Categories
Dieting Eating Disorders History

Why Women? Theories of Anorexia Nervosa

Cases of eating disorders have risen dramatically over the last decade. Between 1.25 and 3.4 million people in the UK are affected by an eating disorder.1 The majority of these are women.

This gender bias is especially true of anorexia nervosa, which is one of the most common psychiatric disorders amongst young women.

The Diagnostic and Statistical Manual of Mental Disorders (DSMV) informs that ‘[m]ore than 90% of Anorexia Nervosa occurs in females.’2 There are also more women diagnosed with bulimia nervosa, the National Eating Disorders Association reporting that 80% of sufferers are female.3

More than 90% of anorexia nervosa occurs in females

While men do suffer from eating disorders, there are significantly fewer reported cases. For more details on this, please click here.

Cases of anorexia amongst males are also believed to have different causes, and are differently expressed to those experienced by the female population. This concept is supported by theorists such as Joan Jacobs Brumberg who writes that men with anorexia ‘exhibit a greater degree of psychopathology, tend to be massively obese before becoming emaciated, and have a poorer treatment prognosis.’4

Historically, anorexia has presented more commonly in women. The reasons for this can be discovered by exploring the origins of this type of eating disorder.

There is evidence of abnormal food-related behaviours throughout the ages: from the fasting female saints of Medieval Europe to the hunger striking Suffragettes.

It was not until the end of the 1800s, however, that anorexia was formally diagnosed simultaneously in England and France. While the French Earnest Lasèque named the condition anorexie hystérique, the term anorexia nervosa was coined by English physician William Gull.

Dr Gull claimed that anorexia resulted from a perversion of the ego

Gull’s description of extreme self-starvation first appeared in a medical journal in 1874.5 He claimed that anorexia resulted from a ‘perversion of the “ego”, and credited his patients’ refusal to eat to psychological affliction. 

Modern medical conceptions of anorexia continue to draw on this work. While the current edition of the DSMV now distinguishes two sub-types of anorexia: binge-eating/purging type; and restricting type which does not involve binging or purging, these behaviours are still attributed to a pathological cause.6

According the modern diagnostic criteria for anorexia, there must be evidence of:

  1. ‘energy restriction leading to significantly low body weight’7
  2. ‘fear of weight gain or behaviour interfering with weight gain’8
  3. ‘disturbance in self-perceived weight or shape’9

In addition, the individual must refuse ‘to maintain, or to reach, 85% of the expected body weight for someone of that age and height.’10

The severity of the condition is based on Body Mass Index (BMI). For an adult, a normal BMI score ranges from 18.5-24.9.11 Mild cases of anorexia are classified as having a BMI score of more than 17, while at the other end of the spectrum, extreme cases have a score of less than 15.12

The term anorexia is misleading, however. This is because the Latin word anorexia literally translates as ‘lack of appetite’; or, in the case of anorexia nervosa, ‘loss of appetite owing to nervous causes’.

Women diagnosed with anorexia, however, are not necessarily lacking in appetite. On the contrary, most individuals who engage in self-starvation experience incessant hunger and are constantly preoccupied with food; resulting in a desperate battle to suppress these urges.

Women diagnosed with anorexia are not necessarily lacking in appetite

Even though they were initially identified as predominantly medical conditions, eating disorders have subsequently been viewed using a variety of non-pathological discourses.

In their attempts to ascertain a cause, theorists have developed several concepts of eating disorders including:

  • psychosexual
  • familial
  • sociocultural

PSYCHOSEXUAL THEORY

At the end of the nineteenth century, a new diagnosis of anorexia emerged that used psychoanalytic technique.

Equating lack of appetite with loss of sexual desire, the psychosexual model was propounded by the founder of psychoanalysis, Sigmund Freud. He conceived the idea that food refusal derived from a desire to maintain the body in a state of pre-sexual adolescence.

In 1895, Freud wrote that anorexia was ‘“a melancholia where sexuality is undeveloped.”’13 His theory relating loss of appetite to disturbed sexual development was reiterated in his report of 1918, where he states ‘“[i]t is well known that there is a neurosis in girls…which expresses aversion to sexuality by means of anorexia.”’14

Freud believed that his patient’s rejection of their bodily appetite was communicated through self-starvation. This resulted in an extremely slender figure, whose postponement of womanhood symbolised a lack of physical desire for both food and sexual interaction.

