Whose Culture is it Anyway? Disentangling Culture and Eating Disorders – Part 2

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

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Andrea is a PhD candidate focusing on individual, familial, and health care definitions and experiences of eating disorder recovery. She has an MSc in Family Relations and Human Development and a BA in Sociology. In her Masters research, she used qualitative and arts-based approaches (digital storytelling) to explore the experiences of young women in recovery from eating disorders. Andrea has recovered from EDNOS. She can be reached at andrea[at]scienceofeds[dot]org.


  1. Another great post! Congratulations!

    Do they discuss the results in connection with heritability studies and general studies on the genetics of EDs, including BN? I know these things – “culture bound” and “genetic influence” – are not inherently conflicting, but I find it interesting to think about how a condition that is apparently heavy influenced by genetics only emerges in certain cultures and periods.

    I have many thoughts, most of them probably obvious or irrelevant:

    1) Unlike, say, height that can be inferred by analyzing bones, BN doesn’t leave material remains in the historical record. This is one of the reasons why it’s hard to say whether it occurred in other periods or not -just because they can’t find written accounts of BN-behaviors in the historical record doesn’t mean the condition didn’t exist. True, AN doesn’t leave those either, but notice what kind of supposition they need to make in order to say that anorexia occurred in other periods. Like, it’s kind of problematic to diagnose a 13th Century ascetic monk as having anorexia.

    2) I’d agree with the statement that the Roman vomitorium doesn’t suggest bulimia (for one thing, it was apparently quite widespread, unlike BN’s prevalence). However, saying that it doesn’t suggest bulimia because they purged to make room for more food is saying that purging HAS to be motivated by body image concerns/weight control in order to be considered a feature of BN (or ED in general), which is an assumption that I find quite problematic, as we know purging might serve mainly the purpose of affect regulation. As you rightly point out, the problem may be with how we are defining BN in these studies!

    3) This assumption that purging needs to be motivated by weight control in order to be a symptom of an ED also seems to plague that Becker et al study that I mentioned in my comments on your first post (they used the EDE-Q which has scores for weight concern etc). In fact, when analyzing the herbal purgative use, they explicitly selected for those who adopted it for weight control purposes, deeming that other sanctioned uses should not be included. This is a fair assumption if you accept that you can’t classify as pathological those behaviors that are sanctioned in the culture you’re studying, but it doesn’t address the fact that some of these individuals who purge for other reasons than weight control would be classified as having BN by “our standards” if the condition were defined more broadly.

    4) Another question could be: if we can conceive of AN without fear of fat, why can’t we conceive of BN without such fears? Again, the reasons they give for dismissing the vomitorium as an expression of BN seem to assume that purging should only be part of an ED if it’s motivated by weight control. Yes, the vomitorium was sanctioned, but so were the ascetic practices they mentioned. I’m deeply skeptical of the claim that extreme forms of these practices were also considered pathological in the past, because some of the most influencial ascetic monks in the Christian tradition couldn’t possibly be more radical in their practices, and they were held as models to be imitated to some degree.

    I haven’t read the study, but I’m quite skeptical about the conclusions. Maybe it’d be better to say that “we couldn’t find instances of strictly defined BN in other periods or cultures”, instead of “BN isn’t culture-bound”. Admittedly, the former way of putting it is considerably less sexy. :))

    • Thanks for commenting- I appreciate the engagement with the posts! Suffice to say I’ve been heavily procrastinating from my actual jobs by writing these posts…

      One of the authors’ arguments for conducting the study, interestingly enough, hinges on the recent turn to focusing on genetic predisposition for eating disorders. In this turn, they suggest, culture has been ignored to a certain extent. I agree to a certain extent, with the proviso that my general sense of the literature is not that culture has been ignored, nor that genetics have, but that the interrelationship therein has been under theorized. They cite studies indicating that BN may have less or more variable heritability than AN; this and the suggestion that genetic precursors for BN “may have produced different forms of psychopathology [across history] such as hysteria in the Victorian era” (p. 764) undergirds the suggestion that BN is more culture bound. I feel to a certain extent that though this article gestures at more bridging between the cultural and the genetic, there is still a division, in how they write about these, that presupposes a kind of dualism rather than an intertwining or nature/culture. I want to see more work that makes this relationship more complex.

