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Rethinking Eating Disorders: The Need to Transform Understandings

Eating disorder. 

 

When you hear that term, what images, ideas, or thoughts come to mind? 

 

Is it the ‘normative’ idea of an eating disorder - a young, white, upper-class, and extremely thin woman? Or is it something else? 

 

Do you think of DSM diagnosis – maybe anorexia nervosa (AN), bulimia nervosa (BN),binge eating disorder (BED), or otherwise specified feeding and eating disorders (OSFED)? 

 

Or certain behaviours associated with an eating disorder? 

 

Do you think they are choices, about vanity, something someone should just ‘get over’? Or is it more complex than that?

 

Do you see them as biologically based, socially influenced, or maybe multifaceted? 

 

Or maybe you see how they may be coping mechanisms, a space of safety, offering care to the individual in their own right? 

 

What comes to mind?

 

The idea here is that eating disorders are complex – they are never ‘one’ thing. 

 

They have been conceptualized in numerous ways – ranging from biomedical definitions (i.e., EDs as rooted in biology and abnormal cognition within the individual), to sociocultural views (i.e., influenced by social and cultural factors and forces) to stereotypical popular culture definitions (i.e., the young, thin, white, affluent woman with AN) and variations in between. 

 

These perspectives converge and diverge across various vectors of biology, cognition, eating, food, distress, embodiment, the social, and more to differently construct what an eating disorder does and is, how we understand and view an individual who is living with the disorder, the way treatment is provided, and so much more.

 

But one element is shared– eating disorders typically result in a plethora of physical, psychological, social, and emotional complications that drastically alter one’s quality of life. 

 

How are eating disorders often defined?

 

Currently, the dominant understanding is that eating disorders are biopsychosocial in nature – they are caused by biological, psychological, and social factors that interact in complex ways to give rise to an eating disorder. 

 

The unfortunate thing is that despite the widespread promotion of the biopsychosocial approach, eating disorder conceptualizations remain disproportionately underpinned and regulated by a reductionist bio-psychiatric model (Lester, 2019; Levine & Smolak, 2014). This in turn, direct treatment.

 

The bio-psychiatric model views eating disorders as biologically based mental illnesses in which specific biological, genetic, and cognitive/psychiatric characteristics within the individual lead to a pathological response toward food and weight (Levine & Smolak, 2014). The role of psychosocial factors (i.e., trauma, bullying, emotional dysregulation, etc.) as important contributors is minimally or not at all acknowledged in such a limited view (Ali et al., 2021). Such a view positions the eating disorder as a dysfunction within the individual, and holds that the person is ‘out of control’, irrational, and in need of ‘expert’ (clinical) intervention to ‘cure’ the illness (Bell, 2006; Holmes et al., 2021; Lester, 2019).

 

Simultaneously, in the broader societal space, the stereotypical image dominates understanding of eating disorders, often intersecting with the biomedical conceptualization to deeply influence who is recognized as legitimately struggling with and in need of care to heal from the eating disorder. 

 

For decades, the dominance of biomedicine in treatment and care spaces, and concerns regarding the stereotypical ideas of an eating disorder have been sites of critique. Since the 1970s, various feminist scholars (Bordo, 1993, Chernin, 1985, Lawrence, 1984, Orbach, 1978) have been calling attention to the depth of complexity in the eating disorder experience. 

 

Similarly, the dominant focus on the ‘normative’ image of an individual with an eating disorder has been repeatedly questioned and critiqued since the 1990s as research has continually drawn attention to higher rates of individuals diagnosed with BN and BED than those diagnosed with AN (Sonneville & Lipson, 2018), the disparities in access to care based on body weight (Harrop et al., 2021), that eating disorders occur across all groups regardless of gender, race, sexual orientation, body weight, etc. (Bordo, 2009; Thompson, 1994), and that severe outcomes occur regardless of weight, diagnosis, and other social factors (Harrop, 2020). 

 

Given that treatment and other care practices are governed by eating disorder diagnoses, conceptualizations, and images, the continued lack of intersectional engagement and relationality in understanding eating disorders, impacts the care provided, leading to numerous individuals being misdiagnosed, experiencing delayed care, not receiving care that effectively meets their needs while in treatment (Harrop et al, 2021), being labeled as “resistant” (Boughtwood & Halse, 2010), and being denied needed support.

.

For me (a person with lived experience of an eating disorder and researcher in the field of eating disorders), and many other scholars, activists, and individuals with lived experience, how we understand eating disorders, eating distress, bodily distress, and everything related to it, needs to be transformed.


 Eating disorders are not and have never been simple and to attempt to define them, ‘treat’ them, and understand them in one frame or a limited frame is and will always be a detriment to those suffering. 

