To this day, I really don't know why, all of a sudden, I decided to have these weird eating patterns and not eat at all. Exercise so much. I think that I was just a perfectionist, just wanting to make my body even more perfect. But the thing is, a skeleton as a body really isn't perfect. So I don't know exactly what my train of thinking was.
The usual explanations didn’t work: she had no weight to lose (“people would always tell me how skinny I was”), no festering trauma, no troubled psyche. To the contrary, an upbeat person (“I’m very energetic and very bubbly”), she got along well at home (“I have really loving and supportive parents”) and school. A top athlete who made excellent grades and had good friends, life was going great when anorexia suddenly came out of nowhere. Neither Becca nor her therapists could explain how it all happened.
Becca’s story isn’t exceptional. Although a clinician would rightly diagnose “atypical anorexia nervosa”, her type-denying case is anything but atypical. Through in-depth interviews with 22 recovered anorexics (20 female, 2 male) in Tennessee and Toronto, we repeatedly heard type-denying cases.2 So did Garrett (1998) who, in interviewing 34 Australian anorexics, found vanity did not explain the disease; and Warin (2010) whose 46 anorexics at three sites (Australia, Scotland, Canada) repeatedly told her “anorexia was not solely concerned with food and weight”. It’s the same for clinicians in Asia (Khandelwal, Sharan and Saxena 1995; Lee, Ho and Hsu 1993), not to mention the U.S. (Katzman and Lee 1997, Palmer 1993), who find many patients neither fear fat nor crave thinness as “typical” anorexics should. Indeed, what the public and many professionals have come to expect—women dieting madly for appearance—does not adequately explain cases on either side of the globe.
Instead of adolescent girls literally dying for looks, we found youthful ascetics— male as well as female—obsessing over virtue, not beauty. Their restricting was never just instrumental (the means to weight loss) but always also expressive or adventurous or even accidental. Most felt transcendence or grace, echoing the “distorted form of spirituality” that Garrett (1998, 110) found in Australia. That said, today’s pathology is neither specifically religious as anorexia once was (Bynum 1987) nor the performance of tradition as monastic asceticism still is (Flood 2004). Indeed, precisely because our interviewees’ self-imposed asceticism developed outside established religious institutions, it had no community or tradition to regulate it, to reign in excess. Initially exhilarating, their virtuous eating and exercising eventually became addictive. That, anyway, was what our interviewees described—the anorexic’s anorexia.
Shockingly, that isn’t the disease that many institutions are treating. Although most professionals know it’s not as simple as beauty-mad dieting, research has yet to capture the complexity that practitioners actually face. Take a distorted body image: it’s still an official diagnostic criterion but that cliche collapsed under contradictory evidence by the early 1990s (Hsu and Sobkiewicz 1991). Or take categorizing anorexia as an eating disorder: many cases might more readily be called exercise disorders and every case is an ascetic disorder. Or slighting adolescence. Or the unsettled issue of gender: while most sociocultural explanations treat anorexia as a woman’s disease (e.g. Bordo 1997), men make up from one-fifth (full syndrome) to one-third (full or partial syndrome) of the sufferers (Woodside et al. 2001). Over the years the explanation has changed—from hysteria or pituitary dysfunction a century ago to malignant mothering or sexual abuse today—but the one constant is how these supposed causes look through rather than at the anorexic as a whole person. The discourse on anorexia thereby detaches from that anorexic’s experience and values. No wonder treatment programs are so unsuccessful (Agras et al. 2004; Ben-Tovin et al. 2001)!
How has healthcare gotten so far from the anorexic’s anorexia? The larger intellectual answer is Cartesian dualism: in dividing mind from body and individual from society, modern thought fights any realistic social and cultural understanding of disease. The more immediate institutional answer is medicalization: over two centuries, by isolating the sick and sickness from their surroundings, biomedicine has complicated diseases like anorexia and obscured their causes. An emerging literature shows how treatment programs can exercise a Foucauldian power over anorexics (Eckermann 1997), replicate conditions that support and possibly cause the disease (Gremillion 2003; Warin 2010) and, by labeling the person an anorexic, inspire efforts to live up to that diagnosis (Warin 2010). Our interviewees supported these findings, testifying to how treatment sometimes aggravated their affliction and inspired resistance. While medicalizing can also save lives, in this regard its hegemony hurt patients.
