Gender Difference in Eating Disorders

One question I have been asked several times is why most people with eating disorders are women. The answer has two parts, the first relates to the role our society plays in eating disorders and the second biology.

The obsession with thinness in our culture has been all consuming for decades. Despite increased interest in the sexualization of men’s bodies in recent years, all the focus has been and remains on girls and women.

The media has idealized thinness and has equated it with success for girls and women for decades. The endless array of photos of girls and women all focus on body size and shape and the privilege accorded to those women. Women’s clothes are often extremely revealing, and status is clearly awarded to those who meet the cultural expectation. The diet culture is aimed squarely at women, and a large majority of women struggle to see any other success as more important then body image and weight.

The result of the onslaught on girls’ and women’s self image and body consciousness is an enormous pressure to diet. As I have written extensively in this blog, the number one trigger for an eating disorder is dieting.

Food restriction kicks off a powerful starvation response first rooted in our biology: our bodies are programmed to adapt to a famine by minimizing energy expenditure and slowing metabolism to survive. Long-standing food restriction triggers a more powerful genetic adaptation to prolonged famine: obsession with food, preoccupation with finding and hoarding food, more permanent metabolic changes and sacrificing less necessary body functions.

Some people respond quickly by developing an eating disorder. Others discard the diet quickly and resume normal life. The decision isn’t conscious but based on how our bodies are designed.

The interesting caveat is that men would develop more eating disorders if the pressure for thinness and dieting was stronger for men because these biological adaptations are the same for men and women.

Instead, the societal pressure on women that have led to the rapid rise in the incidence of eating disorders appears to be a cultural means to force women to expend an enormous amount of energy on the meaningless task of weight loss at a time when their plate is already full: ambitious career goals while still managing other roles always burdened on women. 

It is difficult not to wonder if the increasing pressures that have led to eating disorders reflect a relatively new way to overload women in the current societal climate. The way to change this blight clearly is decreasing the pressure for thinness—a possible but difficult task for a goal so ingrained in our culture.

The Battle against our Obsession with Thinness

Dieting is the main risk factor for developing an eating disorder. When someone begins a diet, they risk triggering an adaptive mechanism humans favored in times of extended famine. Those who could survive with limited food the longest persevered and their genes were passed on. So the starvation response is built into our genetic code and, when used in maladaptive ways, becomes an eating disorder.

Now, the trigger is no longer the lack of food but instead the driving force of thinness as a necessity for success in our modern culture. As long as thinness is a triumph, as long as fat bias exists, as long as the exercise, diet and food industries bombard the public with false messages, the masses will pursue thinness and diet.

Trapped in this funhouse where we are taught to see the distortion of our own bodies, people spend countless days, hours and years expending enormous mental and emotional effort on dieting and weight. We may worry about decreased productivity due to smartphones, but we ignore the endless lost time to weight preoccupation. 

The inexorable pull to thinness and weight loss is pervasive in the culture through urban and rural parts of the world, socioeconomic differences and racial and ethnic communities. At this point, no one is spared.

In addition to the personal and interpersonal changes I have written about in this blog that can help, eating disorders will not begin to decline without a decrease in the pressure for thinness. There are some signs of positive change: the body positive movement, outing of fat shaming, and varying size models for some clothing companies. These changes matter and are noticeable in the community.

But for more change to occur, the true arbiters of personal success need to speak up. Celebrities across the board need to question the overall thin bias and stop supporting the industries that benefit from our collective obsession. The medical community needs to be clearer about the true minimal link between weight and health. The government needs to crack down on industries sapping our mental wellness to live a life lost in pursuit of the number on a scale.

The effects have been long lasting and harmful. The changes that need to happen are starting. If a different way of assessing our own success begins to grow, the power—financial and emotional—of the thinness crusade can be weakened.

Feeling Unlovable in an Eating Disorder

One post I wrote posited that love is the antidote to an eating disorder. I’m rethinking this concept. Perhaps, a better way to understand this part of eating disorder recovery for many people is that feeling unlovable is at the core of many people’s eating disorders.

It’s not uncommon for children to interpret challenging formative experiences as signs that they are unlovable. For some, it is a stage they flounder in until they find value in themselves as they get older. This self-worth can translate into feeling worthy of love.

