Some might argue that bulimia nervosa is more “hidden” than anorexia nervosa — it is not always obvious that someone is suffering from bulimia (though, I would argue, it is not always obvious that someone is suffering from any eating disorder). Even when it is “discovered,” BN is often placed in opposition with AN — as if the two were polar opposites.
Indeed, attempts to define a phenotype (a set of observable traits or characteristics) for AN and BN tend to oppose the two and to suggest that the people who develop AN are inherently different from those who develop BN. While I believe there is some scientific evidence for personality differences between the two, the degree of diagnostic crossover and symptom variability in eating disorders makes me feel like this split is at the very least overly simplistic.
What is interesting is how BN has come to occupy a very different place in our collective social imagination than AN. We know that preconceived notions about what it means to be an individual with an eating disorder in general can have implications for things like treatment seeking (see here, here, and here) and feelings of legitimacy around eating disorders. We also know that misinformation abounds when it comes to the causes, presentation, and experience of eating disorders.
But how does society make sense of bulimia, and individuals with bulimia? How do people understand a disorder that expresses itself through behaviours that may or may not ever lead to visible changes in the body, when eating disorders are so frequently collapsed with their physical ramifications?
One of my favourite post-structuralist critical feminist writers (yes, I have favourite post-structuralist critical feminist writers; don’t judge), Maree Burns, has written about understandings of the bulimic bodies and how BN and AN can come to be hierarchically positioned in social understanding. I recently came across an article she wrote in 2004 (it is open access) that I’d like to explore here.
I do realize that the article is 10 years old; something that has struck me lately, however, is that we still seem to be grappling with similar issues in the eating disorder research field after years and years of debate. So, however unfortunate it may be, it would seem that conclusions drawn 10 years ago may still hold weight.
An important distinction
At the beginning of the post, I briefly touched on efforts to define a phenotype for AN and BN. To be clear, that is not the intent of the author of this article. Instead of looking at whether AN and BN are actually different, Burns looks at how AN and BN are understood to be different, and what impact this might have. She ties this into a broader discussion of the construct of femininity, particularly as it is articulated in Western societies.
This distinction is really important for interpreting Burns’ findings, and speaks to her theoretical leanings. As she notes in the article, using a feminist post-structuralist perspective allows us to locate meaning in discourse by looking at language used.
Rather than looking for some kind of truth about “what” or “who” individuals who binge and purge or individuals who restrict are, we are instead looking at how different ideas around these behaviours (and the individuals who practice them) come to impact their being-in-the-world.
For this study, Burns interviewed 15 women engage in bingeing and purging behaviours and 11 health professionals, including physicians, psychologists, psychiatrists, and a dietician, among others. She also looked for representations and coverage of BN in popular culture (e.g., TV, Internet, magazines), as well as in the psychological literature (e.g., scholarly articles).
In this body of data, Burns sought to tease out the overlap between a created dualism/hierarchy between BN and AN as represented in pop culture, “authoritative discourses” (e.g., experts’ opinions) and the reports of women with lived experience.
Control/Lack of Control
Burns discusses how BN has historically been constructed as a lack of control (e.g., Bruch, 1973) while AN has tended to be described as “over-control” (e.g., Jarman et al., 1997). From the outset, this seems to position individuals with BN as embodying a number of characteristics socially coded as negative. For example, seeing individuals with BN as lacking in control, they are positioned as “at the mercy of their compulsions” in contrast to a “disciplined” individual with AN.
Participants were well attuned to this dynamic, sometimes recounting AN as “the epitome of control.”
I think to get, to actually be an anorexic, you’d have to have like incredible, supreme control, and just to get to that place, something inside you must just push you there. Whereas I think with bulimia, it’s just (long pause) it’s a lot more common because it’s like a, a humans are fallible, that’s what they do. They indulge and they try to make up for it. (Becca)
Participants (both those with lived experience of BN and practitioners) also placed value on the ability to abstain from eating, sometimes describing individuals with anorexia as “overachievers” or “driven.” Burns argues that this reflects a broader value placed on control and success in individualistic culture; one practitioner even described BN as “failed anorexia” (which seems offensive, honestly, but there you go).
The very “doing” of BN could be described as socially disruptive, Burns suggests. Her participants described BN as more of an active, physical endeavour:
[…] bulimia is is a more um, is a more physical thing, you actually have to physically go and find somewhere that you can throw up your food and you have to do it and then you have to sort of . . . come back in and carry on doing what you were doing. Sometimes you’d be in company and other times you wouldn’t, whereas anorexia is . . . I mean, there is no physical doing, you just, you just don’t eat. (Rosie)
Burns links this kind of categorization to a historical tendency toward the construction of female bodies as “sites of unwellness and infirmity.” The focus, in popular culture (both presently and looking back into history) is less on concern for the individual sufferer’s well-being and more on the shock value associated with the symptoms bulimia might entail, for example “gorging” on rich foods or “taking”/stealing food to binge.
Tied in to this fascination with women’s bodies and behaviours that circulates in popular culture and psychological discourses are links (subtle or explicit) to sexuality. Looking at the DSM, individuals with BN are described as being more likely to have impulse control problems and to be sexually active. Throughout pop culture and (perhaps more alarmingly) in clinical accounts of BN, there is a contrast between bulimic “bad girl sexuality” and anorexic “good girl sexuality.”