Our findings stress how medicalizing hurts research: it obscures anorexia’s causes. We set out to contextualize anorexia only to end up demedicalizing the syndrome. Take the mind/body split. In imposing this arbitrary Cartesian distinction, medical-izing makes anorexia into a mental illness—the mind’s war on the body. That sounds reasonable—and if we ignore the “mindful body” (Scheper-Hughes and Lock 1987) and neuroscience it might be—but how and why this happens becomes a total mystery. Yet all we had to do was erase this Cartesian line to see how an intense mind-with-body activity (restrictive eating and rigorous exercise) bootstrapped anorexics into anorexia much as boot camp makes civilians into soldiers. Or take the individual/ society distinction. In isolating anorexics as abnormal, medicalizing takes them out of the surroundings that gives them social and moral reasons to restrict. Suddenly their actions look completely senseless, inviting out-of-the-blue psychological and biological guesswork. Yet all we had to do was put the person back in context for the obvious evidence to suggest that anorexics were misguided moralists, not cognitive cripples. Warin (2010) makes a similar point: seen in context, anorexics are following cultural rules for hygiene, not obsessing randomly or venting secret traumas. Again and again, contextualizing challenges how medicalizing constructs anorexia by isolating it.
One disease, two approaches—who has it right? We don’t deny that anorexics need medical attention—indeed, it’s the most deadly mental illness of all—but medicalizing anorexics and pathologizing their asceticism and other cultural practices have a miserable record of repeated failure. Today, over 130 years after physicians first isolated self-starvation as a disease, biomedicine can neither adequately explain nor reliably cure nor even rigorously define anorexia (Agras et al. 2004). As medicine’s isolating has failed so spectacularly, perhaps anthropology’s contexualizing can do better.
What’s striking about reconnecting anorexia to the light of day is just how much the obvious evidence can explain. Once interviewing gave us life-course and life-world details, anorexia was anything but exotic. Its extraordinary asceticism had ordinary roots: schooling, sports, work and healthy eating all taught self-denial that these overachievers took to heart. Anorexics simply exaggerated—and eventually incarnated—the deferred gratification that’s so widely preached for the young. Anorexia, then, did not come out of the blue. It came out of perfectly obvious surrounding values and local bodily practices.
Take Becca’s case. Although anorexia blindsides her, it develops out of obvious life-course patterns that she readily describes. In her words, “I'm a real big perfectionist”. In growing up,
I kind of had this image of Becca. When people referred to me it was because of something that had been done quite well. That's what perfection came to. I wanted every little thing about me to just—I guess—be an example. That people would look at me and, like “Wow, There goes Becca! Oh that's the perfect child!”
What Becca describes is a virtuous identity, not a mental pathology. What goes wrong is that she applies this to eating. Her diet thereby takes on a moral character where fat is evil and she chooses good relentlessly.
In third grade I almost had an eating disorder. For some reason I just got scared of fat. I would look at nutrition panels and I would observe the fat, what it said, and I really got scared of fat. I would only eat Kellogg's cereal. Mom was like, “I just cooked dinner and you're eating Kellogg's cereal!” “I like Kellogg's!” My mom got to the point where like, ‘Rebecca, if you don't stop eating just Kellogg's corn flakes I'm going to take you to see a doctor”. And that scared me. I didn't want anyone to think that there was something the matter with me. So how my mom and I approached the problem was we started going to this health food grocery store called Whole Foods. They have a lot of organic products. We would go every Sunday. It was quite a distance. I would get really upset when we didn't get food from Whole Foods.
Was Becca idealizing supermodels? No—and neither was Jim. He reports the same third-grade aversion to fat (“I remember I stopped drinking whole milk and eating red meat in third grade.... That was back when the big health trend was fat. We didn't eat anything fat. No fat at all. Never. None”.). Only much later, as a high school runner, does this health-obsessed athlete train himself into anorexia.
