We have heard quite a lot over the past few years about the rise in eating disorders in males, and the ways in which eating anxiety and body confidence issues are not restricted to girls and women. Such stories, and the need to address the rising visibility of eating problems in boys and men, certainly carry an important message about who might be effected by - and need treatment for an eating disorder.
But in presenting the rise of male EDs as something 'new', such perspectives nod to the fact that females have been seen as 'obviously' at risk from eating problems, and therefore the 'obvious' candidates for eating disorder treatment. But does that mean that girls and women - in terms of the highly visible association between eating problems and femininity - have necessarily been well-served by treatment in this regard? Calls for the need to specifically 'tailor' treatment experiences for males seem to imply that the historically gendered nature of eating disorders is already actively addressed within treatment. But is this really the case?
My research into the treatment of eating disorders over the last four years would suggest not.
Although eating disorders are now quite widely perceived as what are known as 'biopsychosocial' problems - so combining biological, psychological and social causes - the 'social' part of the equation seems to be a low priority in most treatment contexts.
This is despite the fact that there is a long history of writing on how eating disorders are bound up with, and emerge from, sociocultural ideas such as gender. Susie Orbach and other feminist therapists and scholars have been making this argument since the 1970s, urging us to situate eating problems within complex cultural constructions of femininity. Studies on how girls/ women talk about their eating problems have revealed the complexity of how gender, and gender inequalities, may be woven into eating disorders, highlighting the significance afforded to the very topical issue of sexual harassment and objectification; the use of an eating disorder to evade or 'opt out' of gender binaries and being sexually available; the conflicting pressures on women to achieve professionally while still being acceptably 'feminine', attractive and maternal; an attempt to stall transition into a culture in which women may not be able to 'have it all; the overvaluation of women as nurturers; and the significance of body/eating distress as a way of dealing with being bisexual/ gay.
As this list suggests, these approaches are more complex than only emphasising the pernicious impact of the slender female idea perpetuated by the media. Such contexts are certainly important, but the pressures of body image do not represent the sociocultural aspects of eating disorders in their entirety. Indeed, if sociocultural issues are addressed in treatment, it tends to be through a limited focus on body image, and this is squeezed into a programme that otherwise largely addresses the patient's problem on a very individualised (rather than social) level.
In my research, I surveyed 86 eating disorder treatment contexts in the UK - both in and out-patient, private and NHS - and none of them said that they had systematic or regular ways of addressing these concerns. In fact, some even asked 'why' they would want to look at these issues at all.
This may well reflect the current treatment context for eating disorders right now, in which there has been lots of talk about the importance of 'evidence-based' approaches. This is clearly important: we want to be delivering treatment that has a weight of research and evidence behind it. But evidence-based for the most part has meant Cognitive Behavioural Therapy (CBT) - the kind of approach which can offer quick, clear stats in terms of a patient's progress, and this is clearly attractive in the face of squeezed NHS budgets and rising waiting times. But 'evidence' comes in different forms and packages, and the research that listens to how girls and women talk about their eating disorder often brings us back to questions of gender. CBT is also one of the approaches least likely to situate the individual within a social context.
In response to this omission, I was involved in designing and trialling a new treatment group at an adult in-patient clinic in Norwich which specialises in the treatment of eating disorders.
The group, which was run over 10 weeks, was called 'Cultural Approaches to Eating Disorders', and included all the patients who were resident in the clinic at the time. These were all female, with a diagnosis of anorexia, and their ages ranged widely (from 19-51).
Each week, the programme examined different aspects of the potential relationships between eating problems and cultural expectations surrounding femininity, including gender and 'appetite'; expectations surrounding female emotion and anger; exploring the meanings of the starved female body in relation to cultural prescriptions of femininity; and the dynamics of contemporary 'healthy eating' and fitness cultures aimed at women (and men).
The group used media, such as television adverts, Disney films such as Frozen (2013), press articles, image bank photography to social media, to stimulate debate about the issue for that week. But the media were not positioned as the 'cause' of anorexia, as so often happens in popular ideas about how culture and society might shape eating problems. In fact, the research confirmed the idea that people living with eating disorders find the tendency to portray women with anorexia as the passive victims of media influence as patronising and simplistic. As one of the participants said, pinning it all on "a skinny model in a magazine" "completely trivialises" the many reasons why many people develop body and eating distress.
Nor is it the case that this approach works on the assumption that issues concerning gender identity are only relevant to the experience and treatment of eating disorders in females. The focus on how eating problems may be used to navigate dominant ideas about gender and sexuality is similarly applicable to male patients, as well as gender minorities, even whilst the cultural ideas at stake may be different.
The groups had complex, and sometimes mixed results, and only represented the start of a dialogue about getting questions of cultural identity more clearly on the agenda of contemporary eating disorder treatment. But perhaps the most worrying thing here is why talking to a group full of female patients about the relationships between gender and eating disorders can be seen as 'new' or innovative. It's not rocket science, is it?
The article, 'Feminist approaches to anorexia: a qualitative study of a treatment group', by Dr Su Holmes, Ms Sarah Drake, Miss Kelsey Odgers and Dr Jonathan Wilson, is published on Nov 13, 2017 in the journal Eating Disorders.