Food refusal was interpreted as expressing anxieties and and fantasies of a purely psycho-sexual nature, such as fear of pregnancy

This psychoanalytic model continued to be drawn upon throughout the twentieth century. In the 1970s, food refusal was once again interpreted in terms of Freudian theory ‘as expressing anxieties and fantasies of a purely psycho-sexual nature, such as fear of pregnancy or of attracting the sexual attention of men.’15

In 1978 feminist writer Hilde Bruch described ‘genuine anorexia’ as ‘characterized by the avoidance of any sexual encounter, a shrinking away from any bodily contact.’16 Fearing sexual maturation and impregnation, at the onset of bodily changes during puberty ‘[t]he girls react with severe anxiety to what they sense are indications of losing control.’17

Lack of sexual desire is also associated with anorexia nervosa in the modern DSM which states that ‘[w]hen seriously underweight, many individuals with Anorexia Nervosa manifest depressive symptoms such as…diminished interest in sex.’18

Contrary to Freudian theory, however, I would argue that this reduced sexual desire is a result of self-starvation and greatly reduced body fat. It is a symptom of starvation, rather than a cause.

In order to address the sociocultural dimensions of disorderly eating, new concepts were developed throughout the 1970s and 80s. During this period, there was a resurgence of interest in eating disorders, and the psychosexual model was joined by Family Systems Theory and various feminist interpretations

FAMILY SYSTEMS THEORY

This theory regarded self-starvation as ‘a sign of disturbed structure and interactions within the family.’19 It is unclear, however, whether this disturbance was considered to be a cause or an effect of self-starvation.

 Amongst feminist accounts of Family Systems Theory, focus is often upon the mother-daughter relationship. Hilde Bruch ‘argued that the anorexic’s home was often “too good” because her mother often anticipated her daughter’s needs.’

This ‘led to the development of dysfunctional feeding practices and the child’s self-awareness of hunger and satiation did not fully develop.’20 Anorexics therefore remained dependent upon their families, particularly upon their mothers. 

A decade later, Susie Orbach (1986) confirmed Burch’s argument, stating that anorexics have difficulty ‘with developing an independent identity that is separate from her mother’s.’21

SOCIOCULTURAL THEORY

Feminist analyses of the late 1970s were therefore amongst the first to challenge dominant pathological interpretations of eating disorders. Departing from traditional medical conceptions, they proposed alternative theories that focused on women’s social position within the Western world.

External pressures and judgement of the body came into consideration as possible causes of female anxiety. It is possible to argue that disorderly eating originates in the patriarchal subjection of women and the pressure to accord with an ideal vision of the female body.

Self-starvation was a form of protest in response to oppressive social structures

Early feminist interpretations drew on social theories. Susie Orbach (1978) argued that eating disorders, particularly self-starvation, were a form of protest in a response to oppressive social structures.22

I would say, however, that patterns of disorderly eating are not a protest against these structures, but are symptomatic of their internalisation.

The story of the cultural ideal regarding women’s bodies over the past century is deeply political. Women’s increase in power throughout history correlates to an increasingly slender ideal. The thin ideal serves as a backlash against the feminist movement: it an ideal that aims to keep women thin, frail and weak.

This backlash has been expressed through society’s efforts to influence and control the shape of women’s figures and consequently, their eating behaviours. This therefore results in a power struggle over the female body.

Disorderly eating and food obsession is so culturally widespread that it has become a normal part of female existence. These requirements of body shape and weight are imposed for the purposes of female subordination and socio-economic gain.

While eating disorders are a product of external oppression; women are themselves the agents of its enforcement, moulding their own bodies in a desperate attempt to accord with sociocultural ideologies. Why do we adopt society’s vision that thin is better? Because of its physical and social rewards: because we want to belong.  

Why do we adopt society’s vision that thin is better?

One critic, however, argues that the ideal of slenderness can also be a source of female power. This theory is proposed by Hesse-Biber in her work, Am I Thin Enough Yet? Here she writes that ‘dieting and physical fitness are not methods for the subordination of women, but ways that women can feel powerful’.23

Yet, other feminists, such as Susie Orbach, argue that while women who conform to the slender ideal perceive themselves as powerful, they are in fact subordinating themselves to a masculine ideal which connotes thin with attractive and ‘good’, and fat with unattractive and ‘bad’. These associations are internalisations of patriarchal forms brought about by the prevailing norm of representation.

Orbach continues to argue that fat is feminist because it opposes social and cultural norms of the attractive, slender body.

The feminist approach to body size lies in women’s ability to choose to shape their bodies according to their own volition

However, uniting Hesse-Biber and Orbach is the belief that whether fat or thin, the feminist approach to body size lies in women’s ability to choose to shape their bodies according to their own volition.

