In the last two decades there has been an astonishing increase of eating disorders all over the industrialized world. Up to the sixties, cases of anorexia nervosa were a rarity. Bulimia nervosa as a nosographic label had to be described and would receive its name only as late as 1979. From then on, both anorexic and bulimic forms of behavior have been spreading among high school and college students, starting at the social and economical higher levels to reach progressively the lower strata of the population; spreading from the more affluent nations (first of all USA and UK) to the less advanced communities; and taking root especially among persons of the female sex. Girls outnumber boys in the ratio of 10:1 (some authors say 6:1). The disproportion is large enough to support the idea of a strong, maybe even intrinsic link, though of a conflicting kind, between anorexia and femininity.|
The clinical pictures.
The better known form and the one more often talked about is anorexia, but actually bulimia has a larger incidence. In any case, there is a narrow relationship between the two disorders. Some author has even coined the name bulimarexia to give the whole set of symptoms a unifying sense. Since, however, anorexia and bulimia involve two different sorts of behavior, I shall keep them separate at the descriptive level.
Anorexia nervosa is a voluntary self-starvation, motivated by the objective of becoming slim and associated to a overwhelming horror of fat. The diagnosis is made when the subject (usually a woman) has lost 15% of her normal weight (older standards said 25%), has had amenorrhea for at least three months, and displays bizarre and distorted views about either food and/or her own body image. The true, restrictive anorexic eats very little, is obsessed with caloric values and metabolic processes, and engages in an exaggerated motor activity in order to consume the already scarce quota of energy she takes in. As a result she gets to a state of malnutrition that may lead to death. As to bulimia nervosa (from Greek, bous = ox, and limos = hunger), it is characterized by compulsive crises of binge eating. The bulimic fit is felt as irresistible and sometimes is said to occur in an alterated, hypnoid state of consciousness. In bulimic persons we find the same terror of becoming fat as is typical of anorexia. The phase of intake is usually followed by the attempt to reject the huge amount of food ingested, either by vomiting or by using laxatives or diuretics, or by a combination of those procedures. The minimum required for the official diagnosis is the presence of two crises a week for at least three months. Many specialists consider that vomiting and the other maneuvers intended to get rid of alimentary input is an integral part of bulimia, no less than overeating fits. In this way they assimilate bulimia to anorexia, in spite of the differences in behavior. In order to make clear the differentiation, while they call bulimia the eating-and-vomiting syndrome, they call B.E.D. (Binge Eating Disorder) the case in which the patient experiences the overeating attack but keeps the food (such as happens in 25% of obese patients).
Half of all anorexic girls become bulimic after some time. Despite the efforts to resist the desire for food (which is present, contrarily to the etymological meaning of an-orexia, lack of appetite), the patient eventually gives in and breaks her fast. Then, once she has started eating again, she cannot stop any longer. Now she will try to control her weight with the purgative techniques of the bulimic series. The nutritional and energetic depletion brought about by vomiting induces a sense of emptiness, which triggers new overeating attacks, and so on in an infernal circle. Other subjects become bulimic without passing through a properly anorexic phase: they begin a too severe diet in order to regain their figure, but, incapable of following it, they think they may resolve their problems by eating whatever they like and then vomiting. So they enter the vicious circle.
Classic anorexia differs from bulimia-anorexia in the mental make up involved in each disorder. The anorexic girl is outerly autarchic, secure, arrogant; she is parsimonious and solitary; she tends to stay on her own; she claims to be perfectly all right and in no need of help; she is proud of her cognitive capacities and school achievements. Inside she feels miserable, helpless, impotent and distrustful, but takes very few people, if any, into her confidence. Family life is difficult; eating behavior is used against relatives as an element in a racket scheme. The attitude associated with bulimia shows more overtly the depressive elements, with low self-esteem and a sense of defeat. Bulimic girls are more likely to ask for help and seek reassurance, but they do so in an inconstant and unreliable way.
The rejection of bodily curves.
