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In this section, we will look a little more deeply into the socio-cultural aspects of eating disorders. We will then attempt to make useful bridges between what is understood about these factors, and the other components of an eating disorder: biological, nutritional, psychological and emotional.

There is a complication. The biological, nutritional, physiological, emotional, and socio-cultural components, factors and causes of an eating disorder need to be understood in context. In essence, unless we understand the context of an eating disorder we will not understand the disorder, or the patient who suffers from it.

And the context is a complex one, since the biological, nutritional, physiological, emotional, and socio-cultural components, factors and causes of an eating disorder not only exist as multiple forces, but they also interact with each other in complex ways. It might be helpful here to use a common metaphor for complex systems.

Context can be understood as ripples in a lake. The ripples interact with and influence each other. Each ripple may begin its life very small, but as the many ripples interact with each other, the energy of each force is combined, expanding and increasing the size of their collective effects. We cannot see clearly when the first one ends and the second one begins; the ripples melt into each other.

Because treatment often involves getting to the source of problems, the overlapping of the various forces can make it difficult to follow any single part of the problem back to its source. If change is to be created, each of the forces must be understood, so treatment can target what is wrong.

Therefore, the next part of this training will be to examine the forces at play from the socio-cultural context. Unlike some aspects of mental health treatment – which are directed by research around specific, limited and controllable variables - some of the understandings presented in this section will be somewhat uncertain, even speculative.

This is because the effects and influences of socio-cultural factors are very complex - with so many complicated variables in play - that even high level multi-factorial analysis yields very uncertain results.

This means that the ideas that will be presented here must be viewed as theories, not facts. As better or more detailed understandings are uncovered, the theories will evolve and provide better knowledge to support the work of the clinician.

However, it is still important to provide this information as a starting point for the clinician. Research does indicate that the contextual factors arising from socio-cultural components do have effects on the prevalence and course of eating disorders. (57) This implies that the course and prevalence of eating disorders can be positively affected by interventions that target the socio-cultural components in informed ways.

In order to be able to target these socio-cultural factors in informed ways, it is necessary to have a relatively deep understanding of what these factors are, and how these factors work and interact with one another. This allows the informed clinician to make good choices about interventions at each point of contact with the eating disordered client.

The overall context concerned with eating disorders includes gendered life, which is one of the first contexts that human beings enter into. Adults respond differently when a baby is presented to them – based upon whether the baby is a boy or a girl. Thus, the baby begins the process of being engendered - right at birth.

(When understanding eating disorders it is important to understand the difference between sex and gender. Sex is composed of the biological and physiological characteristics given by the chromosomes of an individual. Gender is the social manifestation of the sexes. Gendered life correlates to the sex of individuals for most, but not for all individuals.)

Eating disorders occur in both sexes – but with similarities and differences characteristic to each gender. Eating disorders seem to be sensitive to gender. This is most clearly understood in the fact that females outnumber males by a factor of about 10:1.  (101)

However, recent studies from a large epidemiological community based study in Canada found that this gender difference may not be as large. (2)
Male to female ratios of eating disorders in minorities have not been established to date. In one study, Gray and colleagues found low rates of bulimia among Caucasian and Black males in their college population, but found that Black males reported a higher frequency of binging, fasting, and dieting. (35)

The idea of what is means to be a female or a male – with all of the attendant ideals, norms and expectations – will vary, depending upon a variety of other contexts in which the eating disorders occur. While some of these different gender ideals, norms and expectations may be relatively stable over time, others can change relatively quickly in conjunction with new fads or other kinds of cultural shifts.

Mental health clinicians, who are likely to be separated from adolescents by at least a half generation, may not be fully aware of sudden transformations in the peer culture, or in how the larger culture influences the adolescent sub-culture. The increase in eating disorders among younger males may be a clear signal that something has shifted in the context of gendered life over the past few years.

It may suggest that it is not just girls who are feeling the increased pressure to achieve ideals of physical perfection. Whatever factors offered males a higher degree of protection against these pressures appears to have been weakened.

There may be another, interacting factor at play here. Sudden change in the cultural ideals, norms and expectations – or expansion into a diversity of opinions about these ideals, norms and expectations – can create uncertainty about what is the "right" way to be a man or woman.