      Interesting point about history; I think this is an interesting line of inquiry, primarily because I’ve yet to see a kind of archaeological exploration of eating disorders; the anthropological work I’ve seen has tended to be more closely tied to the social anthropology side. I would argue, however, that basing diagnoses on this kind of excavation-based study might be equally as problematic as relying on our current sociological understanding to unearth historical representations of them; though combining a genetic and social exposition of factors related to EDs would of course make our picture more complete. As I alluded to, the posthumous diagnosis of EDs, especially amongst saints, is rife with controversy. I haven’t given it enough serious thought to take a firm stance re: do or don’t.

      In terms of the bulimia/vomitorium link; more so than the presumption that BN is necessarily tied to weight control (which is indeed a problematic association I see to a certain extent replicated in the article though mostly in the conclusion about the absence of BN in non-Western contexts) I see here a tension around the social sanctioning of behaviours; the widespread prevalence and even prestige associated with the historical ability to participate in that kind of practice is very different from the kind of stigma and alarmism associated with bulimic practices. So the distinction might else wise be though of as vomitorium-participation-as-normative vs. bulimia-as-deviant. Interesting.

      In terms of use of EDE-Q (and other measures) is the lack of ability to expand upon WHY someone answered in a certain way. I’ll get into it more in part 4 (sorry to keep dangling carrots about future parts) but as your point alludes to, there’s a problem with assuming that everyone filling out something like a survey in the same way. The idea of social “sanction” goes back, again, to that distinction between vomiting-as-social/cultural-practice and vomiting-as-individual-pathology.

      You wrote: “Another question could be: if we can conceive of AN without fear of fat, why can’t we conceive of BN without such fears?” – Good question, and I wonder the same. I think it has something to do with our pathologization of the very idea of bulimic behaviour (as I wrote about in another post- Polar Opposites? The Social Construction of Anorexia and Bulimia)- i.e., the stigma associated with BN is tied to the behaviour not the resultant body as in AN. So, socially, it is harder for us to conceive of people who induce vomiting as having other reasons for engaging in these behaviours than whatever our dominant social paradigms dictate. That’s an incomplete answer; the real answer is I don’t know, but I see that line of thinking a lot.

  2. Sorry for my mistake in the last sentence: I meant “BN IS culture bound”.

    Thanks for the enlightening comments! I guess I missed that post you wrote about cultural notions underlying AN & BN. I’m sure going to read it!

    Just a final question. You write: “One of the authors’ arguments for conducting the study, interestingly enough, hinges on the recent turn to focusing on genetic predisposition for eating disorders. In this turn, they suggest, culture has been ignored to a certain extent. I agree to a certain extent, with the proviso that my general sense of the literature is not that culture has been ignored, nor that genetics have, but that the interrelationship therein has been under theorized.”

    Do you think the reason for this could be in part that we still don’t understand the genetic “architecture” of EDs very well? I guess it’s one thing to know that there are genetic factors involved, but knowing how this genetic basis look like and how it translates into characteristics that may predispose one to an ED is something quite different. Not that we have a perfect knowledge of the cultural and social factors either – the fact that we still can reduce culture to Xena the warrior suggests that we don’t haha – but I feel our knowledge about the genetics of EDs is still extremely vague, I don’t know. What do you think? Do you know of a good study that theorizes this interaction in more depth?

    • I think that could be part of the reason, for sure. I think the reason that people don’t look at the intersection or mutual influence, though, is because it is hard to really unpack what influences what (i.e. direction of nature-culture relationship), especially when we are prone to thinking about things as either/or & thinking in terms of binaries. The binary between mind and body (head and heart, nature and culture, genes and environment etc.) is still firmly entrenched in how we approach science and social science such that the tools we have at our disposal to conduct research aren’t equipped to explore the interstice. I haven’t seen many studies that do a thorough of the interaction, but I do love Burns’ work (i.e. the article I look at in the post I noted in the above) and I found this one by Easter interesting (Tetyana wrote about it here: http://www.scienceofeds.org/2012/09/06/genetics-friend-or-foe-in-ending-eating-disorder-stigma/

      • I disagree with the notion that the relationship between them has been undertheorized. I think, as Norman alludes to (I think), you can’t really theorize much without understanding more of the genetics involved. Until we have a better understanding of that, we can’t talk about the intersection except in vague, theoretical terms.

