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Authors: Susan Bordo
Unbearable Weight: Feminism, Western Culture, and the Body (9 page)
high among females: approximately 90 percent of sufferers are girls or women. Second, and again like hysteria, eating disorders are culturally and historically situated, in advanced industrial societies within roughly the past hundred years.
9
Individual cases have been documented, infrequently, throughout history, but it is not until the second half of the nineteenth century that something like a minor epidemic of anorexia nervosa is first described in medical accounts;
10
and that incidence pales beside the dramatic escalation of anorexia and bulimia in the 1980s and 1990s.
11
These elements point to culture—working not only through ideology and images but through the organization of the family, the construction of personality, the training of perception—as not simply contributory but
productive
of eating disorders. A parallel exists in the formation of female hysteria. Thanks to the benefit of historical distance and the work of feminist scholars, almost all clinicians and theorists today agree that the ultimate sources of hysteria and neurasthenia as characteristic disorders of elite Victorian women are located in Victorian culture, and especially (although not exclusively) in ideology and upheavals related to gender. Most Victorian physicians, we should remember, lacked this perspective. It is only as hysteria has shed its symbolic, emotional, and professional freight, as it has become a historical phenomenon, that it has become possible to
see
it, in some ways, for the first time. Among the important elements now revealed is the clear continuum on which the normative and the disordered were located for Victorian women; it becomes possible to see the degree to which femininity itself required the holding of breath, the loss of air, the choking down of anger and desire, the relinquishing of voice, the denial of appetite, the constriction of body.
All this is visible in part because, from the perspective of the present, Victorian ideals of masculinity and femininity and the styles of behavior that regulated them seem
themselves
as dusty and distant as the disorders of the era. They are denaturalized for us, as our own constructions of gender cannot be, no matter how intellectually committed we may be to a social constructionist view. Too, contemporary medicine, protected by its myth of progress beyond the antiquated models and methods of the past, is able comfortably to acknowledge the thralldom of Victorian medicine to biologistic paradigms and its implication in a dualistic genderpolitics that we
pride ourselves on having transcended. Our contemporary medical models, gender identities, and other ideological beliefs are no longer enmeshed in a struggle to "conquer" hysteria and the mysterious, rebellious female world it once represented to mechanistic science and patriarchal culture. The cultural deconstruction of hysteria as a historically located intersection of Victorian genderculture and Victorian medicine has thus become possible.
As was noted earlier, it was in the nineteenth century that self starvation among elite women first surfaced with enough frequency to engage the general attention of the medical profession. But for the nineteenth century, "hysterical" symptoms such as paralysis and muteness expressed better than selfstarvation did the contradictions faced by elite Victorian women, for whom the ideology of the compliant, refined, and thoroughly domestic lady was a coercive feminine ideal. Certainly, food refusal was an appropriate symptom in this cultural context, with its rigid prohibitions, both metaphorical and literal, against female appetite and desire, prohibitions that were locked in unstable and painful antithesis with a developing bourgeois culture of affluence and indulgence. But (for a variety of reasons discussed in essays throughout this volume) eating disorders have emerged as an overdetermined crystallization of cultural anxiety only in the second half of the twentieth century. The contemporary woman, who struggles to cope with social contradictions that first emerged in the Victorian era but who confronts those contradictions later in their historical development and as they intersect with specifically contemporary elements, is far more likely to develop an eating disorder than an hysterical paralysis.
It is one thing, apparently, to acknowledge the role played by culture in the production of a virtually extinct disorder, wrestled with by longdead physicians who were working with nowdiscredited models.
12
It is another thing altogether for contemporary medicine similarly to interrogate the status of disorders it is still trying to subdue. Researchers do now acknowledge the preeminent role played by cultural ideology in the production of hysteria, but they still resist applying that historical lesson to the understanding of anorexia and bulimia. Although it is frequently acknowledged that cultural pressures may make women "especially vulnerable to eating disorders,"
13
that acknowledgment is usually quickly followed by the comment that not all individuals exposed to these
pressures develop anorexia or bulimia. Hence, it is claimed, other "nonsociocultural" factors must be required in order for the disorder to be "produced" in a particular individual. These nonsociocultural factors (among those most frequently listed: ''deficits" in autonomy, tendency to obesity, perfectionist personality traits and defective cognitive patterns, perceptual disturbances, biological factors, emotionally repressed familial interactions) are then weighted alongside sociocultural factors as
equally
determinative of the disorders. In this way we slide from the understanding that culture alone is not
sufficient
to "cause" anorexia or bulimia in an individual (which is true, and was true of hysteria as well) to mystification and effacement of culture's preeminent role in providing the necessary
ground
for the historical flourishing of the disorders. Eating disorders are indeed "multidimensional," as David Garner describes them. But that does not imply that all dimensions therefore play an
equal
role in the production of anorexia and bulimia.
Often, too, it is emphasized that "factors other than culture may be at work producing the high ratio of females to males." As the editors of the
Handbook of Eating Disorders
put it:
What can explain the low prevalence of eating disorders in men? Certainly many men have the personality factors and family background of anorexic women. These men may also have role conflicts about profession and family, and they live in a culture that exerts no small pressure on males to be thin There could be complex physiological differences in the way males and females respond to chronic energy restriction. It is possible, for example, that males have a stronger counterresponse to deprivation than do females, so that hunger, satiety, metabolism, or other factors exert stronger pressure for weight restoration. Males who are potentially anorexic may encounter stronger resistance to the self imposed starvation, so fewer males progress from the early signs to the chronic condition.