Since uncertainty is not the most comfortable experience for vulnerable adolescents, this may contribute to the selection of a more concrete set of ideals – predicated upon physical appearance. More firmly defined gender roles may have offered some protection against this kind of uncertainty.

This theory is supported from research around another of the important contexts: culture. Historically, women seemed to have had lower rates of eating disorders when they lacked freedom of choice. According to some authors, within modern affluent Muslim societies where women’s actions are limited and where male power is the norm, eating disorders are virtually unknown. (6)

The influence of culture on eating disorders has been long noted in the literature. Both AN and BN are more common in the industrialized Western cultures. (70)

Several studies have identified more specific socio-cultural factors within the Western world and American society that are associated with the development of eating disorders. For example, examination and analysis of historical patterns have led researchers to propose that eating disorders have prospered during affluent periods in cultures that are more democratic and that create relatively uncensored societies. (6)

Researchers have noted that the latter part of the 20th Century has seen an increase in eating disorders in younger women. (2, 80, 114) Some researchers suggest that BN is a culture bound syndrome while AN has the same prevalence regardless of culture. (57) Therefore, AN has been described as a non-culturally bound disorder.

Other researchers however, disagree. They have described AN as a "culture-bound syndrome," with roots in Western cultural values and conflicts. (69, 85) Both lines of thought agree on the point that the difference between AN from previous centuries and modern AN seem to lay in the fact that modern AN features a fat phobic quality. (37)

Fat phobia was not displayed by anorexics of past centuries. Thus, the cultural aspect of the anorexic symptom seems to be the fear of becoming fat. This is a new development, because ideals of beauty have changed in the icons of the modern culture.

This leads to an important question for this section of our course:

What are the cultural aspects of our Western societies that allow for the development of an eating disorder and the terror of fat?

Eating Disorders Factoid

42% of 1st-3rd grade girls want to be thinner.

Source: National Institute of Mental Health (Citing Collins, M.E. (1991). Body figure perceptions and preferences among pre-adolescent children. International Journal of Eating Disorders)

The Value of a Thin Physique

It is not a secret that influential forces within our culture value thinness. More and more, big cities around the world have health clubs that champion unhealthy attitudes towards the human body. Furthermore, these health clubs are clothed in a mantel of well being for the physical condition of their members.

This longed for, unnaturally thin physique appears to be based on images portrayed by the media. According to psychologist Carolyn Costin:

‘American models weigh 23 percent less than the average American woman whose weights are 140 pounds. …Adolescents are snorting cocaine not to gain weight. Eighty percent of fourth graders report dieting.” (15)

Although not all Western societies adore thinness, globalization appears to be bringing the values of the dominant culture to places where these values were previously absent. Societies that were not concerned with weight in the past are acquiring a taste for thinness.

It is not a surprising thing to find fat phobia in our society. From early on, girls are handed models of beauty that are hardly appropriate. These models of beauty are potentially damaging - because they are unrealistic and because they create insecurities.

Body size is about the most alarming insecurity that it generates. A negative body image is generally believed to be a precursor to the development of an eating disorder. (28) Conversely, a healthy body image is a protective factor against the development of an eating disorder.

The negative body image begins, in general, with the perception that the body is larger than the ideal dictates. The ideal, as we have said earlier, is defined by a variety of influences, including the media. This ideal, however, is also bound into the fabric of a consumerist culture in complicated ways.

Eating Disorders Factoid

81% of 10 year olds are afraid of being fat.

Source: National Institute of Mental Health (Citing Mellin, L et al. A longitudinal study of the dietary practices of black and white girls 9 and 10 years old at enrollment: The NHLBI growth and health study. Journal of Adolescent Health)

Most girls in our Western society are offered Barbie dolls to play with. The physical dimensions of a Barbie doll are not realistic. Little girls who dream of being young women, begin to dream in terms of doing and being like their play objects. They begin to expect (consciously and unconsciously) to be like their dolls.

However, when these little girls grow up, few - if any - will look like a Barbie. It is hardly surprising that little girls feel disappointed with themselves and their appearance when presented with such iconic and unrealistic models of perfection towards which they should strive.