        • I guess that’s true, but what I’m getting at is it is relatively harder (in my experience) to find articles about EDs in particular that focus in a micro-sense on the spaces in which “genetic” and “cultural” factors are co-influential, rather than looking at one impacting on the other. The body tends to be an “absent presence” in a lot of social science and philosophy literature about EDs, for example. It appears in the literature, there, almost as a blank slate to be written on, which it obviously isn’t. Equally, in some of the “hard science” (shudder- I hate the hard-soft science distinction) there are many studies that are done in ideal circumstances (i.e. in a lab) without as much acknowledgment about things like multi-generational shifts in “biological factors” due to environmental patterns. I know I am butchering science in that last and far oversimplifying what is a varied and complex field where some certainly do take other factors into account than simple cause and effect. Perhaps it comes from my social science bent, but I’m unsatisfied with the idea that we can understand more of the genetics involved without implicating “culture” from the get go. Because we don’t live in a petri dish (I know you aren’t saying that. But.) I think in particular, social scientists like myself also need to invest more time in understanding the implications of what genetic explorations we do have, rather than jumping to oversimplified arguments about genetics being solely a matter of unchangeable, inevitable pathways to things like eating disorders. I guess what I’m saying is we need to get over ourselves and work in interdisciplinary ways to explore the intersection of genes & environment, if we want to get anywhere; I don’t see a great deal of that happening. I still find it rare to come across “hard scientists” in the ED field who have read the critical feminist articles I love, and vice versa. I think that’s a loss of things that can be learned from the “other camp’s” work (not that it is a dichotomy- many research in grey areas therein).

          • I suspect you may be overestimating the tools we have in genetics and neuroscience, which is why I think you have come to the conclusions you have.

          • Oh probably, but does that preclude working interdisciplinarily to explore phenomena like eating disorders from multiple perspectives? I’ve seen biologists like Fausto Sterling do some really interesting work about how the relationship between genes and environment is multidirectional. ..

          • It absolutely does because unless we know more specific details, we will just be talking on very broad, theoretical terms. Of course the relationship is multidirectional–but that’s nothing new. I don’t know much about Fausto Sterling, but the first thing mentioned on Wikipedia on her page mentions sickle cell anemia, which is the classic example of something called heterozygote advantage, which is a good example of a type of interaction between genes and the environment, or at least how the environment can affect the phenotype (the physical expression of a gene, in a sense). In sickle cell anemia, we know exactly what is going on on a genetic and biochemical level, which makes understanding how the environment affects the phenotype much, much easier. In eating disorders, we don’t really have an idea what alleles are involved, how/if they are facing selection pressure, how/if they are being influenced by environmental factors (and what environmental factors), and so on and so forth. So sure, we can talk about the theory. Also, there ARE people studying these interactions (for example, Howard Steiger’s group), but again, it is all so preliminary, in my opinion, and until we get better tools, and dig deeper, we’ll just be talking about possibilities.

          • Ok, fair enough. I still (and perhaps this is idealistic?) hope we can get to a point where we do know enough to bring it down from the high theoretical to the actual, practical. I don’t know a lot about what we need to know from a neuroscientific/genetic perspective to make the discussion relevant, but that’s part of my point. I don’t know many social scientists who are interested in knowing more. And I think we should be. Not to co-opt it, or over-simplify it. But to entertain possibilities. But again, idealism is my middle name. I don’t know much about Steiger’s work and I definitely think that people ARE studying interaction; of course I don’t have a perfect knowledge of the whole field of ED research and who is doing what. Good to know that that group is, though. I’ll look for more of that. I guess on a broader level I just don’t see cross pollination between even “mainstream” and “alternative” or feminist perspectives, which I still think is a shame. We could probably debate this backwards and forwards for ages and probably never 100% agree, maybe because I think you might be more practical and pragmatic than I am 😉 I like to think of myself as a pragmatist but discussions like these just bring out the dreamer in me…

          • Oh I definitely think we can GET to that point, and I hope we get there! I just think we are not really close. I do think people are in the silos, but I think that’s true for everything. It *is* a shame.

    • Interesting; I’m not solid on my Roman history, TBH. Keel & Klump refer to 2 emperors in particular (Claudius & Vitellius) who have been retrospectively “diagnosed” (they don’t say diagnosed but …) with BN, citing this article: http://www.ncbi.nlm.nih.gov/pubmed/8932559 as well as a phrase from Seneca (“they vomit that they may eat, they eat that they may vomit”) in referring to what they suggest might have been “a common behavioral pattern
      among the elite in the Roman Empire, and, in the case of Vitellius,
      a not entirely volitional pattern of eating.” (p. 761). I suppose I inferred “vomitorium” from my (apparently and admittedly) partial knowledge of Roman times. They also reference this article when talking across BN in history: http://onlinelibrary.wiley.com/doi/10.1002/(SICI)1098-108X(199612)20:4%3C345::AID-EAT2%3E3.0.CO;2-N/abstract

      • I have no sources and I am going on something I learned in grade school, believe it or not, but I remember learning that in Roman times, vomiting after a meal was seen as a sign of gratitude of the meal, as in, it was so good, you made yourself sick enough to vomit.

