides both lay and professional people an easily understood moniker. Perhaps studying the change in women’s body ideals is an adequate distracter from studying obstacles to achieving these ideals. Alternatively, those making the diagnoses and negotiating the illnesses may feel more justified in monothetic rather that polythetic understandings. Feminist anthropologist Gremillions (1992) has stated that the range of sociocultural influences that are disempowering to women must be figured into our understanding of eating disorders—seemingly obvious yet often under explored.

PREVENTION EFFORTS: THINKING OUTSIDE OF THE BOX

The elimination of starvation in the presence of plenty has thus far belied conventional efforts at prevention. While it is not surprising that colleagues in the fields of sociology and anthropology, one step removed from daily clinical work, are in a position to chal- lenge prevailing biomedical efforts, the time may have come to consider a broader path. Mental health professionals working in the field of prevention may find that the scope of their theorizing (and thus impact) will remain limited, unless a more comprehensive definition of sociocultural influences is adopted. The cessation of troubled eating appears to be inextricably tied to promoting the status as well as the health of women. Economic parity, maternity leave, protection from violence and abuse, an appreciation of home as

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well as money making, appropriation of welfare and research funds all vary with societal changes and can impinge negatively on women’s health. It is daunting yet probably necessary to recognize with humility that one cannot affect individual elective starvation without somehow treating the social world these individuals inhabit.

CREATING CURATIVE CULTURES

In an effort to focus attention on contextual variables that may fruitfully lead to clinical interventions, Katzman (1993b) has suggested organizing thinking about eating disorders as a problem of disconnection, transition, and oppression, rather than dieting, weight, and fat phobia. Disconnection: As women change social class, countries, or gender boundaries, they may use eating as a method of coping with the disconnection endured when one loses a logical reference group or community to identify with. This problem of discon- nection may result from personal life changes as well as political and social transform- ations. For example, for Chinese women in Hong Kong born to families in which col- lectivistic values are emphasized, exposure, endorsement, and experimentation with individualistic models of personhood may result in psychological displacement. Simi- larly, as communist countries in Eastern Europe shift economic schemes, the temptation to attribute increased detection of eating disorders to the infusion of Western marketing will exist and no doubt contribute (Rather et al., 1995). The challenge, however, will be to recognize the impact of ‘‘societal-identity confusion’’ on individual efforts at bodily con- trol in an attempt to conform to changes in physical as well as role prescriptions. Tran- sition, as women attempt to move between two worlds, and oppression, as efforts to adapt to a new culture, whether it be a different country, socioeconomic or subcultural group, or a work force historically dominated by men, may result in women attempting to perfect their physical selves as a method of coping with the prejudices and isolation that ensue.

Relinquishing a loyalty to fat phobic interpretations of food refusal in favor of ascribed meaning that includes transition, dislocation, and oppression allows for an expanded recognition of personal experience and may introduce a new vocabulary for prevention as well as recovery. What is needed is a process that honors personal power, relational satisfaction, and political position in the family and society at large. In fact, these factors were identified in empirical studies that asked patients to name the variables critical to successful treatment (Peters & Fallon, 1994).

Recovery from anorexia nervosa calls for experimenting with new ways of relating to others and defining oneself beyond appearance. It requires a move from isolation to membership in a community to overcome the disconnection of transition. In this regard, one of us (M. A. K.) has found that groups, among the multiple paths to this end, create curative cultures that prompt the exploration and modification of concentric circles of connection as relationships with group members are used not only for support, but as interactions which recreate struggles with peers, coworkers, and family. By opening a sociomoral discourse in which the meaning of symptoms can be explored and new social roles forged, groups may provide a forum in which complaints created in the context of relationships can be healed as new social ties evolve and new body images are formed. Such mini communities may offer a home for women coming of age while dwelling in a psychological diaspora—endorsing the cultivation of their local worlds of living, not their bodies.

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