After more than four decades, Barbie continues to be an item that is in high demand for little girls. Moreover, in an era in which there is much easier and more readily accepted access to plastic surgery, women are allocating resources to approach that ideal in greater numbers. This increases the pressure on other women to keep pace – or lose ground.

But why is thinness so important in our culture?

The Women’s Therapy Center articulates that thinness has come to occupy a too important position in our culture, becoming almost an imperative. This imperative takes place in a context. The key to understanding why thinness is so important understands women’s and men’s psychology in the context of the industrial revolution and the consumer culture, which we will do in this same section.

In the subsequent section, we turn to an examination of the value of thinness as a historical development of the concept of beauty.

The Value of Individualism

Individualism is a Western value. It prioritizes the individual over the group.
In contrast to the Western culture, many Non-Western cultures put the group well-being above the individual person.

Popular media and clinicians have pointed to the value of individualism as a factor on the development of eating problems and disorders. Fierce individualism may be one of the aspects that pave the way to excessive perfectionism.

In an individualistic culture and society, beauty - if it is not a natural attribute - is seen as an attribute that can be acquired: through dieting, workouts, make-up, and/or surgery. “If I put, my mind to it, I can do it” is a motto, an individualistic way of thinking. This can lead to an individualistic and narcissistic quest to be ideally attractive, a quest to which many in our culture subscribe.

Additionally, individualism has been seen as a partial culprit for lack of communal feelings. This lack of communal feelings may contribute to women and men feeling alienated.

By contrast, within cultures in which the well-being of the group supersedes the needs of the individual, individuals are valued not for their individual selves, but as part of the group they belong to. This value allows for the formation of a strong sense of community, and a sense of belonging to something meaningful that is larger and more durable than the individual self.

With the sense of self connected to and supported by the presence and successes of the whole community, there is less pressure on the individual to aim for individual standards of perfection. In fact, in many community based cultures, individuals may be punished or ostracized by the community if they stand out too much as individuals. Theoretically, in such cultures there may be less vulnerability for the individual person to acquire an eating disorder based upon a drive to individual perfection.

However, although the value of individualism seems to be a factor in a culture that reveres thinness, it is also important to understand its underpinnings in interactions with other contexts. It has been proposed that people in our culture sometimes look for simple solutions to solve complex problems.

The problems experienced by people in our culture may be multiple and diverse, and may belong to many different realms of reality: ethical, moral, social, economic. The individual – in cultures that value individualism – may receive many messages that each person is responsible for how successful he/she is in handling these complex problems.

However, many of these problems exceed the capacity of the individual to solve, potentially leaving the individual feeling like a failure. The individual, rather than tolerating an absence of control, begins to look for areas of his/her life that can be controlled – hoping that success in that area will magically and miraculously serve to correct the larger ailments.

Some theoreticians believe that this aspect of the interaction between the individual and his/her culture leads to an obsessive search for physical perfection as a substitute for solutions that are more real and more substantive. This is thinness as life success.

This aspect is enhanced and magnified by the next context issue we will examine, the value of perfection.

Eating Disorders Factoid

51% of 9-10 year old girls feel better about themselves when dieting

Source: Academy for Eating Disorders

The Value of Perfection

The need for perfection and other personality traits may be related to genetic and biological factors in some eating disordered patients (AN). (15)
When these factors get coupled with a culture that sees perfection through the achievement of thinness, the results can be disastrous.

We live in a culture whose core values include ideas about having ‘the best’ and striving for ‘perfection’. Wines and teas and steaks need to settle, brew or be cut to ‘perfection’. Schools for our children, even pre-schools need to be the best or, at the very least the perfect-fit for our children. Performances in small and big companies need to be nothing short of perfection.

Not surprisingly, we live in a culture that has exploded with the need to perfect the body, too. The body has become the temple where perfection is shown, or needs to be achieved. Perfection has become a badge of honor that can be achieved with hard working tenacity.

The Ancient Greeks believed that beauty got them closer to the gods.
However, unlike the ancient Greeks, the present quest for perfection - as far as physical beauty goes - has no religious underpinnings. It is beauty (the current and very subjective concept of beauty) for beauty’s sake alone. There is no spiritual connection in today’s achievement of beauty.