  3. Oh, that’s interesting! They note that Vitellius had a “not entirely volitional pattern of eating”, and cite this interesting statement by Seneca, but they don’t regard any of this as indicative of bulimia, whereas they regard the ascetic practices of the various religious traditions, which were sanctioned and revered in many periods of history (perhaps even still today depending whom you speak to and where you are), as indicative of anorexia. 🙂

    I guess it also goes back to the question of how we define bulimia. If we see BN’s purging as motivated primarily by weight control/body image concerns, just as Becker et al. do in that study about BN-like disorders in the Fijian population, then it is more likely that BN will seem culture bound to us. But if we accept that purging as part of BN can also be primarily motivated by other reasons (affect regulation, etc), then my guess is that we’d be more likely to see BN as not being culture bound.

    I don’t know…I feel I keep coming back to the same two points: 1) these researchers accept that AN can occur without fear of fat, but apparently can’t conceive of BN in similar terms, which I find curious and intriguing; 2) it’s all culture bound to me in the sense that these are all categories created by our culture. No doubt the neurobiological correlates of these conditions occur in different cultures and periods, but the abstract notions of AN and BN are creations of our own. And we know how these notions are given different definitions throughout time in our own culture, sometimes even being regarded as arbitrary (the weight criterion or amenorrhea for AN, etc). Now, I’m not saying the weight criterion is clinically wrong or anything – I’m just pointing out how these notions are social/cultural bound within our own culture, if that makes sense. It probably doesn’t. : )

    • It definitely does come down to how we define and delineate BN, and AN for that matter. I also agree that it is interesting to think about why it is possible for people to entertain the idea that AN might be diagnosed without fear of weight gain/body image concerns but not BN. Again, I think this is somewhat paradoxical considering how both are represented in popular media (i.e., anorexia is more commonly represented in general and when it is, often oversimplified in a way that links it to body image and body dissatisfaction). At the same time, I guess I can kind of see why this framing might persist. I think it is hard for people who are not bulimic to imagine a reason for purging except to control weight. Which is one of the reasons why I think we need to be doing more research and knowledge mobilization around bulimia, particularly research that centralizes the perspectives of people with bulimia to better understand what role symptoms have that are completely untied to body image/dissatisfaction. Not to say that none of this exists, it just tends to be less talked about (and ultimately it still seems like there is more research about AN).

      And yes, definitely, the categories are bound up in cultural assumptions, which informs, as all of the discussion about Roman times alludes to, not only our perception of what “counts” as a disorder cross-culturally but cross-historically.

      • “It definitely does come down to how we define and delineate BN, and AN for that matter.”

        Not entirely. At the end, BN requires access to food and ability to purge. AN doesn’t require anything. You cannot be bulimic if you do not have access to food to binge on and ability to purge it. It seems both of you guys have issues with the assertion that BN is culture bound; I find that interesting. I certainly think the BN phenotype can exist in much narrower environments than AN; that is, there are more environmental requirements for BN to occur than for AN to occur. I wouldn’t necessarily say the boundaries are cultural per se — as in, I don’t think it is so much about culture as it is about access to food and access to ability to vomit/purge.

        • Hm. To a certain extent, I think it does come down to that, though. As you say, not entirely, but… I think that how we define and delineate BN and AN rests on our social understandings of them, including taken-for-granteds like the ability to access food. Class and poverty remain very much outside of many analyses of eating disorders, for that matter (studies exist but are less common than studies involving middle class white young women). I don’t necessarily have an ISSUE with the assertion of BN being culture bound; I just think it is curious that BN is called cultural bound and AN is not based on a tacit definition of culture (or not always so tacit, when they note an absence of BN in “non-weight concerned” forms) as linked to appearance focus. Because of the very things you note. Culture also involves access to food and behaviour around food that is linked up with poverty and/or cultural practice, broader political economic forces that govern the availability of food, and ideologies of choice or subsistence. It is disentangle-able (nice new word, eh?) from those things. So, I have an issue with some of the things Norman has been referring to in his replies… this idea that AN could be AN without appearance/weight focus, but BN couldn’t. So I agree with all of what you’re saying in terms of the environmental requirements for BN, but I don’t see that being represented in the description of “culture bound” ness of BN in the article.

