The categorization of causes in this chapter requires some explanation and history. When beginning this research, I was interested in how broad categories of causes might be pitted against each other: biological forces vs. social forces and individual agency. If biological forces get center stage, do they push social forces to the wings, and change the politics of who ought to be held responsible? Do biological forces appear to remove
individual agency? I developed three broad codes to describe the types of causes mentioned by respondents: “environmental”, which included anything that was clearly external to the individual; “biological”, which included anything about the material body or brain; and “individual”, which was created to capture diverse material that was neither external nor biological and was located in the individual. The latter code included statements about individual agency and personality, as well as thoughts, feelings, and beliefs cited as causal factors. When I began coding, I already knew I wanted to capture statements about environmental and biological causation. I created the “individual” code after reading transcripts.
I found, however, that when respondents spoke of causes they could not usually be categorized in this simple way. Frequently, a causal factor implied two or even all three categories.1 For example, respondents often spoke about a felt imperative to control their weight as a causal factor. It was not uncommon to cite some aspect of the body as a contributing factor (coded as “biological”), and discuss dissatisfaction with it (coded as “individual”), and describe social contexts that promoted or intensified this dissatisfaction (coded as “environmental”). Similarly, coping with stress incorporated elements of
1 This observation may be useful in thinking through the partitioning of variance in twin studies between
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“individual” and “environmental” factors. The code for “individual” included a wide
diversity of phenomena, including psychological characteristics (e.g., low self-esteem, being depressed), desires or preferences (e.g., wanting to lose weight), interpretations (e.g.,
thinking that Dad left the home because the respondent was overweight), and agency. Many respondents thought of the eating disorder as a coping strategy or coping “mechanism” to deal with problems in their environment. Thus, the behaviors they adopted were influenced by the environment as well as some individual predilection or choice, and were combined into the concept of coping strategy, which cannot be reduced to either one. Coping strategies and other compound causes will be described in more detail in the next section.
Some causal factors seemed particularly likely to have a bearing on how respondents think and feel about genetics. All the material presented in this chapter appeared well before the idea of genetic causation or other specific causal factors were introduced in the interview. This early material is the best view I have of their pre-existing ideas, relatively free of
influence from me. Some of the ideas appeared to be more fertile ground for genetics than others (a proposition that is tested in later chapters).
Discussions of causation were elicited by specific questions but also occurred spontaneously in other sections of the interview. All the material described in this chapter appeared not only before I brought up genetics, but also before I asked them to react to specific models of eating disorders (e.g., as mental illness) because these models frequently prompted respondents to think of new causes. (I refer to these questions about specific models as “reaction terms” and “reaction questions” as a convenient shorthand for the rest of the chapter.) The questions encompass themes that go well beyond some narrow definitions of cause. Specifically, I asked them how their eating disorder began; what causal factors, risk
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factors, or other factors might have contributed to it; why it started when it did, why they might have developed the eating disorder as opposed to other people they knew, and whether it could have been prevented in some way. The purpose of this breadth was to bring to the surface any existing ideas about biological predisposition, as well as environmental factors. 2. COMMON, COMPLEX, AND COMPOUND CAUSES
Respondents‟ causal accounting included many different kinds of causal factors operating in conjunction with each other across time. Several said that their stories changed over time as they learned new things about themselves and about eating disorders.
Sometimes they expressed uncertainty about whether something they cited was actually important. In the following I present three categories of causal factors presented by
respondents: valorization of thinness, response to stressors or other problems, and factors that encourage the maintenance of the eating disorder. I organized commonly-cited causal factors into these three categories because the categories are general enough to encompass a great deal of variation. I do not report frequencies for causal factors and offer them primarily as background to illustrate the range and variety of causal accounting. These also help prepare the reader for subsequent discussion of individual agency and lack of agency in eating disorders.
2.1 Valorization of thinness
Most respondents described concerns about their weight or size as a contributing factor to their AN or BN. This was inseparable from their own valorization of thinness, and often closely tied to people and environments that valorized thinness. After a brief
description of weight concern, I present in greater depth the most commonly mentioned contexts in which thin body size and shape were prized.
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Almost all respondents reported a conscious desire to lose weight or avoid gaining weight. For most, this desire began as a result of being overweight or gaining weight themselves, and was identified as one of the causes of the eating disorder because it was the reason to begin dieting, purging and other eating disorder behavior. They reported being “pudgy”, “chunky” or “chubby” as a child and resolving to lose weight as they got older; some resolved to lose weight in order to avoid becoming as overweight as a parent. Several talked about gaining weight as an adolescent or adult as a result of puberty, pregnancy, birth control pills, injury (inability to exercise), or over-eating due to stress, which prompted them to take action in the form of restricting, exercising, and purging.