When anorexic or bulimic women tell the psychotherapist how the story began, they usually say that they have undertaken a low-calorie diet because they looked plump, felt "swollen", and understandably wanted to get slim. The body perception may be realistic or not. A 29 years-old woman recognized that at 18, when her troubles started, she was indeed quite slim, but as she had a round face, she could not stand people telling her: "How fine you look!" So she felt compelled to try to lose weight, eventually becoming awfully emaciated. While this patient focused attention on her face, other anorexic women are obsessed with the idea of having heavy legs. But the main target of the anorexic's hate is the bodily curves brought about by the puberal changes. Many patients say that, as girls, they were ashamed of growing breasts and tried to compress them to appear as flat as possible. Thighs and buttocks were still other signs of an awful transformation. Menstruating itself was a terrible suffering and, the first time, had often been experienced as a shock. In some cases amenorrhea has been contemporary to the onset of fasting. All these aspects give fuel to the hypothesis that the loathing for fat and refusal of food in anorexic girls have to do with a rejection of becoming a woman with well defined sexual characters.
In the prototypical picture of anorexia (which may begin at puberty but has an incidence peek at age 16-17), the girl rejects still other elements more or less connected to her gender identity. She questions the value of the feminine model proposed in her family and in her social environment. She generally feels ill at ease with normal average girls who are interested in clothes, mundane success and love affairs. She invests all her residual energy (the largest part is consumed in the struggle against food) in intellectual acquisition pursued in a perfectionist way. She may like staying with male companions, as long as they remain just friends, that is, as long as her body and sex are not taken into account. Sex is excluded from her life and thought. "I cannot bear the idea of a man desiring me, while I loathe myself so much", said a girl in a psychotherapy group.
Is anorexia a refusal of femaleness?
But the fact that anorexia makes sex life problematic and child bearing impossible does not entail that a refusal of the female sex is either a cause or an aim of anorexia. Moreover, the fact that girls hate their female bodies is not a sufficient reason to say that what they reject is just femaleness. They might reject any other aspect of bodily condition: being alive, being material, being mortal. Softness, sweetness, and roundness are also characteristic of babyhood, and the rejection might symbolize the need to free oneself from the helplessness and the dependence of infants. Indeed the literature (1) reports a case of anorexia in a male adolescent, whose struggle was against his round cheeks, because his schoolmates nicknamed him "Bébé Cadum" (an ad for a French soap in the sixties).
May we have been misled into a superficial interpretation of the anorexic girls' "wish to get slim"? Indeed, we might take this formula to mean that the patients have in mind a model to reach and emulate. Many persons consider that anorexia is a direct product of the contemporary myth that proposes thinness as an ideal of beauty. If it were so, it would be easy to explain why anorexia has assumed an epidemic form over the last thirty years, along with the growing success of skinny top models. But it would be a deceptive simplification, which anyway would leave unexplained why so many girls and women insist in their enterprise beyond any realistic regard for both aesthetics and life.
Image-body and appetent body.
Rather, the social model of thinness offers a pretext, either to patients or to scientists, to think of the body predominantly in terms of an image. In my book Il corpo in fame (2) I introduced a distinction between two aspects of the body: the image-body, i.e. the body as viewed from outside, with its physical appearance, its gender, its social collocation; and the appetent body, i.e. the body as a bearer of needs, drives and desires. The image-body is the body "for the others", while the appetent body is "one's own body". The struggle against fat (which concerns the image-body) passes through a control of the appetent body. While normally this control should result from a mediation between internal and external pressure, in anorexia it amounts to a complete suppression of the appetent body. We may get a hint that the real target of anorexia is the appetent body. We shall understand this point better through some examples.
For Barbara, a young woman in her thirties, the anorexic experience began when her husband decided to leave her and get a legal separation. In her anguish and grief, as she ate almost nothing, she lost nine or ten pounds and for the first time found herself at the weight level she had always wished for. She felt euphoric about her slim figure and experienced a sense of lightness, as though she had a new chance. Her husband had always criticized her for being plumpish and lazy. Now she was lean and hyperactive, finally free from people trying to model her according to their will. So Barbara was at one time mourning her marriage and rejoicing in what she felt as a sort of rebirth. As the stress situation passed off and hunger returned, she was not able to restrain herself and resorted to vomiting after meals, entering the ominous spiral of bulimia.