  4. It’s possible to read on google books many pages from Gerald Russell’s detailed, erudite chapter about the history of bulimia nervosa in D. Garner & P. Garfinkel’s “Handbook of Treatment for Eating Disorders”. I didn’t know he was the first to describe and define Bulimia Nervosa. : ) He mentions Crichton’s study about the two emperors, by the way. It seems this study is quite influential in this particular line of research.

    Russell’s observations confirm my impression that one of the reasons why bulimia seems “culture bound” to us lies in the criteria of “fear of fatness” and “weight control”. BN seems to be viewed as culture bound mainly because our own criteria for this condition are clearly culture bound, probably in a way that the criteria for AN are not (at least in research). After noting that some people who studied the history of bulimia used a broader definition of the disorder “for the compelling reasons that the modern diagnostic criteria for bulimia nervosa are too <>”, he notes: “It is essential to avoid jumping to the conclusion that overeating or vomiting in ancient accounts is equivalent to the disorder we know as bulimia nervosa. This is a trap into which even modern writers may fall. This is not altogether surprising when one considers the long period of confusion that followed the diagnostic criteria for so-called <> published in the Diagnostic and Statistical Manual of Eating Disorders, third edition (DSM-III; American Psychiatric Association [APA], 1980). At that time, at least in North America, bulimia was simply equated with recurrent episodes of binge eating, including elaborations of its behavioral characteristics and some psychological accompaniments. More specifically, the important criterion of a morbid fear of fatness was omitted, and even the criterion of attempted weight loss by self-induced vomiting was optional”. And finally, when commenting on Crichton’s study about the two emperors: “Crichton does not claim that the excesses of these two emperors could be considered as early examples of modern bulimia nervosa, for the reason that there was no drive for thinness on their part. On the other hand, he considers that their excesses might be viewed as <> (p. 205). There is doubt whether their eating excesses should be considered an eating disorder, in the author’s own words, such behavior <> (p. 207) during the early Roman Empire.”

    The reason he dismisses the other historical references as examples of BN is the same: as these examples don’t seem to feature the “nervosa” part of BN, which is related to fear of fat and drive for thinness, they could at best be considered “bulimia” in the “confusing” definition of the DSM-III, but not “true” bulimia nervosa. The book was edited in 1997, after the publication of the DSM-IV.

    It’s slightly disappointing that Russell’s historical survey takes the strict DSM-IV’s definition of BN for granted. Right, he witnessed the emergence and increasing frequency of this particular manifestation of the disorder, and I guess it’s natural that he and many others would regard it as the “true” bulimia. However, in doing so, other possible manifestations of the disorder in the historical record were discarded, and the DSM-IV criteria, far from being taken as very general guidelines, were reified and regarded as objective entities that admitted no deviations, causing (in my view) substantial distortion even in historical research. In fact, this focus on the traditional DSM-IV criteria leads Russell to basically brush off centuries of history as irrelevant in a few paragraphs and jump right to the 20th Century where “true” BN begins (he explicitly states he isn’t going to lose much time on the more ancient history because those past examples didn’t match the modern criteria for BN, which assume fear of fatness and weight control). By doing this, though, he loses the chance of exploring in more depth the possibility of different – though perhaps equally serious – manifestations of this neurobiological condition.

    I wonder whether this approach to BN could have caused patients to go undiagnosed and untreated. A scary thought…

    • Yeah, I’ve read some of Russell’s work; it felt pretty dated to me. I think our fascination with the Roman emperors is of itself interesting.. I bet they’d get a kick out of it. Or maybe I just imbue my imaginings of Roman emperors with pomposity…

      As for DSM categorizations, they’re always by necessity exclusionary to a certain extent and most definitely reflect social, cultural, and historical influences (including politics and economic interests). Not that the categories are useless; we seem to need something to define what warrants treatment etc., and cut off points (e.g. for insurance purposes) but to unproblematically and uncritically apply the categories often results, unfortunately, in that undiagnosing, untrusting, and assumption making about who “fits” (culturally or otherwise) in the realm of the pathological (or “pathological enough to receive treatment). The whole DSM discussion will likely just open up another can of worms though. By way of a short exposition, I do think it is interesting to consider that despite our acknowledged critiques of the DSM, it continues to be used, as well as to hold currency even for people with things considered pathological. I think there’s a certain appeal of labels and categories, for many.