The research is not yet available to determine if this value – and the valuing of individualism – contribute to a vulnerability to developing eating disorders in the Western World, and some protection against eating disorders in non-Westernized communities. It is a theory that still requires clearer substantiation.

What is clear is that in a consumerist culture, a whole industry has been developed to take advantage of the present state of affairs: the dieting industry.

The Norm of Dieting

The dieting industry is a 50 billion dollar industry targeting both women and, increasingly, men. Men, unfortunately, are joining in the norm of occasional or constant dieting.

Currently, males comprise 10% of eating disordered individuals. (15) However, studies show that 41% of men are unhappy with their weight. (15) In a sample of high-school students, 28% of men wish to gain weight and another 15% were trying to lose it. (15)

This may suggest an unhappy truth: both overweight and underweight men can be unhappy with their "imperfect" physical attributes. Both can feel the pressure to achieve physical perfection.

This is different than statistics for women. Of the women who are unhappy with their weight, 63% of those want to lose weight. (15) The ability to diet has become a worthy asset in a society obsessed with perfectionism and a mindset that worships individualism. Dieting is the proof of the idea of mind over body.

One of the more common topics for conversation among women is the subject of food and dieting. The pressures to be thin and to diet are ever present among women and a way to bond to each other as well. Dieting is one of the conversation pieces that equalizes and brings women together.

Not only have fashion models and actresses gotten thinner (and more toned and muscular) in the last forty years, but the size of Miss America contestants have become considerably smaller, too. Moreover, according to some studies, these contestants can even meet weight criteria for AN. Playboy centerfolds have gotten considerably thinner, as well – down to a size 4. (114)

Dieting is almost a rite of passage for adolescents. Studies show that 50% of girls between age 11 and 13 believe they are overweight. (15) By age 13, 80% of these girls have attempted to lose weight. (15)

Many professionals in the field have shown that there is whole stable of research backed literature that is consistently disregarded by the medical world and the diet industry. This literature points to evidence that it is better to have a heftier- but stable - weight than it is to force the body into a false set point.

However, if this research was to be acknowledged, the diet industry would run the risk of missing half of its potential clients. In a recent movie comedy, one of the characters, who owns and runs a health club, can be seeing telling his employees to add some weight to the scales his clients use. He is also seen admonishing his clients that they are looking fat – even when they are at a sound and very healthy weight – so they will feel badly about themselves and purchase more training services. Sadly, this may not be so far from the truth with regard to the marketing of dieting services.

Eating Disorders Factoid

37% of boys and girls in grades 3-6 have already been on diets.

Source: Academy of Eating Disorders (Citing Maine, M. Body Wars: Making Peace with Women's Bodies, 2000, Gurze Books)


The Importance and Role of Food

Food, like weight and dieting, are constants in women’s lives and conversations. It is interesting to note that almost every woman’s magazine shows a delicious meal to prepare on one page; a meal that will most certainly be prepared by a woman, while on the next page it discusses the diet plan that the same woman should be following.

Women are bombarded by double messages around food and eating. Men are bombarded with messages about food, too. For them, the diet industry hides behind the message of low cholesterol and dieting for health reasons.

It has also been suggested that that Jewish, Catholic and Italian cultural origins may lead to a higher risk of developing an eating disorder due to cultural attitudes about the importance of food. (96) The interplay between one culture's values about the importance and nurturing aspects of food, and another culture's values about the importance of thinness can create dueling and interacting pressures: the ripples on the lake being strengthened through interaction, to use our earlier metaphor.

When one is seeing a client suspected of having an eating disorder and who comes from a specific culture or sub-culture, a thorough assessment should always include investigation of the role and importance of food within that client's culture or sub-culture. From there one can assess the interplay with the message from the dominant culture.

d risks for eating disorders just because of physical changes that can occur when weight drops below a starvation point.

Eating Disorders Factoid

Among female athletes, the prevalence of eating disorders is reported to be between 15% and 62%.