Similarly Elsa, now 40 years old, had become anorexic, then bulimic, after an affective loss. It had to do with her parents, who at the very moment she was on the point of buying a flat broke their promise to finance her project and caused her to lose face to her in-laws. This disappointment was the classical "last straw" and brought about the rupture of the family relationship. Elsa started a diet to get slimmer and soon changed into bulimia. She became aware of the danger of her condition when she discovered blood in the food she had thrown up. Frightened, she stopped vomiting and came to me for psychotherapy. She confessed that she could not tolerate being fat, although after the diet she had realized thinness had not brought any change: she was unhappy as before. She could not free herself from the relationship to her mother, for whom she still had a feeling of hate and distrust, but also an unwished-for nostalgia. She told me that in the evening, after a session in which she had talked at length about her mother, she had felt sick and swollen, as if the mother evoked by our conversation had taken possession of her body and materialized inside her.
Affective rupture at the root of anorexia.
In many other cases as well, if we go back to the circumstances preceding the onset of symptoms, we find there has been a rupture in an important personal bond, such as a broken engagement, the discovery of a sexual partner's unfaithfulness, or (it happened to a girl of 16) a mother's late pregnancy experienced as a betrayal. The affective strain brings about a decrease in food intake, either as a direct effect of depression (a real lack of appetite associated with sadness) or as a reaction against it (a severe diet initiated "to get slim", "not to let oneself go", with a mixture of ascetic pleasure in control, pride in dispensing with the necessary and elation in denying any need of other people's love). As we saw in the case of Barbara, there may be first a depressive, "passive" anorexia, which secondarily transforms into an active form of self-deprivation. There is what psychoanalysis calls a narcissistic withdrawal.
The struggle against bodily fat indeed becomes the struggle against the very softness in character that makes a person dependent and vulnerable. The subject rebels against a) other people who have abandoned her, b) herself who needed their love, c) herself who would have done anything to be loved, including molding herself on what she took to be the wishes of others.
The negative as self-representation.
The wish to be "oneself" with one's own personality is another of the anorexic person's claims. Anorexic persons profess that they want to present a different image in respect to the one other people want them to present. But as their personal wishes are so much enmeshed with other people's opinion, they cannot find an angle of themselves that is not inhabited by (and contaminated with) others' thought or desire. Therefore they can express what they want only as a refusal of models.
Ippolita (age 30) has always felt that her mother required her to be a nice, sweet, elegant lady, ready for the double role of high society wife and tender mother. When she married, she discovered that her husband also expected her to assume a double role, but in another direction: on the one hand he wanted her to associate in perverse sexual play like an expert prostitute, on the other to be a lean and plain intellectual with long gray gowns. Now that her childhood was a long way off and her married life too was finished, she thought she could finally disregard the others' models, but she did not have a positive alternative ideal: "It is not that I want to be the leanest in the world. I don't want to be like those mannequins. I just want to be different". Not only does she not see herself in some future projection, but she has difficulty in seeing herself at present. The way she feels does not match the way she sees her own image. While looking at the mirror she may acknowledge that she is quite lean, but she immediately forgets it. In recent times she does not even "feel" any more; she is insensitive. Anyway she would rather believe the scale's data than her own visual perception. Only the figures may reassure her she has not being growing. But her greatest pleasure, she says plainly, is in watching the needle go lower and lower.(3)
For Ippolita it was impossible to follow all the contrasting models proposed to her. But the question is rather not to feel obliged to follow any, and to be able to produce a personal self-representation of one's own. The fact that Ippolita's self-representation can be measured only against numerical figures and has no sensorial qualities means that it is a mental entity, an idea rather than an image. Like Elsa, who realized thinness did not solve her problems, Ippolita discards the visual proof that she is lean, as if the body image in the mirror had nothing to do with herself. She seems to experience only negativeness (= not to be so and so) and be sensitive only to negative differences. Indeed she is fascinated by the scale's needle going down.