NOT ALL WOMEN DEVELOP ANOREXIA

Women within the Western world are exposed to the same cultural environment, yet not all women develop an eating disorder. Some are more vulnerable to social influence than others. The extent to which a woman is affected by ideologies of bodies and female beauty depends upon the individual.

There is no institution solely responsible for creating patterns of disorderly eating: they arise from various factors, including economic, psychological, familial and biological.

Eating disorders are embedded in a discourse of femininity

The fact that women are more affected by eating disorders than men suggests that these disorders are culturally, rather than pathologically created. Eating disorders are embedded in a discourse of femininity, arising from the pressures upon women to accord with a physical ideal.

From a cultural standpoint women are more judged in terms of their physical appearance and, according to Susan Bordo are ‘more tyrannized by the contemporary slenderness ideal than men are.’24

Therefore, until we are able to resist the social ideal of thinness, as women we will continue to be more obsessed and dissatisfied with our bodies.


  1. https://www.beateatingdisorders.org.uk/how-many-people-eating-disorder-uk
  2. Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013)
  3. https://www.nationaleatingdisorders.org/anorexia-nervosa
  4. Bruch, Hilde, Fasting Girls: The History of Anorexia (Vintage: 2000)
  5. E.L. Bliss and C.H. Hardin Branch, Anorexia Nervosa: Its History, Psychology, and Biology (New York: Paul B. Hoeber, 1960)
  6. Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013)
  7. ibid
  8. ibid
  9. ibid
  10. http://www.b-eat.co.uk/about-beat/media-centre/facts-and-figures/
  11. http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/
  12. Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013)
  13. J. Strachey (ed.), The Standard Edition of the Complete Psychological Works of Sigmund Freud Vol. 1, Pre-psychoanalytic Publications and Unpublished Drafts (London, 1996), pp.200-201, in Brumberg, From Fasting Saints to Anorexic Girls
  14. Jacobs Brumberg, June, From Fasting Saints to Anorexic Girls
  15. Bordo, Susan, Unbearable Weight: Feminism, Western Culture, and the Body (University of California Press: London, 1995)
  16. Bruch, Hilde, The Golden Cage: The Enigma of Anorexia Nervosa (Harvard University Press: Cambridge MA, 2001)
  17. ibid
  18. Diagnostic and Statistical Manual of Mental Disorders 4th Edition, Text Revision (Arlington, VA: American Psychiatric Association, 2004)
  19. Jacobs Brumberg, June, From Fasting Saints to Anorexic Girls
  20. Julie Hepworth, The Social Construction of Anorexia Nervosa (Sage Publications, 1999)
  21. ibid
  22. ibid
  23. Hesse-Biber, Am I Thin Enough Yet?
  24. Bordo, Susan, Unbearable Weight: Feminism, Western Culture, and the Body (University of California Press: London, 1995)

Categories
Dieting Eating Disorders History

It’s Not Just Us! A Brief History of Restrictive Eating

Eating disorders are now a widespread problem. Between 1.25 and 3.4 million people in the UK are affected: around 10% of these suffer from anorexia nervosa.1

The current Diagnostic and Statistical Manual of Mental Disorders (DSMV) defines anorexia as:

  • restriction of energy intake relative to requirements leading to a significantly low body weight
  • intense fear of gaining weight
  • persistent behaviour that interferes with weight gain.2

Restrictive eating practices are not new, however. Self-starvation has a long history, dating right back to the fifth century.

The first evidence of self-starvation comes from the Middle Ages. During this time, food restriction was commonly practiced a form of religious observance. This occurred particularly during Lent, where the control and reduction of food intake was culturally institutionalised. This provided women with the means of experiencing bodily suffering through spiritual fasting.

In her book Holy Feast and Holy Fast, Caroline Walker Bynum explores the role of women role in divine practices that involved abstaining from bodily desire. This included renouncing their appetite for food.3

These women would fast in order to prepare themselves for Christ’s body and blood. They derived nourishment from prayer and the Eucharist, rather than from real food items.

In England this practice lasted until 1534. With the advent of the Protestant Reformation, worship of saints was abolished and ‘[t]he renunciation of food, once experienced and explained as a form of female holiness, was increasingly cast as demonical, heretical, and even insane.’4

A century later, however, the development of scientific and medical understanding shed new light on restrictive eating behaviours.