      Anyway, rambling response, I know- it’s been a long day!

    • I think BN is bounded by geographical constraints and access to food. As I blogged about before, there’s an urbanization effect with BN that doesn’t exist with AN; opportunity is a limiting factor, and I don’t think that opportunity really exists for AN. I’d probably dismiss the historical accounts of emperors too, and not because I don’t think it was/wasn’t “true” bulimia, but surely few people had access to the amounts of food we have now. Super size everything. Food everywhere. How can BN exist in a culture where most people barely have access to food, or live in tight-knit families where they cannot engage in that behaviour? The emperors might have been eating and vomiting, but the common folk?

      • I think that the analysis of BN and urbanization is maybe more interesting than BN and “media” or weight focus, in a way. Many of my notes from the above reply apply here, but thought I’d just say that. In terms of historical accounts; I actually feel like most people don’t dismiss them? Or at least, there seems to be a real fascination with the idea of emperors-as-bulimic that I think is partially but not fully debunked in the article. I really feel that posthumous diagnosis is impossible because we can’t get their subjective experiences, which I feel are essential. And yes, I doubt the common folk were eating and vomiting. Generally, I would agree that the practices don’t appear to be BN. I think that the historical stuff is interesting but less so than the cross-cultural, if only for the reason that history is itself socially constructed so no matter how much we think we know about what went on, we can never really know.

  5. I’m not replying directly to your replies because of formatting issues with my browser, which shifts the replies more and more to the right side of the screen as the debate goes on, up until the replies become these odd texts with 2/3 letter lines (an issue I have reading the most popular threads with this browser!)

    Right, I could agree this is more descriptive of socioeconomic factors than strictly cultural ones, as access to food varies considerably within cultures (not only cross-culturally). I’m ok with the term “geographical” if it is used in a critical marxist sense (like in David Harvey). Geography has had a curious trajectory in many Western countries, and many schools still equate it with stuff like drawing maps and knowing about other countries’ natural resources. Haha. It’s a colonial discipline in its origins, I guess. But no, if geography is used here in the sense that spacial configurations are a product of capitalist processes (or economic processes more generally), then this issue is surely geographical! And sure, some people adopt a definition of culture that results in these socioeconomic factors being classified as “cultural” too!

    I’d only add a couple of points:

    1) there could be a point where AN becomes constrained by such factors too. In this study they couldn’t find any important difference in the incidence of AN across urban and rural areas, right, but I can imagine scenarios where poverty and deprivation are such that you don’t even have enough access to food to be able to exert active restriction – it’s simply a situation of sheer famine and scarcity, not of food restriction. I guess only extremely severe cases of AN would result in restriction in such contexts too, as the person would avoid even the little amount of food that is occasionally available. But this is all speculative. : )

    2) I have no issues with BN being culture bound! I only find it curious that these researchers dismiss the occurrence of bulimia in other periods and cultures based mainly on the criteria of fear of fatness and weight control, which they no longer regard as essential to AN (“polar opposites”? Hehe). I am more inclined to think both are culture bound in the sense that AN and BN are very specific Western constructs of mental illness. The neurobiological and ultimately behavioral correlates of these conditions probably existed in many different periods and cultures, but AN and BN as we came to understand them are not literal,
    value-neutral descriptions of neurobiological processes, but concepts imbued with cultural/social norms and values. The discussions over the weight criterion for AN are a good indication of that. Also, the criteria for these conditions change over time, so I always remind myself of how important it is not to see them as fixed concrete objective entities. It seems all these studies (including the urban/rural one) are using pretty strict traditional definitions of AN and BN. So we may be actually discussing whether a relatively small percentage of ED manifestations are culture bound…which is so odd! It seems to me that this could be a way in which the DSM ends up limiting and perhaps even distorting the scope of very good research efforts. On the other hand, someone could say that the DSM is actually useful in this regard, as its criteria provide a basis of comparison and some kind of delimitation for research, etc.

    • Ah, I see you’ve addressed similar points to some of my above replies, too. I absolutely agree that AN could also be bound up in urban-rural access-to-food issues as well. Food and food behaviours take on vastly different meanings in contexts of wealth and poverty, and culture of course (referring here to some kind of intra and inter-familial pattern); I actually wonder what a context of scarcity might do for the stigma around eating disorders- should they exist would they be seen as “selfish” because of the context of refusing something there is not a lot of?

      Also: “some people adopt a definition of culture that results in these socioeconomic factors being classified as “cultural” too!” Yep, I fit in this camp.

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