The more I write about culture and eating disorders, the more I want to know. I keep finding more articles to add to the mix; I know I’m far from the first to be interested in how culture and eating disorders intersect, and for that matter, what counts as “culture.” Still, this has been a fascinating exploration so far! In case you’re curious, this is to be the second last post in the series, for now at least. There will be one more after this, about eating disorders in Ghana (from a Twitter request). In this post, I will continue to explore the “culture boundness” of eating disorders by looking at a study relating to eating disorders in Africa. In this study, Le Grange, Louw, Breen & Katzman (2004) illustrate how eating disorders have emerged in Caucasian and non-Caucasian adolescents in South Africa.
Le Grange and colleagues set out to complicate the package picture of the eating disorder/culture-of-thinness relationship by exploring the emergence of eating disorders in groups traditionally presumed to be “immune” to eating disorders (i.e., black adolescents in an impoverished context). This article begins by exploring several of the tensions I’ve written about so far in this series; first among them, the idea that (as Keel and Klump’s work so clearly highlights) anorexia nervosa might not be so cleanly tied to a culture that prizes thinness as one might expect.
Rather than being culture “bound,” Le Grange et al. suggest that eating disorders might be better understood as “culture reactive” (DiNicola, 1990). This would mean that people living in societies undergoing large-scale social and cultural changes (such as those introduced in prior posts–Fiji and Mexico) might become more prone to developing problematic eating. In this model, instead of the thin ideal, other aspects of culture shifts come to bear on individuals’ sense of self, potentially contributing to the development of eating disorders. What might those “other factors” be, you ask? The authors note:
- Gender role changes (Ruggiero, 2001)
- Pervasive inequalities, leading to frustration (Szabo & Le Grange, 2001)
- Increased competition (Catina & Joja, 2001)
Come to think of it, any of those articles could make for quite an interesting post about the political and economic sides of “culture.” In any case, the authors explore what this means in the South African context. Among developments they noted in South Africa at the time of writing (post-apartheid, i.e., 1994 and onwards), particularly for Black South Africans:
- Shifting gender roles
- Increased mobility between rural and urban settings
- Increased presence of Western ideologies; e.g., the “Coca-Cola culture,” which Le Grange et al. describe as “an embracing of American individualism, competition, individualistic aspirations, and general worldview”
- Shift from collectivist to individualist orientation to the world
These shifts, Le Grange et al. argue, may be more pronounced amongst adolescents, who are actively seeking to make use of the new discourses on identity in order to be competitive in society, but who may feel conflicted about where traditional values can factor into this new identity. This relates back to the point in part one of this series about the kinds of multiple pulls on individuals in this “in-between” space of “new” and “traditional” cultures: there is confusion about where one fits, which set of rules govern social life, and how to negotiate between conflicting ideologies one is confronted with every day.
To look at increasing rates of eating disorders in South Africa, the authors note two key tensions:
- Are increases actually illustrative of increased prevalence, or are they more closely tied to methodological issues (e.g., how representative the sample is of the population studied, validity of questionnaires used in cross-cultural groups, as translation of words does not necessarily mean translation of meaning)?
- Do eating disorders look different in the South African context?
To try to move toward a more nuanced cross-cultural analysis, Le Grange et al. conducted a two part study with surveys and follow up interviews.
The authors surveyed a mixed sample of students (mean age 16.8; 58% female) from high schools varying in rurality, race segmentation, and affluence, for a total of 813 responses to the EAT-26 and the Bulimic Investigatory Test, Edinburgh (BITE):
- 362 white students
- 230 black students
- 221 mixed-race students
They then conducted follow-up interviews with students (5; all female, ranging in age from 15-19) from one school that historically had primarily black students enrolled. Here, they aimed to confirm a diagnosis of an eating disorder if students scored in range on the questionnaires. They also wanted to use this exploration to look at the Black South African students’ interpretations of survey items.
Perhaps surprisingly, they found that black students were more likely to score in clinical ranges on the EAT-26 and BITE than their white peers. Upon interviewing five young women (interestingly, 59 participants from the chosen high school scored in clinical ranges but only 5 were able to be reached and agreed to participate in an interview), none explicitly espoused what we might think of as “Western beauty ideals”; for instance, 3 noted that they expected older women to be larger, and all chose South African news media sources as preferable.
One of the main problems with the questionnaires for measuring disordered eating in this population emerged while conducting the interviews: the fact that participants were not able, in the context of the questionnaire, to expand on their reasons for the behaviours they engaged in. Le Grange et al. give some examples, including:
- Preoccupation with food might be related to food insecurity; in other words, a concern about there not being enough food for a family to eat
- Purging might follow a meal that included pork as an adolescent might have no other food to choose from, but the digestion of the pork would be against religio-cultural beliefs
- Laxatives were found to be used relatively frequently to counter constipation upon eating some traditional foods
Though these 5 participants had scored in clinical ranges on the EAT-26, their responses to the EDE-Q, administered during the interview, did not indicate an eating disorder. Notably, the finding of more eating disorder pathology among black South African adolescents (versus white and mixed race South African adolescents) might be linked to other complex and intersecting factors, rather than only to an increase in “Westernization.”
What does it mean for our understanding of eating disorders as culture bound?
While these 5 participants’ interviews are obviously not representative of everyone who scored in the clinical range on the written questionnaires, the difficulties the researchers encountered as they conducted this research, including both logistical issues related to making contact with young people living in poverty and needing to clarify questions that did not easily translate, are indications of just how different this “cultural context” might be.
The authors offer some suggestions for future cross-cultural work, including:
- Not assuming that scores on questionnaires reflect the same “reality” they might in the cultural context in which they were created
- Working to translate instruments not only into other languages, but carefully attending to different cultural meanings tied into eating behaviours
- Making note of how poverty and food insecurity can profoundly shape relationships with food in a way that challenges the divide between normal and abnormal
- Considering that (especially young) people raised in other contexts may not be accustomed to reflecting on behaviours and cognitions in a way that will necessarily translate into a score on a questionnaire
I think that this last point is an especially interesting one. It speaks in part to the assumptions that underlie “Western science,” as it were. We might take for granted that participants will be used to the kind of (particularly psychological) research that requests an objective evaluation of a behaviour, thought, or emotion on a rating scale. This is very much a part of the “culture” of evidence-bases and quantification we live in.
I have to say, this was one of my favourite studies for this series thus far. The nuancing of culture and poverty contexts reveals a lot about our systems of categorization and ways of doing research cross-culturally that offers something beyond a simply movement of assessment strategies from one place to the next.
Le Grange D, Louw J, Breen A, & Katzman MA (2004). The meaning of ‘self-starvation’ in impoverished black adolescents in South Africa. Culture, medicine and psychiatry, 28 (4), 439-61 PMID: 15847050