Source: National Eating Disorders Information Centre of Canada (Citing Costin, C. The Eating Disorders Source Book, 1999, Lowell House)

Larger Scale Influences

There are a number of historical influences that may have participated in the shaping of a culture in which eating disorders could take root. These influences are more connected to a sociological analysis of eating disorders than to a psychological analysis. For this reason, the coverage of this area will be brief rather than extensive.

However, there are compelling reasons for bringing this information into a course on eating disorders. The sociological context within our current culture is – to a great degree – one of the important influences that has supported and encouraged the increase in the incidence of eating disorders.

There are effects on patients with eating disorders from the presence of a whole culture that values thinness - and champions a quest for perfection through thinness.

Patients with eating disorders generally present with a high degree of resistance to change, particularly change in terms of their fundamental cognitive constructs around their body image and concepts of an ideal body weight. They do not necessarily see their weight as the sign of a problem – and they will find evidence in their cultural landscape that supports this position. This is to say that a culture that honors and champions thinness will provide support and encouragement for maintaining patient resistance.

The first steps in a therapeutic change process will involve identifying a problem (including having the patient acknowledge the problem), developing goals for change, and building motivation to engage in the actions to bring about those desired goals. For most clinicians – since they will not be eating disorder specialists – the actions to address the identified problem will include facilitating a successful referral to specialists who can provide the proper kind and level of care.

If the patient is not willing to take the first steps – if they are not will to even acknowledge the presence of a problem - then motivation for treatment is very difficult to develop. Therefore, the appropriate role of the clinician at that point in time includes bringing to bear the knowledge and skills to move through that point of initial resistance.

Eating Disorders Factoid

A survey of parents found that one in 10 would abort a child if they know it had a genetic tendency to be fat.

Source: National Eating Disorders Information Centre of Canada (Citing Fraser, L Losing It: America's Obsession with Weight and the Industry that Feeds on It, 1997, Dutton Press)

This is where a deeper level of understanding of the forces at play in the development of eating disorders comes into effect. Changing the patient's ideas about their body weight will require discourse. The discourse is not only between the clinician and the patient, but also between the clinician and the sociological forces that have been evolving to make eating disorders more common and more difficult to treat.

To the degree to which the values of the culture have contributed to the warped ideals of the eating disordered patient (and the resistance to change, even when these ideals produce a life-threatening outcome), the clinician needs the ability to enter into a deep discussion with the patient about the meaning and effects of those values.

The knowledge of the historical background of these values improves the clinician's ability to deconstruct those values. It allows for a more knowledgeable discussion of these values, and allows the clinician to make a more compelling case for change.

Whether the clinician uses motivational interviewing, or some other approach to increasing motivation for change, the larger the knowledge base - and the more thoroughly the clinician understands that knowledge base - the greater the degree of authority in building a case for change.

Sociologists have noted that we are in the time of the "Third Wave". This is the third of three major sociological changes that have reshaped society and culture in the Western world. The beginning of the first major restructuring of modern culture - the "First Wave" - is also known as the Industrial Revolution. This created a major new division between the public and the domestic sphere. Labor was no longer a communal affair, as it had been in the villages. Men left the home and went to work. Women stayed at home.

For the first time women were alone and isolated in nuclear families without the connections they felt when they lived ‘in the villages’ or, during the Middle Ages. In this new family structure, the concepts of individuality and subjectivity and personal growth - for better or for worse - began to flourish. The protections of communal identity and communally defined roles and self-worth began to diminish, replaced by definitions of worth created through one's competitiveness in a competitive society.

The influence of the media

Studies among teenagers have shown that poor body image and dieting is correlated to the amount of time that teenagers spend reading magazines such as Seventeen. (26) The more time teenagers spend reading popular magazines, the worse their body image becomes - and the more they are prone to dieting.

Studies concluded that since teenagers are so affected by the written word it is worth speculating whether teenagers would also respond to positive articles that provide them with sound non-dieting advice. (26)

The Choice of Certain Professions

Certain professions make individuals vulnerable to develop eating disorders. These professions demand that the individual attain and maintain a certain weight. These high-risk professions include: modeling for runways, for magazines or for catalogues, actresses and actors, dancers, jockeys, wrestlers and weight lifters.