For others, the core of unlovability grows into something with deeper roots in one’s psyche. Adolescence, especially for girls, is very frequently tied up with looks and self-image in our current culture. When the lack of self worth is matched with a powerful urge to perfect one’s looks, two things happen.

First, the risk of an eating disorder goes up significantly. Equating personal value with body image sets up a constant desire to lose weight or perfect looks in order to escape the feeling of not being lovable. However, this battle can never be won.

Second, the growing power of food and weight and the impossibility of fixing the problem justifies the fact of being unlovable. Since this person can never achieve her goals, she will always be unlovable. This is no longer an internal feeling. It begins to feel like a fact.

And so treatment for an eating disorder often involves countering this belief that, at the core, the person is unlovable. Separating self-worth from body image is a part of recovery that is very much achievable, if long and hard.

But convincing someone that they truly are lovable underneath is even harder. It demands an intensity in the therapy to question how someone sees themselves. And it puts pressure on the therapy to essentially prove that the eating disorder has always been wrong.

This work in therapy is very much possible. It demands a consistent treatment structure, significant trust and a complete understanding of the issue at hand. With these three pieces, therapy can undo the underlying and usually long lasting belief of feeling unlovable and free the person from this self-doubt that has often dominated their sense of self.

Flexibility and the Food Log

Eating disorder treatment needs to include some focus on food and eating patterns. Even though these illnesses are primarily psychological, restricting, binging or purging all cause disturbances in thoughts and emotions. Addressing the eating patterns is still critical to recovery.

In most treatment, the expectations around how to monitor eating is standardized. There are clear methods to track food: food logs or apps like recovery record. But many people don’t find these strict programs to be useful. They can feel limiting, infantilizing or restrictive. Even if someone has an eating disorder, that doesn’t merit being treated like a child.

In these circumstances, it’s easy for treatment to focus more on the eating disorder thoughts and frustrations of having a chronic illness while sidestepping the need to track food and eating behaviors. However, no one seeking treatment wants to avoid a necessary part of success. Instead they need help finding a different and more palatable way to monitor food.

A clinician needs to try to meet the patient where they are and respect their needs. Revealing the details of daily food intake is incredibly exposing for someone with an eating disorder. Nothing is more personal since food is at the center of their lives. Accordingly, they need enormous respect and understanding about setting up a way to follow food. It may seem simple to the clinician but could not be more difficult for the patient.

A conversation about food journals needs to start with flexibility. There are so many ways to track food: written logs, spreadsheets, apps, emails, texts, photos, voicemail. Given the options, people are more likely to think about what would make a regular log possible. Often people would prefer to send it off daily in some form so they don’t have to review their food for the last few days or weeks. Ease of communication is central too. Many people have trouble overcoming the idea of spending a lot of time on a log.

Also the flexibility of how to make a log sets the tone for treatment. It implies there is not just one way to do things. Overall the idea is for someone to recover. There is no right way, just the way that works.

The Tension between Hope and Hopelessness in Eating Disorder Treatment

Hope is the foundation of true eating disorder recovery. The last post named one of the most difficult obstacles in this work: hopelessness. It’s critical to differentiate between hopelessness and depression because conflating the two implies that the hopelessness can be treated completely with medications. This tenet would take the success of recovery out of the hands of the person who has an eating disorder and instead place it in a pill.

The hope for recovery stems from several important points at the heart of eating disorder treatment.

First, people do fully recover and get well. They can come to a place where their eating habits normalize; eating disorder thoughts wane and body image also returns to a more typical way people see themselves. The first step in recovery is always to fight to normalize eating and tracking with through food logs. The second step is to tackle eating disorder thoughts followed by the longer process of mitigating body image distortions. 

Second, every person can find the clinicians who will understand them profoundly and know the path recovery will take. As I have written in this blog many times, put in the effort to find the right practitioner. Settling for someone who doesn’t feel right only reinforces the hopelessness in the end.

Third, remember that recovery won’t just be about changing eating patterns. The underlying power of an eating disorder relies on certain philosophies that pervade our society: the superiority of thinness, the diet culture, the exercise culture, the food industries and the money and clout behind maintaining these issues as important in our lives. Recovery will promote individualized thoughts, prioritize personal wellness and value care and love. 