With 22-years-old Sabina, the problem is perhaps not so much to refuse external models as to avoid being encaged in one or another of many possible identities. Sabina has been anorexic since age 16 and has had psychotherapy with me for a little more than one year. For some time she has been talking of a growing difficulty in reaching the place where she gets design lessons. She goes out, but stops at a supermarket, and goes back home to eat and vomit. The summer before, while she traveled back from her holiday over a distance of 500 miles, she had had to leave the train at every station, go downtown, enter some bar or bread-shop to stuff herself with milk and muffins, after which she would take the next train, vomit in the lavatory, and start all over again at the next intermediary station. The length of the journey, like an interminable bridge between departure and arrival places, frightened her, and she felt the need to touch the soil in between. She worded her problem as "the fear of not reaching her destination". In a recent conversation, she realized that she was also afraid of reaching it; that she had started missing lessons after she had successfully passed an exam; that she was trying to procrastinate her training and subsequent autonomy; that as long as she did not finish anything, she could think of having all the roads still open before her eyes. The fear was that of defining herself, solidifying:
SABINA: Clearly, clearly, about design lessons the question is not to pass exams by fear of closing a parenthesis, as we may say, although it actually opens another one, but the impression is that it is a definitive conclusion, and then what is there left?
PIERRETTE: Then I cannot any longer, I have already chosen, I have no longer those possibilities of choosing, because I have chosen, I have done.
SABINA: Of course.
PIERRETTE: Maybe that's it.
SABINA: Instead, exactly, instead a potential that remains open is more reassuring. ... Choice implies giving up, you, you, you take shape, warmth and fullness, therefore you are effectively emancipated from so much else.
PIERRETTE: And from others, from the persons who, while one studies...
SABINA: Of course!
PIERRETTE: There is this aspect, but also the other one, the taking shape, that once a person has taken shape, in some way she feels it as definitive.
SABINA: And assertive too, yes, it is like saying, also in the relationship to the others he is more assertive because he is less unshaped (she laughs), then less, he models himself less, because one can enter any container, I mean one who is still a little in a liquid state, if I dissolve him he may enter any container, if he becomes thicker it is already more difficult, but still more feasible than when he solidifies. It is like water in the ice-compartment, in so many figures, isn't it?(4)
The image of liquid, which can enter any container, is highly evocative of Sabina's thinking interpersonal relationships in terms of adapting to the other persons' mold, and also, naturally, of the extreme temporariness of any choice. In fact, in the rest of the conversation, after expressing the need to conclude her studies, Sabina reverses to the opposite, talking of all the alternative routes at her disposal. This doing and undoing, so strikingly symbolized in the eating and vomiting syndrome, is typical of the anorexic's discourse(5). Sabina has an extreme difficulty in saying "no" to anybody, but she manages to do so all the same by affirming everything and its own contrary in short lapse of time. Her terror, on the alimentary level, of "assimilating" the food (hence the necessity to vomit at once, and as much as possible) has its psychological counterpart in the difficulty of taking in any idea or thought coming from the other person, despite her need for agreement. In the fragment of quoted dialogue, she accepts what I am telling her but then immediately tends to displace the focus of discourse through the abundance of her metaphors.
We now try to explore, on the basis of our reflections and examples, the possible connections between anorexia and femininity. Is there something exquisitely feminine about anorexia? But, as femininity is even more difficult to define than anorexia, is there some trait in anorexia that accounts for its being so much more frequent in the female than in the male population?
Rebellion against models: Anorexic women rebel against the gender models they have been exposed to. Of course the rebellion against models and particularly against gender models has nothing specific about it: It is an universal trait of both male and female adolescence. As to the exposition to models, there is no reason why it should be more of a problem in females, because males too are presented with gender models to equal. We ought to look for something which makes it more difficult for females either to accept models or to reject them.
Difference in models. The first undeniable difference has to do with the preference afforded by society to the male sex over the female one. (In the anamnesis of anorexic girls one often finds that the patient was expected to be a male and therefore was born with a negative quality). The difference in value makes it difficult for anyone to assume a less valued social role; probably girls have more trouble in assuming their own gender identity, as they may feel socially depreciated.
Difference in the psychological equipment. Moreover, there is a psychological factor which seems to be partly of a biological, partly of an educational origin. The equipment necessary to assimilate or to select models consists of various introjection, projection and identification mechanisms, which are present in all human beings. But the observation of small children shows that girls are more liable to adapt to situations than boys; they tend to be autoplastic (trying to change themselves), whereas boys are more alloplastic (trying to change their environment). Be it innate or not, the feminine tendency to "take in" is generally enhanced by education. Girls are taught to be sweet, obedient and acquiescent. Thus they may have more difficulty in being selective, especially when they are involved in an intense relationship. Conversely, once they rebel, they will tend to reject everything in block.
Psychological make-up in anorexia. The basic psychological traits we find in the anorexic-bulimic patients are:
a) an emotional dependence (the need of a tie to a person in order to feel all right, i.e. loved and protected);
b) a mental dependence (to have to think in the same way as the other person does; to have to conform one's own thinking to the other's; to consider differences in thinking as a threat to the relationship); hence:
c) the impossibility of saying no;
d) the impossibility of building a self-representation that may be felt as one's own (there are too many persons who think of you in a different way and you feel you should agree with everyone);
e) the need to escape from the other's thought (but also trying to be "the contrary" of the other's models, you are entrapped in the other's game. You want to be different);
f) the lack of a capacity to think oneself in a positive way and the negativity in itself as the only resource.
The anorexic girl does not know what to be, how to be; she cannot afford to define herself, because any definition would mean she yields to someone else's model and gives up the chance to become her own self. (Here Lacan's formulation about the Other's language as a fundamental alienation is pertinent.) She has to fight against her own acquiescence and bend her autoplastic tendency to her own purpose. The anorexic girl does not so much rejects models, rather she rejects the introjective tendency, which is the basis of all model-adopting, the interface through which models get assumed.
The choice of the symptom. But this is in no way specific of anorexia. A person with this type of problems might as well develop deviancy, drug addiction or schizophrenia. Anorexic people express conflict through the body, and they experience the other's influence in their body as an invasion or a contamination. The more they feel their mind soft and ready to surrender, the more they want to reduce their body to hard bone. To eliminate fat is the equivalent in the body of eliminating the influence of others in their own mind. My hypothesis to explain this "choice of the symptom" would be that living one's problem in the body allows one to save one's mind, one's thought. Anorexic people's delusional thought is channeled into the food-weight-body image topic and leaves the rest comparatively untouched. But why women are more prone to feel or express problems through the body and especially through the body image? Let us go back to the gender models.
Difference in male and female gender models. Boys, from the very start, are encouraged to develop skills, to practice sport, to make objects, to take initiatives. Girls are taught to give an image of themselves (which comprises physical aspects, clothes and hairdo, as well as personality traits). Males are expected to do, whereas females are expected to be. This is a simplifying contrast. Adolescent boys too are influenced in their clothing by current fashion passwords, and girls too are encouraged to study and develop abilities. But a man can be successful even if he is not particularly handsome; for a woman, being plain is more of a handicap. So the importance of body image is particularly impressed upon the girl's conscience, whereas the pressure on the male is rather about professional realization. This could be the reason why women are more threatened by psychopathologies centered around the body (hysteria first, now anorexia).
Why anorexia now? It was a mystery that single individuals separately developed the same rare syndrome, as was the case of anorexic girls in the 1950s or 1960s. But it is still more mysterious how and why the syndrome in question becomes epidemic. The mystery does not concern so much the mechanisms of its diffusion, as the starting point itself. At a certain moment, the picture and the language of anorexia, as was true of hysteria a hundred years ago, provide a stamp in which the individual may cast her own suffering.