 

To truly understand eating disorders as bio-psycho-social requires engaging with critical approaches that recognize the relationality, complexity, and emergent sensibility of eating and body distress. Recognizing that the biological, psychological, social, and all related elements cannot and should never be separated, as they are always entangled. 

 

By conceptualizing eating disorders as relational (i.e., always about interactive factors and forces between people, space, time, discourses, etc.) and tied not only to biology, but also to broader sociocultural, economic, and political systems, and experiences of trauma and dysfunction, treatment systems and broader society may begin to recognize that these biological, psychological, and social elements of eating disorders are deeply entangled and require many different forms of care. 

 

We have to remember that for many of those struggling, their eating disorder does something for them (provides safety, control, care, etc.), and this shifts across time and space. When conceptualizations and accordingly care focus disproportionately on biology, nutritional rehabilitation, and behavioral change while sidelining emotional, social, and embodied experiences, the individual may be left emotionally exposed (Lavis et al., 2015; Musolino et al., 2016; Musolino et al., 2020). Eating disorders serve a purpose. Thus, the complete removal of behaviours and ideas that recovery is a choice, which is common in treatment spaces, can be and often are incredibly distressing for many individuals. This can result in ongoing relapses for individuals, coercive care practices by clinicians, ongoing poor treatment outcomes, clinicians leaving intensive care settings, labeling patients as ‘resistant’, and perpetuating the revolving door phenomenon.

 

A multidimensional relational orientation ultimately illuminates core aspects of eating disorders that are obscured in medical and popular discourse. Eating disorders are not simple – they are and do different things for each individual who experiences living with one. To continue to view eating disorders in simplistic ways is detrimental to all those struggling, as it continues to result in so many individuals not receiving the crucial support they need to find their path of healing. We have to broaden how we understand eating disorders, or we risk perpetuating rising rates and detrimental outcomes for those struggling. 

So, I ask again – when you hear/read the word eating disorder – what do you think? 

I challenge you to question this, to rethink your understanding, to expand your understanding, to listen to the complexity of experiences, and to understand eating disorders are not and can never be simply defined. 

 

References


Ali, S.I., Dixon, L., Boudreau, C., Davis, C., Gamberg, S., Bartel, S.J., Matheson, K., Farrell,

N.R., Keshen, A. (2021). Understanding the effects of reductionist biological views of eating disorder etiology on patient attitudes and behaviours. International Journal of Eating Disorders, 54, 488-491.

Bell, M. (2006). Re/forming the anorexic ‘prisoner’: Inpatient medical treatment as the return to

panoptic femininity. Cultural Studies <-> Critical Methodologies, 6(2), 282-307.

Bordo, S. (1993). Unbearable weight: Feminism, western culture and the body. University of

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Bordo, S. (2009). Not just ‘a white girl’s thing’. In H. Malson & M. Burns (eds), Critical

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Boughtwood, D., & Halse, C. (2010). Other than obedient: Girls’ constructions of doctors and

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Holmes, S., Malson, H., & Semlyen, J. (2021). Regulating “untrustworthy patients”:

Constructions of “trust” and “distrust” in accounts of inpatient treatment for anorexia. Feminism & Psychology, 31(1), 41-61. https://doi.org/10.1177/0959353520967516

Lavis, A., Abbots, E.J., & Attala, L. (2015). Careful eating. Routledge.

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Women’s Studies International Forum, 7(4), 201-209. https://doi.org/10.1016/0277-5395(84)9003-8

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Musolino, C., Warin, M., Wade, T., & Gilchrist, P. (2016). Developing shared understandings of

recovery and care: a qualitative study of women with eating disorders who resist therapeutic care. Journal of Eating Disorders, 4(36). https://doi.org/10.1186/s40337-016-0114-2

Musolino, C.M., Warin, M., & Gilchrist, P. (2020). Embodiment as a paradigm for

understanding and treating SE-AN: Locating the self in culture. Frontiers in Psychiatry, 11, 534. https://doi.org/10.3389/fpsyt.2020.00534

Orbach, S. (1978). Fat is a feminist issue. Arrow Books.

Orbach, S. (1986). Hunger strike: The anorectic’s struggle as a metaphor for our age. Faber &

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Sonneville, K., & Lipson, S. (2018). Disparities in Eating Disorder Diagnosis and Treatment

According to Weight Status, Race/Ethnicity, Socioeconomic Background, and Sex Among College Students. International Journal of Eating Disorders 51(6), 518–526. https://doi.org/10.1002/eat.22846

Thompson, B.W. (1994). A hunger so wide and deep: a multiracial view of women’s eating

problems. Minnesota Press.

 

 

 

 

 


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