Above all, recovery must have hope at the core to be successful and valuable. Acknowledging and recognizing the hopelessness is important. No one should be alone with those feelings, yet every treatment needs to fight for hope as a central theme of the process.

Hopelessness as the Engine of an Eating Disorder

There is a distinct and important difference between depression and hopelessness in the experience of having an eating disorder.

Depression is a host of symptoms including low mood, decreased energy and motivation, lethargy, poor or too much sleep and sometimes thoughts of wanting to die. It is a disorder that comprises an entire experience of physical and psychological symptoms that consume daily life.

Hopelessness can be part of a larger depressive episode but often signifies something different in the context of an eating disorder. It is an intellectual understanding of one’s own life and, at its most intense, feels like an absolute truth.

Hopelessness represents the inability to see a future in one’s life. This thought makes it seem like nothing in life will change and that the current experience is the only experience. This sense of life and the world is how it is now and how it will be forever.

People often describe hopelessness as drowning in the misery of the moment with no escape. When combined with the reality of an eating disorder, hopelessness can make the eating disorder symptoms appear to be the only way out even if it is only temporary. The behaviors take up time and emotional energy that provide a respite from the relentless, hopeless feeling. The end result of the eating disorder behavioral cycle is to feel even more hopeless and unable to see any route to change one’s life.

From this perspective, hopelessness can be the engine of an eating disorder. If it is impossible to see any change in the future and if it feels like this misery is going to be what life entails, there is no reason to avoid the eating disorder symptoms. These behaviors almost always reinforce this sense of depression and low mood combined with hopelessness.

This vicious cycle can be the centerpiece that keeps an eating disorder alive. More importantly, the hopelessness can pervade every relationship in one’s life, including any clinical and therapeutic relationships. At some point, clinicians can start to feel as hopeless as the patient.

The key change for the person and clinician to consider is to question the hopelessness directly. If left to dominate, the hopelessness will derail treatment and someone’s life.

But there is no factual foundation to the hopelessness. There are always new ways to approach a problem, the hopeless thoughts or an eating disorder. How one feels never lasts forever. Given the new possibility of a direction for recovery can often be enough to break the hopeless cycle and start a new path.

Self-Loathing in an Eating Disorder

A common core belief at the heart of an eating disorder is self-loathing. It feels like a deep, unshakable fact. That person feels like there is something wrong at their core. It’s an old thought they typically have believed for a long time and not one that even feels very logical. It just feels true.

Interestingly, someone can feel trapped by a sense of self-loathing and simultaneously be able to recognize positive traits about themselves. They may see they are competent, kind or caring. They may recognize an innate ability to be a good friend or employee. However, recognizing these qualities doesn’t seem to make a dent in the core negative belief.

Often when someone has a deep sense of themselves, it isn’t based on true events from their past. The belief seems to precede any sense of identity or of the true essence of that person. It’s a belief that feels grounded in their basic self-image. Rather than the belief stemming from events in someone’s life, generally facts of one’s life are twisted to reflect the core self-loathing.

This is the place where the eating disorder becomes relevant. Once the eating disorder starts, the behaviors reinforce the core belief that there is something wrong with the person and justifies the self-loathing. Even though the self-loathing always precedes the eating disorder, the eating disorder morphs into the overall explanation and justification of the self-loathing.

It then becomes easy to see why this cycle becomes difficult to break. If the self-loathing encourages the eating disorder and the eating behaviors strengthen the self-loathing, it feels like there is no escape.

Treatment needs to aggressively question the self-loathing. The therapy can bring to light the nonsensical logic behind the self-loathing and help that person see that this core belief is not rooted in reality.

The harder part of treatment is that the self-loathing needs to be replaced by love. This doesn’t mean a false belief in self-love. It means the experiment of being lovable, of accepting a profound sense of being loved even when that core of doubt and fear is exposed.

It’s remarkable how letting that love land can help someone find their way out of the vicious cycle of an eating disorder and self-loathing. As I have written many times in this blog, love is the true antidote to an eating disorder.