A psychologist Burns interviewed for this study articulated this linkage between appetites for food and for sensual pleasure:
She [friend with bulimia] just loved to eat. She was a very sensual person and she loved to eat and she liked to to sleep with strange guys (laughs) and you know I mean she she she / MB: yeah / she um she she really lived and and she couldn’t bear putting on weight so she used to vomit.
What I find most interesting about this particular area is that “really living” or having an appetite (for food, for sex, for life) could also be seen as positive; however, it becomes negative through clinical discourse when described as “promiscuity” or lacking in control. The degree to which this reflects our social understanding of femininity and sexuality is striking.
Dualism and Severity
Maybe there is nothing inherently wrong with the oppositional categorization of AN and BN. But what does this say about our understanding of the severity of the two? Further, what implications does this have for individuals suffering from either AN or BN (or for those who experience diagnostic crossover)?
Burns suggests that this dualistic construction informs understandings of the severity of AN vs. BN such that AN is understood as deviant by way of the appearance resulting from practices and the associated potential outcomes of these practices (e.g., ultimately, death). On the other hand, it is the practices themselves that are seen as deviant in BN.
While either AN and BN could result in death, AN may more obviously represent, to the gazer, “closeness to death.” The interpretation of the bodies of individuals with eating disorders explicitly informs others’ understandings of the severity of their practices.
So, “bulimic practices” are seen as deviant while “bulimic bodies” may fit the norm; on the other hand, “anorexic practices” seem to fit the norm (until a certain point) and may even be reinforced/praised/rewarded, while “anorexic bodies” hold a “shock value” and are read as deviant.
Burns also suggests that “the bulimic body” is more readily tied into dominant historical and cultural notions of femininity. To succinctly and perhaps inexpertly summarize Burns’ insights into this dynamic:
- AN reflects a commitment to a “mind in control of body” that one would expect of accounts of the (rational, controlled) masculine body
- BN is more explicitly linked to the physical, suggesting that the bodily appetite is in the driving seat
- This “body ruling over the mind” is more in line with historical conceptualizations of female (irrational, uncontrolled, dangerous) bodies
There are nuances to this analysis that would make this post excessively lengthy if I were to really delve into them, but I also think it is important to note Burns’ acknowledgement of the paradox of understandings of anorexia: while AN in some ways reflects a “traditional” (passive) femininity, the mind-over-body control is more clearly linked to a historical understanding of masculinity.
With this, Burns also explores how the idea that AN and BN have culturally and historically occupied binarized positions, this does not mean there is one way of understanding AN and BN; AN in particular occupies an ambiguous place between positive and negative, normative and deviant. BN, on the other hand, has tended to more consistently occupied an abnormalized (but more invisible) place in the cultural imaginary.
Ultimately, Burns suggests that this dualistic construction of AN and BN can prevent women from being able to express different elements of their subjectivity. Perhaps especially for those who have experienced diagnostic crossover and have thus experienced both “anorexia-like” and “bulimia-like” symptoms, the hierarchization and dichotomization of BN and AN may lead to confusion about “what kind” of person one is, and who is the “real self.” This reflects the very real consequences of being labelled “anorexic” or “bulimic”; as one participant in this study reported:
I don’t know how the atmosphere had been created but I know that it felt right away that there was some kind of hierarchy between those labelled with anorexia and those labelled with bulimia and that anorexia represented this more kind of achievement of perfection and it was a cleaner disorder because you weren’t throwing up and there were just all of these things that um made – made that category. I mean that’s the ultimate achievement of anorexia is to kind of have it perfectly / MB: mmm / um . . . and I was labelled with bulimia and right away um the problem grew really really strong and difficult for me and decided that it needed to be called anorexia and um I went rapidly down hill in all ways and I I was in this supposedly very supportive environment but things took such a turn for the worse that I was um you know an inpatient in a matter of months in a couple of months / MB: right / and that was not being addressed at all in the program I felt like I couldn’t speak about it at that time but it was there was some kind of competition happening there that was really unhealthy.
Burns also suggests that a different understanding of AN and BN could facilitate a less pathologizing understanding of behaviours, bodies, and subjectivities. For example, a more fluid construction might place eating disordered behaviours on a continuum and sometimes engaged in simultaneously, rather than fixed at either end of a spectrum.
In the years since the article was written, I believe there has been a move toward a more “continuum-based” understanding of eating disorders. However, a polarized understanding of eating disorders does still circulate, particularly when you look at popular culture representations of eating disorders.
Something I see a lot is a lack of recognition of diagnostic crossover and the subtypes of AN; for example, it is far more common to see someone described as having anorexia and bulimia than to see them described as having “anorexia, binge-purge subtype,” in popular culture. I wonder about the impact of this kind of framing on general understanding of eating disorders.
Importantly, this article reveals the potential negative impacts that creating a hierarchy around eating disorder diagnoses can have. Further, I would suggest that it highlights the importance of not judging individuals’ eating/health status based on their appearance. I’m likely preaching to the converted, here, but it is an important point to reiterate.
Burns, M. (2004). Eating Like an Ox: Femininity and Dualistic Constructions of Bulimia and Anorexia Feminism & Psychology, 14 (2), 269-295 DOI: 10.1177/0959-353504042182