These professions are so competitive that there is a lot at stake – and a lot to lose - if the “correct” weight is not maintained. As we have noted earlier, there may also be increase

This new social order and context promised new modes of creating happiness and fulfillment. However, the new order also restrained people’s sexual freedom, bred gender limitations, marginalized people according to income and used people instrumentally for capitalistic gains. In essence, the new order bred its own sources of frustration and unhappiness.

In lieu of support and shared purposes provided by one's larger community, the new model began to rely on the strength of the nuclear family. The nuclear family began to harbor all that is related to emotions, feelings and nurturance. However, because no family can fix what is wrong with the macro social context, families began to harbor the same frustration of desires and alienation that they were supposed to fix.

At the same time, other types of progress were occurring. New inventions created increased creature comforts – some of which came with new sets of problems. In the fifties, women for the first time had access to a refrigerator. Now, they could store as much food as they wanted. However, modern amenities did not assuage feelings of loneliness and disconnection.

Some social historians argue that during the industrial revolution commodities began to be manufactured in mass. Thus, the need for mass consumption appeared. At this time, these historians believe marketing made its appearance and people began to feel the need for things they never knew they needed before.

Some feminist scholars that have studied the influence of industrialized world and marketing in women’s psychology believe that new industrial world and its new marketing strategies were the culprits, at least partially, of women’s unhappiness with their bodies.

Advertisements for the new items included information that may have taught women to hate their natural hair, their natural odor, in essence, natural aspects of their female body. The same directed marketing may have influenced them to dislike their natural weight, too. They began to buy artifacts to get rid of their bodily hair, sprays and bars to get rid of their smell and pills, special foods or powders or pre-made dinners to control their appetites or feed their families.

According to this analysis, the new industrial world tried to sell the new manufactured goods by advertising them as products that would help with the nuclear family with “bliss and happiness”. Definitions of what was necessary to achieve happiness could be manipulated by outside forces, instead of being determined by more personal or communal forces. This is the effect of the market consciousness.

"We live at the end of a century in which the competitive economic market has demonstrated its powerful ability to shape the dominant consciousness of the planet. That market consciousness has convinced many that the highest goal of life is to consume, that the proof of one's own self-worth is how much power and money one has at one's disposal, that the "natural" inclination of each person is toward selfishness and egotism, that every other person is a potential rival for scarce economic or emotional resources, that societies should be constructed primarily to protect the individual so that s/he may pursue her own self-interest without external constraints, that progress means the increasing scientific conquest of nature and its transformation into forms that can be used or sold to others, that the goal of knowledge is to increase control and domination of the world, and that the rational way to look at others is in terms of what they can do for you to advance your own agenda." (64)

Eating Disorders Factoid

80-90% of women dislike the size and shape of their bodies.

Source: National Eating Disorders Information Centre of Canada (Citing Hutchison, M Transforming Body Image, 1985, The Crossing Press)

These changes – and the forces driving these changes – have been so thoroughly incorporated into the cultural landscape, that viewpoints challenging or questioning the direction of the dominant culture are at best marginalized and at worst demonized as radical and dangerous. It has been posited that even the ethos of the mental health profession has been unable to maintain clarity about how far these values have insinuated themselves into treatment modalities and philosophies.

"There has never been nor could there ever be an ethically and politically neutral definition of mental health. When therapists argued that they were merely seeking to empower individuals so that they could make their own choices, they were already deeply enmeshed in the market-oriented way of viewing society, one that privileged individuals and imagined that they could be healthy without regard to the quality of human relations and social realities around them. In this way, the definition neatly replicated the logic of the competitive market itself, which saw human beings as isolated monads equally fit to compete against each other for societal goods." (63)

If people in the mental health professions are having more difficulty in sorting through the sociological changes responsible for some of the deterioration in overall mental health, it should not be surprising that eating disordered patients absorb - without too much questioning – certain ideals and values that contribute to mental health problems.

These sociological forces, if anything, appear to have intensified over the past decades. Not surprisingly, the incidence of eating disorders has increased, but not just for women. As noted earlier, eating disorders are on the rise among younger men, as well.

There is some thought that men have recently been subjected to some of the same manipulation by mass marketing. In the last decade or so, men seem to have been physically objectified in the same manner than women have been objectified for years – with products and services conveniently available to help men in their quest for perfection.

There are now men’s only magazines, and men’s fashions magazines. These issues talk about looks, fat intake, exercising and dieting, just as women’s magazines have for years. It seems that the consumer culture has recently learned that it could tap into men's fear and worries, and make them insecure about their bodies just as they had done with women decades ago. (3)

Predictably, in the last decade more heterosexual men have begun to come into mental health offices and inpatient units showing signs and symptoms of eating problems and disorders, in greater numbers than ever before.

Psychologically for some men, eating disorders may represent a double whammy. Men in clinicians offices seemed to display not just eating problems, but also feelings of shame and distress at what have been perceived as having a ‘woman’s disease or problem.

During the last decade, certain male feminist psychologists, mental health professionals and writers have attempted to validate eating disorders as men disorders, too - with the intention of unburdening men from the stigma and shame that eating disorders may have brought them. (2)

These mental health professionals stated that - for men - it is not easy to open up and admit having emotional problems, much less easy to admit issues around body image and self in relation to appearance. (2)

Eating Disorders Factoid

Body Dysmorphic Disorder affects about 2% of people in the US and strikes males and females equally.

Source: Anorexia Nervosa and Related Eating Disorders, Inc.

Some authors believe that it is certain specific aspects of our culture that drives men to think that they are supposed to keep their college weight through life, even if it is not the natural thing to happen. (2)

This same culture, apparently, calls for a ‘new man’, a more emotional and available man, more tender and less cut off from his feelings. However, simultaneously - according to some thinkers - this culture seems to ask some men at least, nothing less than an almost perfect body, a Spartan warrior’ body. (2)

Certain researchers consider that from the 80% of men who desire a body different than the one they have, 40% wish to be thinner than they are, but the other 40% wishes to be heavier. (2)

However, the 40% of men who wish to be heavier desire their weight to be very specifically distributed. They do not desire just to be fat, In fact, apparently; above all, they desire no fat in their bodies.

Apparently, the men who want to be heavier want to have more muscle, not more fat. These men want to develop very specific muscles in very specific parts of their anatomy (six packs referring the abdominal muscles that look like a six pack of beer); or, broad shoulders.

Another view is that men’s roles in society are less clear and more fluid than they once were, especially for young adult men. On the one hand, this allows more forward thinking men to have a wider variety of ways to be in the world, without pressure for rigid conformity to a "masculine code". On the other hand, with more fluid roles men may feel the need to be physically more muscular to have clearer physical representation of the fact that they possess sufficient amounts of what makes a man "masculine".

There is another possibility related to this. It may be that when individuals do not have well delineated roles to adhere to, they may experience a certain sense of insecurity or uncertainty. One way to deal with such insecurities may be to "create" a certain body, the ideal one, the one accepted by society. Apparently, men suffering from eating disorders and problems have become engaged in transforming their bodies in the same manner as women have tried to transform theirs.

The role of the health professional in prevention with respect to socio-cultural factors

The role of health professionals in this complicated state of affairs is important and complex. The mental health professional working with eating disorders needs to be empathic, as well as real. However, the professional also needs to stand as an expert, working from a position of authority. This authority is created by the skills in intervening – and the thoroughness of the knowledge base from which interventions proceed.

Health professionals need to be prepared to discuss with their patients – and their families/support systems - the socio-cultural and psychological factors of eating disorders. They need to able to enter into a complex dialogue with the patient concerning the pressures to be thin, pressures that can come from family, friends, and the culture as a whole. This dialogue must examine – with the participation of the patient – the meaning, purpose and outcomes of these forces in the internal emotional life of the patient. The goal of this dialogue is to reorganize the forces and pressures in a manner that allows the patient to embrace a healthier ideal of the self.

The choice of the word, dialogue, is deliberate. Eating disordered patients can be terribly resistant to coercive or pressurized approaches to get them to alter their behavioral choices when it comes to eating. The change that must occur for the patient to move to a healthier position will take place in the inner landscape of the patient's emotional world. The patient must be helped and invited to come to this changed place; he or she will find ways to resist being forced or coerced.

The dialogue must be patient, deliberate and responsive to the cues and messages from the patient about how quickly or slowly to proceed. The dialogue must include a method of validating the norms of attractiveness inherent in the patient’s particular subculture, even if those norms – as expressed in the client's choices – must ultimately be reconfigured.

A good starting model for this discursive process is Motivational Interviewing, a technique employed used most frequently by professionals who work with clients with substance abuse/addiction, and which was developed by Miller and Rollnick. (72) They define motivational interviewing as a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

Motivational interviewing has two basic phases. In the first phase the emphasis is on building motivation for change and in the second phase the emphasis is on strengthening the commitment to change through setting goals, considering change options, developing a plan, and eliciting commitment.

Motivational interviewing focuses on helping to motivate individuals toward making changes using such strategies or techniques such as:

- Normalizing client uncertainties
- Rolling with resistance
- Asking open-ended questions
- Discovering client’s beliefs
- Reflective listing
- Conducting empathetic assessments
- Amplifying client doubts
- Developing discrepancy between person goals and problem behavior
- Conveying confidence in client’s abilities to change
- Supporting client choice and self-efficacy
- Reviewing past treatment experiences
- Working with client to develop a treatment plan
- Providing relevant feedback
- Summarizing and reviewing potential sources of non-adherence
- Negotiating proximal goals
- Discovering potential roadblocks
- Displaying optimism
- Involving supportive significant others

In this case, the dialogue would be concerned with helping the client to explore his/her ambivalence about maintaining the desired "ideal" body weight – as defined by the larger culture and interpreted by the patient - versus the desire to stay alive, be physically and emotionally healthy, etc. Rather than force-feeding the client information about the consequences of his/her choices, however, motivational interviewing gently directs the patient to examine for him or herself the outcomes of various choices.

In such a dialogue, the clinician must be prepared to explore – with the client – the socio-cultural information about what the "right" body weight is, what the "correct" reasons are for attempting to reach perfection, what the "real" benefits are to being oriented towards individualism and consumerism. The techniques of motivational interviewing – open-ended questions, reflective listening, rolling with resistance – help the patient to begin to discover questions about their own choices, as well as the purposes of socio-cultural factors.

Done correctly, the patient will begin to educate him or herself about how some of the historical and socio-cultural factors have created difficulties for the members of present day Western culture. With a trusting relationship, the clinician can slowly and gently support the deconstruction and restructuring of these meanings to a healthier position.

While this socio-cultural exploration is occurring, mental health professionals must understand - and may need to explain to their patients - that food may be used as way of coping with negative emotions, at the same time that food has a positive adaptive function. The dialogue concerning this issue will also be oriented towards resolving ambivalence and conflict.

Mental health professionals also need to be aware of the history of the individual with regard to any possible sexual abuse that may be an unspecific factor in the development of the eating problem. The need to be thin may have a deeper psychological meaning for the patient with a history of sexual abuse. Having a "perfect" body may be used as a way to compensate for the loss of a sense of "goodness" that can occur as a consequence of sexual abuse.

Some clinicians have also thought that extreme thinness may be used by some sexual abuse survivors to remove the external signs of sexuality. This may be a method of feeling safer by looking like a pre-pubescent, non-sexual child. This may be similar to what occurs for some early adolescents, when their nascent sexuality confuses and frightens them so much that they diet to try to return to a pre-pubescent state.

To add one additional contextual feature, clinicians working with men with eating disorders need to have available to them the same patience that therapists have been providing to women when they deal with eating problems. They must also always keep in mind the additional pressures for men of having a "woman's" disorder, and the increased pressures on men to submerge their emotions and internal needs.

The dialogue for men, therefore, will have some additional external forces and pressures to reconfigure. Psychologically, men will need additional help in learning to embrace the whole of who they are, without getting cut off from certain emotions and without getting trapped in the pressures of externally driven ideals coming from consumer culture.

According to some mental health professionals, men who suffer from eating disorders seem to need professionals that are able to do away with the “Boys will be boys” attitudes and stereotypes that make it easier for this subset of men to over-exercise and strain to sculpt their bodies.

Eating Disorders Factoid

It is estimated that one million men in the US have an eating disorder.

Source: South Carolina Department of Mental Health