Some were not overweight but nevertheless came to desire weight loss. Some inadvertently lost weight and then adopted it as a goal. For example, Barbara lost weight because she began to play a new sport. When the season was over, she dieted and exercised to compensate for anticipated weight gain. Lynn lost weight because she had very little money for food during graduate school. Gillian began restricting because of a phobia about throwing up. As a result she lost weight and found that being smaller helped her avoid bullying. Willa consciously valued the extreme thinness of models and aspired toward that ideal, even though she was not overweight.
The concern about weight reflected a social valorization of thinness, in respondents‟ estimation. Respondents spoke about monitoring and evaluation of weight by “society” generally, family members, and in athletic and performing arts contexts. Some linked it to gender, others did not.
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For example, Ingrid describes the general valorization of thinness in “our society”, particularly among peers at her school. As someone who was “heavy” and “chubby” she developed a fear of food as an “enemy” because she associated it with abuse from her peers.
… you‟re trying so hard to get away from the enemy that made you so fat. And, made you suffer as a result of that. And, by suffer I mean not just physiologically. But, emotionally. Socially. And, so forth. Fat is not fun. And, fat is not a sociable or likeable attribute to have. And, in our society anybody who is overweight is not considered worth even talking to. So, the thinner you got, the more – you would equate being thin with being popular. And, I was a hundred and seventy pounds when I was twelve years old. And, at four ten that‟s a hefty size. And so, I went on this diet with a doctor who – I mean I went through emotional and verbal and physical abuse as a child from my peers. Classroom bullying. And, all these things. … So, when I found something – a medium called dieting. Which allowed me in fact to feel better about myself. Suddenly the whole world opened to me. So, I started when I was about thirteen. Maybe fourteen. And, by the time I was in high school, I had reached the weight I wanted. I was extremely popular. My grades went up. And, gee. That‟s the best thing since sliced bread. Why would I want to give it up? (Ingrid, T-AN2)
For Ingrid, “society,” specifically her peers, judged her negatively and excluded her because of her weight. By losing weight, her “whole world opened.” She equated dieting with feeling better about herself and being popular.
Most respondents described contexts that valorized thinness in ways that suggested that gender was important. This ranged from uncritical statements about trying to be
attractive to men to critiques of beauty norms for women and broader critiques of patriarchy. Yolanda (T-BN) said that the main contributing factors for her eating disorder were “The fact that I was overweight for so long. And it felt so good to be skinny.” I probed about the good feeling she had about skinny, and she linked it to her attractiveness to men:
It was something that I had always been envious of and always wanted. And then I finally had it. And I was finally able to go to the store and pick out the clothes that I wanted. And think that it looked really good on me. And I was getting attention from boys. And beforehand I‟d always have a crush on the boy. And like, I would just be
2 “T-AN” stands for “In treatment for AN.” I will provide such brief descriptions when quoting or referring to
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their friend. And I mean I was the same way. The boys that I had crushes on weren‟t overweight. So I was finally – I was just really, really happy.
She connected her happiness about being thin to positive attention from boys, and in this sense it relates to gender. Other respondents cited gendered beauty norms as causal factors, suggesting more critical distance than the excerpt from Yolanda. Rebecca (T-BN) spoke about comparing herself to media images and revising her sense of what was beautiful.
I do kind of blame the media a little bit. Because I feel like – I didn‟t have TV growing up. So until I was in high school I never really watched TV. And then I started going over to friends‟ houses. And we‟d watch TV there. And I think it changed my perception of what beautiful was. Like, I‟d always had, like, a lot of confidence in myself. And, like, thought I was a pretty girl and everything. And then like, I started putting on weight. And I started seeing like, these celebrities who were beautiful. And they‟re like, bone thin. And so I think my perception of like, what was beautiful changed. And I didn‟t feel like I matched – I matched what I thought of [as] beautiful anymore.
Rebecca‟s description suggests that she sees the celebrity version of beauty as one possible standard, rather than the only one. Some linked their eating disorder to gender inequality more directly. Alyce (R-BN) described puberty as a betrayal, because it meant she was a woman and therefore disempowered.
Why did it start when it started? It was totally puberty. I felt betrayed by my body. And, I felt it was a demotion. I was always taller than the boys. Smarter than the boys. Faster than the boys. Meaner than the boys. Better swimmer than the boys. Even those five years older I could lick 'em. And, it was totally disempowering. I‟m still mad about it. Honestly. And, not many women will talk about it. I don‟t know. But, it just really sucked. All of a sudden I was like the back-up singer. Or, the secondary status of women just hit me like a log. And, I hated it. I hate it now. In retrospect I think I was conflicted. Because, part of you wants to conform. It‟s puberty. And, part of you doesn‟t. I was very conflicted.
