Eating disorders are typically seen as an illness of the middle class, with most patients coming from that socioeconomic group. However, the invisibility of poorer patients within eating disorder research in part reflects the barriers to treatment that they face, including both cost and lower levels of awareness. This paper, written by a Hong Kong social work professor, Joyce Ma, focuses less on the process of eating disorder recovery, highlighting instead the context of treatment. She discusses how family dynamics and socioeconomic status come into play in her encounters with 7 Hong Kong teenagers from low-income families.
While her sample size is very small, it reveals a more diverse — and less body image-focused –disease pathway than most American studies, with Ma breaking down the precipitating factors as follows (patient numbers in brackets):
- Constipation (1)
- Desire to be thin (3, 7)
- Relationship issues (6)
- Parental conflicts (5)
- Poverty (2, 4)
So only 2 out of 7 patients from a lower-income family felt pressured to achieve the thin ideal. This distribution perhaps partially reflects the prevalence of ‘atypical’ non-fat-phobic anorexia nervosa in Hong Kong, with primarily physical explanations such as ‘constipation’ highlighted in Lee (2003). Nevertheless, the accounts of participant 2 and 4 both emphasized the how their family’s poverty contributed to their eating disorder. Participant 2 said that
“I was unaware of the adverse effects to my health for skipping lunch and delaying my meals. I thought that it was the best way of coping with my meager pocket money: by doing so, I had unexpectedly had the secondary gain of being slim.’” (p. 156)
Both patients also experienced difficulty in seeking help for their eating disorder due to the “stigma attached to being poor” and out of “filial piety” (p. 156), or the feeling that they should not add to their parents’ strain. In fact, concerns over money continued to manifest themselves during the treatment process. Some attributed their failure to gain weight and difficulty in making progress to the lack of money for food, with one in particular unable to afford “powdered nutritional milk” (p. 157) prescribed by the dietitian. These families – one of which was a recent immigrant family – were able to access healthcare and treatment because healthcare in Hong Kong is public and there are subsidies available for lower income families. In another context – i.e., in the United States – it’s quite likely that they would never have been able to obtain any treatment in the first place.
Another important finding from Ma’s study is that low socioeconomic status is implicated in eating disorders not just in terms of finances, but also in relation to family dynamics and relationship difficulties that come with living in a state of chronic poverty and disadvantage. Participants 3, 5, and 6’s parents all had marital difficulties that contributed towards their financial difficulty – divorce or unemployment that caused tensions within the family – and also prevented them from establishing a supportive home environment to support their children in their recovery. However, the author also suggests that patients’ resilience in face of such difficulties helped to create greater motivation for change in recovery, as it did in the cases of participant 3 and 7. The filial piety that they felt worked for the better in these cases, as they did not want their parents to worry about them. Testimony from other participants suggests that this can go either way, though – another participant “reported recovery only after she moved out from her conflict-ridden family, suggesting that family is not always conducive to recovery” (p.158)
Regardless of the role of the family in helping the patient recover, what is common to all participants was how they had heightened needs for treatment and therapy, including processing a much broader range of family issues beyond the eating disorder itself. Their reflections on things that supported recovery also focused on relationships and contexts, as the authors write:
Besides the mother and the sibling’s’ support, there were other reasons given by these adolescents for recovery in the post-treatment interview, including starting a new job, separation and divorce of the parents and improved marital relations of parents (p.158)
Being able to access a holistic treatment team is important for such patients, whose eating disorders were strongly tied to their social situation. In concrete terms, I would suggest that the paper points to the need for greater access to medical social workers, not just family therapists, and clinician sensitivity to socioeconomic variations in eating disorders. The most challenging part of treatment for clinicians was not the eating disorder itself but handling the complex issues of the patients’ families, and possibly knowing when to step back and pick their battles. As the diverse experiences show, change within the broader family can help recovery – but it isn’t always possible.
Ma, J. (2007). Living in poverty: a qualitative inquiry of emaciated adolescents and young women coming from low-income families in a Chinese context Child & Family Social Work, 12 (2), 152-160 DOI: 10.1111/j.1365-2206.2006.00453.x