Eating Disorders Cross Culturally
We’ve mentioned the demographics of who gets eating disorders a couple of times before in our ED series, but I’d like to spend a little bit more time going in depth on this. For the most part, we view eating disorders as disease that afflicts white people, and that is primarily in America and other Westernized countries. Many people believe that eating disorders are caused by Western media and beauty ideals. While there hasn’t been a lot of study on cross-cultural EDs, or EDs in other places, I am going to try to review some of the literature about these topics and suggest some conclusions about how we diagnose and treat eating disorders.
So the first major problem is the lack of research on eating disorders anywhere that’s not the US or Europe, and that isn’t on white females. This is getting better, but an important thing to recognize is that we won’t start to recognize a variety of symptoms and patterns until we start studying a variety of people. We won’t be able to diagnose or recognize the full spectrum of the disorder until we look at everyone who could get it.
Second, there are some problems with the diagnostic tools that we use. They are very much slanted towards the presentation of the disorder in white females. This shows itself in a variety of ways: the biggest one of these is the “fear of fat” diagnostic criteria. It still isn’t apparent whether or not this is necessary to have an eating disorder. In many other time periods and cultures, people have exhibited similar behaviors but for different motivations. One of the most common is religious. There are some studies which suggest that eating disorders are an expression of autonomy in some Chinese patients, where the individual is more often expected to subsume themselves under the whole of the family or the community. Our diagnostics assume that all presentations of an eating disorder will be the same as the presentations we have already seen, instead of being open to the possibility that culture may influence the presentation.
So what are some of the differences in different demographics? One obvious demographic that is often overlooked in eating disorders is men. Anorexia athletica is more common in men, and reporting of all eating disorders is highly underreported. However there is evidence that the rates of eating disorders in men are much higher than previously thought, and that many men experience eating disorders less as an issue of body image and more as an issue of desiring strength or muscle tone.
In addition, many studies of other ethnic groups and races show that eating disorders are fairly common in situations where an individual feels that they are caught in between two places. Immigrants report eating disorders as a way of coping with change, or as a way of trying to assert an identity. African-Americans with eating disorders report less body dissatisfaction than white Americans with eating disorders, but they report higher on bad self-image and low self-esteem. Bulimia is far more common than anorexia in Hispanic youth in America. And eating disorders of all kinds are reported at far lower rates in many Asian countries. Clearly there are a variety of motivations and situations at play in cross-cultural understandings of eating disorders. Different behaviors may be considered more or less acceptable (dieting is highly accepted in upper middle class cultures, while restricting food may be considered crazy in other situations), the ability to assert an identity or some control over a changing and confusing situation is always prominent, and different demographics struggle with different self-esteem and self-image issues.
Interestingly, many countries that are considered Westernized have similar ED rates to that of the United States. This includes Japan, South Africa and Australia. While this could indicate that Western media is at fault, it also could mean that these countries simply have started to manifest eating disorders in a way that is consonant with Western diagnoses, and that the images of beauty and self-esteem have been influenced by Western media. In contrast, many of those who feel they’re straddling different worlds report different motivations for their eating disorders. This motivation could be religion, displacement, self-assertion, or identity rather than fear of fat. So while we can show a correlation between influx of Western media and ideals and eating disorder rates, we are still uncertain about the causation, and the complicated nature of the diagnostic criteria and their situated nature makes it even more difficult to understand what exactly is going on.
Overall, we simply need more research into what eating disorders look like across the world, and an in-depth re-evaluation of what makes an eating disorder. It may be the fear of fat, or the body image issues, but it may be the preoccupation with food and the use of food to manage emotions. Once we have a firmer grasp on the underyling similarities between all eating disorders, we will have a clearer picture of the worldwide rates.