Becca’s restricted eating copies her mother directly (“I look up to my mom a lot and my mom eats really small portions because she gets full easily”) whereas Jim’s regimen develops mutually with his mother (“we pushed each other into having these athletic, healthy lifestyles”). That familial link was typical: nearly three-quarters of our interviewees (16 of 22) grew up valuing healthy eating and living. Then, as anorexics, all obsessively exaggerated how healthy eating restricts. And now, in recovery, all of them watch what they eat, a reasonable yet distant echo of their earlier obsession.
Are these fringe attitudes, the delusions of a few health fanatics? No, our informants echo how contemporary culture moralizes eating. Witness the popular prejudice where fat people, in “letting themselves go”, get stigmatized as weak or even bad; and slim people, in being strict with themselves, exemplify strength and goodness. Or consider how people readily judge their own eating, speaking of “sinning” with dessert, “being good” with veggies, or “confessing” a late-night binge. What’s at stake here is virtue, not beauty. Over roughly the last century, as the body has increasingly become a moral arena, eating and exercise have come to test our mettle (Brumberg 1997; Stearns 1999).
Anything but marginal, this discourse of individual responsibility is heavily promoted by health agencies and widely accepted by the public. It urges the good person to eat sparely and nutritiously, exercise regularly, avoid all health risks, and—as a matter of self-respect—keep a slim and attractive body. True, few people live up to this demanding discipline, but fewer still contest it is “right”, the proper way to live. So it’s a bit like a Sunday sermon where the lifestyle urgings are scientific, not reli-gious—or are they? Healthy eating’s discourse cherry-picks science. A more realistic perspective would recognize that health is broadly social, not narrowly individual, and that the “domain of personal health over which the individual has direct control is very small when compared to heredity, culture, environment, and chance”. So says Marshall Becker (1986, 21, 20), a public health school dean. He goes on to characterize today’s faith in healthy living as “a new religion, in which we worship ourselves, attribute good health to our devoutness, and view illness as just punishment for those who have not yet seen the Way”. Well, it is religious—evangelical even—but it’s not very new. Early 19th-century health and fitness movements developed this moralizing discourse (Green 1988), but it took until the turn of the 20th century to become mainstream (Stearns 1999).
What draws people into this discourse? Our interviewees gave us two answers: a bodily predisposition and identity politics. Here’s Becca on identity:
My best friend’s family—whenever I would come to their lake house or something—they would always, “Goodness Gracious, we gotta have fruit for this child! We have to have carrots. Here we have all the other little girls that are having cookies and this kid's eating carrots and fruits and healthy peanut butter snacks”.
Becca restricts and, given today’s cultural concerns, others notice. Their feedback makes this a point of pride, an arena for further achieving. This isn’t exceptional. Most of our informants described how a slim body, strict eating, rigorous exercise, or even being anorexic became an identity that they began to value and build into their youthful sense of self. Here age matters: our informants all develop anorexia during adolescence, a transitional time that intensifies the need to find and express one’s identity.
A further anorexia-explaining factor appeared once we looked at our informants historically rather than just situationally. Here, in shifting from a life-world to a life-course context, we found a biocultural “flywheel” carried them into anorexia. To make sense of this evidence, we had to revive the old fashioned and decidedly non-Cartesian idea that each person has a distinctive constitution. Our update is biocultural.
Anorexics are not culturally but bioculturally constructed. To starve oneself taps capacities and inclinations that develop only over years. From conception to adolescence, each person’s initially wide possibilities progressively narrow as the organism grows and adapts to a particular environment. Day-by-day, the interaction of biology, culture and chance fix points that shape later interactions; and, bit-by-bit, this biocul-tural hybrid—a constitution—grows in guiding force. Our informants had developed constitutions as children that later predisposed them to anorexia as adolescents. Three dispositions stood out:
Were someone to take up dieting, healthy eating or training for any reason, these dispositions would intensify their practice. In this sense our informants were primed for anorexia. All of this was quite obvious once we looked at life-course.
None of what we’ve attributed to constitution, identity and healthy living is guesswork. It’s what our informants reported, each speaking independently. With remarkable consistency they describe paths into anorexia that are obvious and rather ordinary—at least until the last step. That final exceptional step—becoming anorexic—is mysterious. None of our informants could say how or even when it happened. So perhaps here, as the change comes invisibly, clinical inference might reasonably replace everyday evidence. And yet, when we pieced together what our informants said separately, we discovered that even the final move into anorexia had left empirical tracks. We found eight recurring features that, taken together, suggested how intense restricting and exercising integrated into a self-sustaining system. That’s not to say facts speak for themselves—in this instance Foucault’s (1988) technologies of the self elucidated the dynamics; it’s to say that, taken seriously, empiricism can penetrate even the enigmatic.
Empiricism has answers that medicalizing dismisses. Instead of making the most of what’s obvious, specialists assume anorexia has an underlying pathology, that the cause is deeper than what the surface suggests.3 And that might eventually prove right—surely we can’t rule out what’s still undiscovered—but for now it’s better to reason with the obvious rather than guess at the obscure. That’s better science: by Ockham’s razor (the principle of parsimony) simple and direct explanations should take precedence over the complex inferences the now “explain” anorexia. And it’s better medicine: addressing the obvious—by showing anorexia’s everyday dimen-sions—would allow anorexics to participate in their own recovery, quite unlike some treatment programs where specialists take control (cf. Gremillion 2003).
What a culture knows about an illness can help sufferers interpret the experience, share it with others and work towards recovery. Yet with anorexia what today’s culture supposedly knows—stereotypes about media excess, gender inequity, sexual abuse, dysfunctional families—stigmatizes sufferers and their families. As this distorted picture has little or nothing to do with the experience of anorexia and its causes, it misdirects self-help as well as treatment. No wonder anorexics resist therapy and nothing seems to work!
To do better at treating anorexia we should stop searching the shadows for hidden causes when the sunlight reveals so much. By this standard everyone—family, friends, clinicians, sufferers—should consider four facts. First, what outsiders see as stubborn self-destruction is not what the anorexic experiences. Quite the contrary, inside the regimen, restricted eating and intense exercise prove moral worth, showing one has world-class willpower and self-control. Here, to open a dialogue, outsiders must first appreciate this achievement. Then, and only then, can one help anorexics see the vice in their virtues.
Second, once established, the syndrome has all the visceral momentum of an addiction. So anorexics may want to change long before they can break free of the body’s discipline. Some credited their recovery to loved ones or friends who kept trying to help them break free, refusing to give up hope or to accept rejection.
Third, long before anorexia, our interviewees had set a constitutional course for the disease. We asked them how they stayed healthy after recovery returned them to their earlier inclinations and immersed them in a society that moralizes eating. Three suggestions emerged: develop activities with mind/body integration (e.g. playing piano, nature walks), reverse anorexic inclinations (e.g. seek friends rather than solitude) and cultivate balance in everyday life.
Fourth, the disease develops through training. That suggests the need for retraining, perhaps in healthy practices described above, and it argues against digging up deeper pathologies. The latter unleashes doubt and blaming that can impede recovery.
* Originally published here
1. Based on the book How Virtue Becomes Vice: ExplainingAnorexia as an Activity by Richard A. O’Connor and Penny Van Esterik [under review]. From age 13 to 16, O’Connor’s daughter was anorexic. Researching how she and other anorexics embodied ascetic values raised larger biocultural questions about nurtuance and society that we explore in The Dance of Nurture: Embodying Infant Feeding [in preparation].
2. Use of “we” throughout this article recognizes the collaboration of our interviewees as well as the contribution of Penny Van Esterik, second author in the original Anthropology Today article (2008, Vol. 24, No. 5, pp. 6-9) entitled “Demedicalizing anorexia: A new cultural brokering”. We would also like to acknowledge the help and insights of Anne Becker, John O’Connor, Leeat Granek, Jim Peterman and Anthropology Today's editor and reviewers.
3. In the 19th century, as modern medicine developed its scientific authority, rationalism theorizing often trumped empiricism’s everyday evidence. Where the former was Platonic, seeing reality behind appearances, the latter followed Aristotle in learning from direct observation. At one point calling a physician an “empiricist” implied he was a quack who practiced by personal observation rather than scientific theory (Oxford English Dictionary 1989).
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