Having a woman‟s body was a “demotion” from her previous status as a young competitive swimmer, whose low bodyfat was praised by her family and doctor. Alyce was one of 23 who explicitly tied the eating disorder to gender in a way that was more critical than others such as Yolanda above. Although puberty is important, Alyce does not present it as a
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biological event but as the inauguration of an unwanted identity as a disempowered woman. By explicitly connecting gendered disempowerment to the eating disorder, Alyce may be more critical of medicalized ideas of and genetic explanations for eating disorders. (More about this more gender-conscious group of 23 will be presented later in this chapter, in the section on causal factors that are likely to inform a respondent‟s reception of genetic ideas.)
In addition to speaking about shared social norms, respondents spoke about specific people and contexts that valorized thinness. Family members created environments in which thinness was valued. Several respondents thought their parents had eating disorders or “eating issues” of some kind. Victoria described her mother‟s “competitiveness” with her about eating small amounts and being a small size:
… she‟s a lot smaller than I am. Like, I‟m not just saying that. She really is. But she‟ll say things about how, like, she‟s so fat. And she like, can‟t fit into my clothes because I‟m small. And she‟ll, like, send me like, clothes that are obviously too small for me. And that just makes me feel worse too. And she‟s like, “Oh. What‟s the matter? Didn‟t it fit? Were they too big?” I‟m like, “No.” They were, like, size zero like, pants she‟ll send me or something. I‟m like, I obviously don‟t wear this size. It‟s like, stuff like that. I mean maybe she could. So it‟s just like, “Uh yeah.” Or she‟ll just be, like, competitive about eating with me. Like when I just had surgery. Like, I couldn‟t eat a lot at certain times. Like, at night for the surgery because I had surgery in the morning. It was a bunch of different procedures that they did. And,like, she wouldn‟t eat if I couldn‟t eat. (Victoria, T-BN)
Victoria thought this kind of comparison and “competition” about body size and eating encouraged her eating disorder, even without explicit criticism. Willa also describes even more subtle encouragement from her mother about weight loss, against a backdrop of a self- described affluent area of the country.
And it‟s kind of understood I guess that – I mean you‟re supposed to be beautiful and thin and wealthy and all that kind of thing…. My mom was very thin. And so she I mean never said “Oh my gosh. You really need to lose weight.” Or anything like that. But anytime I made it clear that I wanted – was trying to do that. It was always encouraged. … I mean to me moms eat salads. It was just kind of that was that‟s just
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what you do. You grow up. And I honestly think I believed “Of course that‟s what you do when you become a mom.” (Willa, R-AN)
Willa‟s mother does not tell her to lose weight, but through example and encouragement about weight loss, the importance of thinness is clear; “it‟s kind of understood.” (Clearly, Willa‟s description of expectations for moms is related to gender, as are many of the following examples of specific contexts.)
Others reported comments from family members that were far from subtle. For example, Margaret and Tammy were told they were “chunky”, Emma‟s mother declared, “Your thighs are starting to get big.” Fran‟s father “harped on me…and offered me five dollars for every pound I lost.” Later, she married a man who monitored her weight in ways that were not only non-subtle but even abusive:
He liked me thin. That was what he was used to. He had no tolerance for any extra weight. So, by the time I was three months pregnant. And, I wasn‟t huge. He wanted me to shower in the guest bathroom across the house so that he wouldn‟t risk seeing me with a larger stomach from my pregnancy.… I was married to him for fourteen years. But, he wanted to know how much I weighed every day. Did not want me gaining any extra weight. Even made the statement that he‟d divorce me if I got fat. (Fran, R-BN)
Weight control was also part of Yvette‟s abuse as a child by her father. In addition she cites his attitudes toward her mother‟s weight, some of which happened before she was born.
For me my biological father when I was little – he would tell me how fat I was. And he would tell me like basically how disgusted he was with me. And so when you‟re a little kid, like, you don‟t realize that your dad is crazy. And he did a lot of other – like, he abused me. And he‟d have me and my older brother do stuff. … it was like he wanted control over me and my brother. And like, my mom had said he always wanted her to be thin. He had always liked her being thin. And … he had always prided when she – taking her out when she was really thin. And they wouldn‟t do much when she got pregnant. He was, like, disgusted with her. And that‟s why when she got pregnant with me he was more disgusted. Because he had to go through having a larger lady again. Even though she was pregnant. Like, I don‟t know. So it