14
Similarly, in
New Hope for Binge Eaters
Harrison Pope and James Hudson suggest that bulimia may be biological ("Perhaps the hypothalamus, or some other part of the central nervous system concerned with eating behavior, is more easily affected in women than in men") or may be "the characteristic 'female' expression of [an] underlying disorder" which men express in different ways. These hypotheses are offered, equally valanced alongside sociocultural explanations, as part of a fascinating panoply of "possibilities," suggesting diverse "new areas of research."
15
My point is not to deny that biological factors may play a contributory role in determining which individuals will prove most vulnerable to eating disorders. (It seems, however, virtually impossible to sort out cause and effect here; most proposed biological markers are just as likely to be the
result
of starvation as the cause.) But to suggest that biology may protect men from eating disorders is not to be open to possibilities; it is to close one's eyes to the obvious. Are the editors of the
Handbook
unaware of the statistics on dieting in this country? Do they not know that the overwhelming majority of those attending weightloss clinics and purchasing diet
products are women? Men
do
develop eating disorders, by the way, and, strikingly, those who do so are almost always models, wrestlers, dancers, and others whose profession demands a rigid regime of weight control. Looking to biology to explain the low prevalence of eating disorders among men is like looking to genetics to explain why nonsmokers do not get lung cancer as often as smokers. Certainly, genetic and other factors will play a role in determining an
individual's
level of vulnerability to the disease. But when tobacco companies try to deny that smoking is the preeminent source of lung cancer among smokers
as a group,
diverting attention by pointing to all the other factors that may have entered in particular cases, we are likely to see this as a willful obfuscation in the service of their professional interests.
I am
not
suggesting that, like the tobacco industry, eatingdisorders researchers have a vested interest in keeping people addicted to their destructive behaviors. Nor do I mean to suggest that medical expertise has no place in the treatment of eating disorders. The conceptualization of eating disorders as pathology has produced some valuable research. But the medical model has a deep professional, economic, and philosophical stake in preserving the integrity of what it has demarcated as its domain, and the result has frequently been blindness to the obvious. This is not a conspiracy; rather, each discipline teaches aspiring professionals what to look at and what to ignore, as they choose their specialties and learn what lies outside the scope of their expertise, and as they come increasingly to converse "professionally" only with each other.
Arguments have been made, however, that are deeply threatening to the very presuppositions of the medical model and are therefore resisted more consciously and deliberately. What I will
I do that, however, I will first describe the broad contours of the feminist/cultural model, examine some specific contexts in which it has clearly issued a challenge to the medical model, and attempt to correct some common misconceptions about feminist/cultural criticism.
The picture sketched in the last section is not seamless. The groundbreaking work of such investigators as Kim Chernin, Susie Orbach, and Marlene BoskindWhite has helped to shape a very different paradigm which has been adopted by many eatingdisorders professionals.
That feminist/cultural paradigm has: (1) cast into doubt the designation of anorexia and bulimia as psychopathology, emphasizing instead the learned, addictive dimension of the disorders; (2) reconstructed the role of culture and especially of gender as primary and productive rather than triggering or contributory; and (3) forced the reassignment, to social causes, of factors viewed in the standard medical model as pertaining to individual dysfunction. In connection with (3), many of the "nonsociocultural" factors that have been dominantly conceptualized as "distortions" and "delusions" specific to the "pathology" of anorexia and bulimia have been revealed to be prevalent among women in our culture. The ultimate consequence of this, for eating disorders, has been to call into question the clinical value of the normative/pathological duality itself.
The feminist perspective on eating disorders, despite significant differences among individual writers, has in general been distinguished by a prima facie commitment both to taking the perceptions of women seriously and to the necessity of systemic social analysis. These regulatory assumptions have predisposed feminists to explore the socalled perceptual disturbances and cognitive distortions of eating disorders as windows opening onto problems in the social world, rather than as the patient's "idiosyncratic" and "idiopathic . . . distortions of data from the outside world."
16
From the latter perspective, when a patient complains that her breasts are too large and insists that the only way to succeed in our culture is
to be thin because, as one woman described it, "people . think that someone thin is automatically smarter and better,"
17
it is described as flawed reasoning, a misperception of reality that the therapist must work to correct. From a feminist/cultural perspective, this approach ignores the fact that for most people in our culture, slenderness is indeed equated with competence, selfcontrol, and intelligence, and feminine curvaceousness (in particular, large breasts) with wideeyed, giggly vapidity.
18
Virtually every proposed hallmark of "underlying psychopathology" in eating disorders has been deconstructed to reveal a more widespread
cultural
disorder. A dramatic example is the case of BIDS, or Body Image Distortion Syndrome, first described by Hilde Bruch as "disturbance in size awareness,"
19
and for a long time seen as one of the hallmarks of anorexia nervosa, both in the popular imagination and in the diagnostic criteria. In both contexts BIDS has functioned to emphasize a discontinuity between anorexic and "normal" attitudes toward weight and body image. In the clinical literature, the initial theorizing of BIDS as a visuospatial problem, a perceptual defect, firmly placed anorexia within a medical, mechanistic model of illness (and a positivistic conception of perception, as well). A person who had this "defect" (sometimes conceived as the result of impaired brainfunction; sometimes, as by Bruch, as part of a more general pattern of defective processing of body experiences due to inadequate infant development) was unable to see her body ''realistically." In more popular renditions, the "bizarre" and mysterious nature of the symptom was emphasized; such descriptions were often accompanied by line drawings of the anorectic standing in front of a mirror that reflected back to her a grossly inflated and distorted image (Figure 3). As one not atypical 1984 article, from a magazine for nurses, described it: