In this post I’ll continue on the trend of considering the “culture bound” nature of eating disorders by looking at another commonly-cited article about eating disorders and culture. In this article, Keel and Klump (2003) look at the cultural and historical facets of anorexia and bulimia. They looked at whether eating disorders were present in other sociohistorical and cultural contexts in order to determine whether AN and BN are “culture bound.”
Their research, as I alluded to at the end of the first post in this series, suggests that anorexia is not culture bound (i.e., it can occur in the absence of certain aspects of culture), while bulimia is (i.e., it only/primarily appears in certain cultural contexts). As this finding might actually run counter to what popular press would have us believe, looking at this article provides us some interesting insight into how spin can really be everything. While I’m not 100% convinced that AN and BN differ in “culture-bound-ness,” I do think that this study offers us quite a bit to think about when we consider the relationships between aspects of culture and elements of eating disorders.
To tease out the cultural and historical framings of AN and BN, Keel and Klump explored:
- What changes have taken place in the incidence rates of eating disorders since the introduction of formal recognition/diagnoses for AN and BN (via a quantitative meta analysis)
- What evidence we have about the existence of eating disorders across history before this recognition/diagnosis (via a qualitative summary)
- Whether eating disorders have been documented and studied in non-Western cultures
The authors make a concerted effort to define “Western” (and non-Western). This is important because, as they acknowledge, “the West” has come to signify many different things in different studies. So, they choose a definition that allows them to differentiate between cultures that developed according to “the Greco-Judaic-Christian tradition” and those that did not. They acknowledge that there are variations within “Western” cultures/societies but argue that these are less relevant to exploring how eating disorders could be on the rise.
I see why they made this distinction, but I am actually more curious about differences within Western and non-Western contexts. I’ll get into this in more detail in my next post, but I wonder about how culture has come to be a stand in for “society” in many writings. I wonder whether we might get a more comprehensive sense of the picture of why eating disorders arise in some places and not (or less frequently in) others (or how they look different in different contexts) by actually looking at factors within a certain society that might impact people differently based on their multiple and intersecting spaces of belonging.
Keel and Klump provide a deep exploration of eating disorders across history. It is revealing to see how and when eating disorders were noticed, in what groups of people, and how this has implications for contemporary framings of these disorders. In this look across history, the authors find that AN has been linked to:
- Refusal of food resulting in admittance to an asylum
- Religious fasting
- Asceticism (i.e., piety often linked to saints, where people seek purity)
Of course, the association between spiritual fasting and eating disorders is not without controversy; Keel and Klump suggest, however, that fasting in pursuit of purity might resemble some of perpetuating factors for eating disorders. For example, “holy anorexia,” as described by Bell in 1985, refers to the refusal of food in order to “please god” or be pure in order to invite spiritual intervention. Similarly to “modern” eating disorders, engaging in such restrictive behaviours often elicited responses from others encouraging the individual to eat or even force feeding.
This reflects the idea that though the pursuit might be socially sanctioned (e.g., in historical contexts the pursuit of religious purity and in contemporary times the pursuit of a “thin ideal” have generally been seen as morally superior strivings, for better or for worse) when the behaviours undertaken to achieve this are seen as extreme, they provoke concern and (often) intervention. In both cases, people might also have many reasons for engaging in disordered eating behaviour; it is no easier to disentangle the complexity of “historical” eating disorders than it is to unpack those in modern times.
BN, on the other hand, has less of a historical legacy. Keel and Klump note that it is difficult to determine, in historical representations, which cases might be called BN and which would be categorized as BED. Thinking historically, one might consider the vomitoriums of Roman times, for example. The authors note that this practice was actually quite normative (socially sanctioned) at the time, especially among the elite. Other authors (e.g., Ziolko, 1996) claimed that this type of excess eating followed by purging is not similar to bulimia nervosa as the main point was to make room for more food. The examples the authors provide actually highlight, more than the lack of BN in history, the difficulty of tying down diagnostic criteria for BN (which could be the topic of a completely different post!); they also note that though incidence of BN seems to have increased since its formal categorization, incidence rates don’t exist before 1970.
This historical exploration also underscores some class-based analyses of eating disorders, wherein we can start to consider which behaviours are considered to be “normal” for what sets of people. Fasting, in the case of religious pursuit, and vomitoriums in the case of Roman elite classes, also reflect a class-based position relative to food: they are, in part, bound up with the idea that there is access to food to be refused or indulged in to excess. Class, culture, and food refusal will come up again in part 4, but I will flag it here as well, as food for thought.
In terms of culture, Keel and Klump suggest that “AN has been observed in every non-Western region of the world” (p. 754). Alongside evidence that AN has been observed in contexts other than those espousing a “cult of thinness,” the authors argue that AN is not culture bound. Instead, a cultural focus on thinness might have an (at best) marginal impact on rates of AN.
Notably, the authors acknowledge that eating disorders can have significant variation in terms of symptoms and cognitions in different cultural contexts. As an example, they cite Katzman and Lee’s (1993) cross-cultural work, including Lee’s (1991) study in Hong Kong wherein participants reported anorexia-like symptoms without a fear of weight gain (Tetyana has written about EDs without a “fear of fat” here and here). Still, the idea that thin-idea internalization might influence or exacerbate eating disorders appears here, when the authors note an increased presence of body dissatisfaction alongside other symptoms in more urban centres.
Keel and Klump found it more challenging to find cross-cultural evidence of BN, leading them to declare that BN is culture bound. I find this quite a curious conclusion. They do note that the lack of representation of BN (relative to AN) they found could be linked to a lack of recognition of BN. I am unsure about the authors’ suggestion that there are no “non-weight-concerned form[s] of BN” (p. 761); is it possible that the criteria used to determine if something is or is not BN might get in the way of it being diagnosed if it looks slightly different from the diagnostic norm? Nonetheless, using the definition of “culture bound” Keel and Klump chose (i.e., identical symptoms in different historical or cultural contexts, regardless of meaning made), I suppose BN would be culture bound.
What does it mean for our understanding of eating disorders as culture-bound?
As I mentioned in the introduction to this post, Keel and Klump’s results might seem surprising because there tends to be an assumption that AN is more closely tied to (Western) culture, particularly through the vector of thin-ideal internalization. Against this assumption, through looking at historical and cultural variations in eating disorders, the authors argue that BN is bound by culture as it has not been found in non-Western cultures to the same degree as AN.
Again, it is unclear whether this is more representative of the relative lack of information about BN, and the links between BN and culture (Western culture in particular) remain somewhat fuzzy. I suppose, however, that this is consistent with pathway models of eating disorders that have found associations between media exposure, thin-ideal internalization, and bulimic symptoms in particular (e.g., Stice & Shaw, 1994).
Still, I wanted to see more of an unpacking of the “culture” backpack just a little more, extending beyond culture as media or even history (which still tends to be written from a Western point of view). While the historical focus in this article was fascinating, some of the themes in the prior post, including the impact of political, economic, and social factors are quite interesting and could be linked to eating disorders through other pathways than the media.
In my next post, I’ll explore an article by Rebecca Lester, who offers some much needed complicating of “culture.” The conclusions Keel and Klump draw about body dissatisfaction being more present in urban than rural centres also makes me think about what the driving force is, here: is it indeed the increased presence of thin ideals as represented in media images, or more about similar political economic trends (industrialization leading to increased competition and individualization)?
Keel, P.K., & Klump, K.L. (2003). Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychological bulletin, 129 (5), 747-69 PMID: 12956542