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Certain social structures are implicated in the formation of anorexia nervosa. We found most salient to the development of anorexia nervosa an overvaluation of appearance and a rigidly held belief that what one does is more important than who one is to be.
Overvaluation of appearance. Eight women in this study believed that beauty and thinness were the most valued attributes of women by society. When a researcher asked Dana (age 20) if there were any other questions that the study should have asked, Dana cautioned her not to forget about the reality of cultural expectations: "Well, I think just the main thing that I've noticed in the world is that there really is a difference in how you get treated [based on how you look]."
Based on this belief, the women in this study held themselves to very strict and externally defined standards of beauty that involved, foremost, restrictive dieting. Gutwill and Gitter (1994) discussed the effects of chronic dieting and stated that the long-term experience of starvation involves the dieter in a system in which she becomes unable to read internal body signals such as hunger. This research was important to the present study because a woman who is unable to assess her internal condition becomes increasingly vulnerable to external media messages about beauty and successfulness. Similarly, there was often a complex relationship between what these women consciously believed about appearance and what they felt they had to achieve in terms of weight.
Although invested in achieving extremely low weight, the women in this study deplored a culture in which an appearance orientation was so important. Ami (age 18) stated, "Girls always say 'I know I shouldn't worry about my weight' but they're trapped because ... the way the world judges them is based on that, and it's hard for them to break free." In one of the only displays of anger that took place during this project, Stella (age 19) stated that involvement in the social scene of college included wearing "like, caked-on makeup and, you know, huge hair that they spend hours on and the tightest clothes they can get and these huge, big heels and everything, it takes them two fucking hours to get ready, excuse me." While these women often exaggerated the belief in the paramount importance of physical appearance, a culture that values women for their physical appearance promotes a belief that one can and should change oneself to fit others' expectations. Trying to describe herself, Josslyn (age 19) first talked about self-identity but then struggled to find a sense of identity that was not appearance-related: "Sometimes I have a stronger sense of me and myself and sometimes I'm at a total low in myself. I think, umm, I want to be perfect and I want to do things always in the right way and I don't, so I feel like a failure a lot of times, umm, I---you know---when I think of myself, I think a lot about the way that I look, you know."
As she continued to talk, she discussed how she measured herself against others. For example, she changed her personality to fit the characteristics of those who were around her, and she knew that she was intelligent when she received proof through high grades. Because she felt that she could not change her basic looks, she felt she must diet because "everybody looks good when they're thin." This woman experienced, and overcame, a personal history of physical abuse, neglect, and separation from a parent. Josslyn understood the effects of her history on her self-esteem mainly through her appearance. It was easier for her to focus on her body than on her feelings. To varying degrees, all these women used the development of anorexia nervosa to avoid internal or external conflict. We found this strategy, the avoidance of conflict through a displacement onto the body, to be similar to Coen's (1992) description of the usefulness of psychosomatic symptoms. Sarah (age, 18), who developed anorexia nervosa at a time when she became more clear about the nature of her parents' difficulties, states that anorexia nervosa was, for her. "A way to prove to myself that I had control over something in my life because I think I felt like a lot of, everything in my life felt out of control including my future, you know, I had no idea what was going to happen, where I was going to school, my parents were selling our house, every solid aspect of my life wasn't in control anymore ... so even though I knew I shouldn't want to be thinner, internally--there was something internally--that said, you know, you do. "
The symptoms of anorexia nervosa were a solution to a host of problems that all related to a loss of ability to sustain a sense of self. What one does is more important than who one is. These women had internalized the belief that what one does is more important than who one is.
"I'm searching for the thing that people associate with me (Karen, age 20)."
Several theorists writing from a feminist viewpoint have noted the increase in depression, anxiety, and eating disorder symptoms in the transition from being girls to being women (Brown & Gilligan, 1993; Chernin, 1985; Jack, 1993; Wolf, 1994). There was a social reality to the difficulties that these women faced as they began to recognize new pressures to succeed socially, professionally, and personally. These women were growing up with more opportunities available to them than were available to their mothers. While this indicated progress on the front of equal rights, these young women found themselves breaking from a sense of identification with their mothers. Chernin (1985) wrote: "At a moment when serious political gains have been won and women are able to take up the opportunity for further development, there is a marked tendency for women to retreat, to experience a failure of nerve, a debilitating inner conflict about accepting advantages and opportunities denied to their mothers" (p. 43). In addition, the new possibilities for women have not necessarily added to their options as much as they have expanded their duties. Today's young women have to face the stereotype of "supermom" (Linda, age 18), the woman who can have a career, raise a family, and remain attractive. Whether accepted or rejected as a goal of development by the participants of this study, the discussion of the stereotype that women would be both homemakers and career women was conspicuous in all their narratives. This was similar to the findings of Steiner-Adair (1990) in which women with eating disorder-like symptoms were more likely to accept a stereotype of the autonomously successful career woman and mother as the societal ideal to which they were being held.
The core experience of growing up in Families and Social Structures that Encouraged Substituting Others' Needs for One's Own was salient in all these women's narratives. Although the women grew up in a Western culture that valued certain roles for women, the actual circumstances of each woman's life were different from the others. The relationship of each woman to the dominant culture was variable and depended on issues such as ethnicity and social class. Nevertheless, for these women, certain aspects of family structure that involved being made use of in relationships were echoed by a culture that stressed functionality and sex-role stereotyping. Without family inoculation to these stresses, these women were more vulnerable to these effects in the culture.
The families, also produced within cultures, were subject to many of these same pressures and values. Zerbe (1993) writes: "If ... an ambiance exists at home and is fostered by society that we must continue to pursue our original quest for perfectionism, than we will feel compelled to seek the unattainable ideal" (p. 119). For these women to define a mature sense of agency and relationship would mean defining themselves in' ways that were not supported by their experience and would include the threat of loss of identification as well as concrete losses such as loss of parental monetary support. In situations in which this conflict was unable to be managed intrapsychically, the development of the psychosomatic symptom of anorexia nervosa both expressed and controlled this sense of conflict. The use of the psychosomatic symptom of anorexia nervosa to manage anxiety was evocative of the work of Goodsitt (1985) and Sands (1989).
"When you feel out of control, you turn to this [eating disorder] as your crutch .... Not just coping with stresses, but being in control of something. Like if you were beaten as a child, there is an element of feeling out of control, so you want to be in control of things, in control of how you look and things like that" (Theresa, age 21).
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