Thinness, body and image as socio-cultural factors. One has to take into account a conjunction of various socio-cultural and economical factors to try to explain the epidemic of anorexia from the late 1970s/ early 1980s onward. First, there is the standard of thinness as an ideal of beauty. It has been accepted for the whole century in all sophisticated societies, only a little mitigated in the post-war years (especially in the 1950s), when the western world's ideal woman had generous breasts and bodily curves. Afterwards, thinness triumphed again, as is shown by the emblematic figure of the fashion model, Twiggy, in the 1960s. (Probably the influence of such models has been exaggerated. Girls normally want to be slim, but only a small number of them aim at becoming skeletal.) Secondly, in our rich nations, there has been a remarkable development of a culture of the body. Preoccupation with health and fitness has taken up more and more space in the magazines. Health journals have multiplied, offering advice on diet, physical exercise, body building. Movies, television and show business are more and more explicit about sex, on uncovering the body up to its most intimate parts. In the third place, in connection with body culture, there is an overall obsession with image and visibility. Gossip magazines are full of indiscreet photographs, and even information newspapers publish the most ghastly visual evidence on war and crime.
The crisis of woman's role. This culture of image might be a symptom of a social disease, just as the obsession with one's own body image is a symptom of individual suffering. In any case, the anguish and uncertainty over defining oneself on the individual level (the "identity crisis") seems to correspond to a crisis of woman's role in society. Not by chance, the anorexia-bulimia syndrome started inflating in the early 1980s, when the feminist movement gave up the political line of struggle for equality with men and shifted the focus of its reflection to difference. Woman's very way of thinking had to be freed from male standards and redesigned in accordance with what woman "really is".
Ambiguity in the feminine role is a tangible reality which girls have to deal with. It is the reality of a society in which apparently equal opportunities for males and females mask a persisting disparity among genders. Independently from contingent economic conditions, the current mentality (at least in Europe) still holds to the image of a woman whose main destination is family life rather than professional work. Together with the rhetorical affirmation of the right to be trained for a job, women suspect that training may be useless and illusory or that the future job shall be subordinated to affective bonds. A woman's career may remain a virtual potentiality. Whereas boys know they shall have to find a job, and may consider what they do as a social necessity rather than a personal aspiration, girls may find themselves in the situation of getting ready for something that answers to their own psychological necessity but may not interest anybody else. The lack, or the comparative narrowness of social demands, has to be compensated by an internal calling; or, professional choice has to correspond to the best possible fulfillment of one's own capabilities, irrespectively of its practicability. Work has to be not only rewarding, but also particularly meaningful. There is an "anesthetization" of one's activity, which must fit in the whole personality picture. In this perspective, existential choices are tinged with the shadows of introversion and perfectionism. Thus the specific problems of anorexic girls fit in the general trend.
Economic factors. The anorexia epidemic started in the higher social classes because there the wish for self-realization is not counterbalanced by the pressure of necessity. From then on, the forces of imitation and other unclear factors have spread the epidemic downwards to the less affluent strata of the population. The threat of unemployment may aggravate some girls' frustration of feeling socially unwanted and add to their sense of indeterminateness. But it may also encourage some others to relinquish unrealistic aspirations and look out for available solutions.
(1) Evelyne Kestemberg, La faim et le corps (Paris: PUF 1972).
(2)Pierrette Lavanchy, Il corpo in fame (Milan: Rizzoli 1994).
(3)Giampaolo Lai, "L'abisso del nulla percettivo", Tecniche conversazionali, 18, 1997 (next publication).
(4)Pierrette Lavanchy, "Il buio al di là della siepe", Tecniche conversazionali, 18, 1997 (next publication).
(5)Salvatore Cesario, "Sono uno scolapasta", Tecniche conversazionali, 17, 1997, pp. 84- 94.