Rejection of food was thought to result from a lack of appetite caused by other illnesses

The first medical account of self-starvation is credited to the seventeenth century physician Richard Morton. He observed that rejection of food that resulted from a lack of appetite was the symptom of other illnesses, including tuberculosis and chlorosis (anaemia). Morton named chlorosis the ‘Green-Sickness’ and in 1694 described the case of an eighteen year old girl, ‘who resembled ‘“a skeleton only clad with skin.”’5

He writes that she: ‘fell into a total Suppression of her Monthly causes … her Appetite began to abate, and her Digestion to be bad; her flesh also began to be flaccid and loose, and her looks pale.’6

Further evidence of this green sickness came 150 years later in 1838. A medical adviser in The Penny Satirist described a common disease ‘to which the tender sex is subjected, particularly in the large towns of over-refined countries’, which was identified as ‘chlorosis or green sickness.’7

The medical establishment responded by perceiving this susceptibility as a female trait and as further evidence that women were the ‘tender sex’. The advisor continues to observe that: ‘in the streets of large towns there are young ladies with a pale yellow complexion, mixed with a peculiar greenish tinge, a bluish circle around the eyes, an air of languor and debility.’8

They had cravings for strange substances such as chalk, dirt, ashes, or vinegar

These symptoms were thought to result from the patient’s ‘capricious’ appetite. Sometimes they exhibited symptoms of pica, cravings for ‘strange substances such as chalk, dirt, ashes, or vinegar’. At other times they lost their appetite altogether, sometimes refusing to eat.9

Chlorosis was diagnosed in psychosomatic terms. It was thought to arise from ‘bad physical and moral education’, which was the result of ‘[w]ant of proper exercise, improper dress, tight lacing, too much sitting, improper development of the imagination at the expense of the reasoning faculties, boarding-school education, play-going, and novel-reading’ (!)10

At this time, other ‘morbid mortifications of the appetite’ began to be diagnosed alongside chlorosis. In 1840 physician Thomas Laycock added ‘“[b]ulimia and pica’ to the list and claimed that these conditions were all characteristic of the pregnant, chlorotic, and hysterical female.”’11

Even though Morton and Laycock established a specific pathology of self-starvation, however, anorexia would not be formally named for almost two hundred years.

In 1873, anorexia nervosa was simultaneously diagnosed in England and France

By the nineteenth century, the physicians’ social status and power increased as medical authorities grew secure in the scientific validity of their own assumptions. This coincided with the official medicalisation of appetite in 1873. This was when anorexia nervosa was simultaneously diagnosed in England and France by Sir William Gull and Ernest Lasèque.

Sir William Withey Gull

While Lasèque named the condition anorexie hystérique, the term anorexia nervosa was coined by Gull, whose description of the malady first appeared in Transactions of the Clinical Society of London (1874). In an 1888 issue of the Lancet, Gull credited his patients’ refusal to eat to a psychological, rather than a physical affliction. He stated:

That mental states may destroy appetite is notorious, and it will be admitted that young women at of sixteen to twenty-three are specially obnoxious to mental perversity.12

Yet, while Gull noted the psychological cause of anorexia, he chose not to engage with his patients’ subjective mental states. By concentrating upon the physical effects of the condition, rather than psychological causes, Gull thereby dismissed the emotional states of his female patients.

In 1883, anorexia was divided into two sub-conditions: anorexie gastrique and anorexie mentale. Anorexie gastrique applied to patients with digestive complaints. ‘Hysteria was believed to cause a physiological disturbance leading to impaired gastrointestinal absorption.’ Anorexie mental, on the other hand, occurred in patients with ‘“pure” psychiatric conditions and involved mental rather than digestive problems.’13

Despite a more detailed definition of anorexia, however, this did not significantly alter methods of treatment, or the way in which female mental health was regarded. Patients diagnosed with anorexie mentale were still treated by controlled or forced feeding in order to overcome the physiological effects, rather than by engaging with the underlying causes.

In conclusion, from this brief history of restrictive eating it evident that it’s not just us. Self-starvation and other similar eating practices have occurred throughout history in various guises.

For more information on how theories of anorexia continued to develop into the 20th century, please click here. {link to why women theories of anorexia when its published!}


  1. https://www.beateatingdisorders.org.uk/how-many-people-eating-disorder-uk
  2. Abraham M. Nussbaum, M.D., The Pocket Guide to the DSM-5 Diagnostic Exam, American Psychiatric Publishing (Washington; London, 2013)
  3. Walker Bynum, Caroline, Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women (Berkeley, 1986)
  4. ibid
  5. R. Morton Phthisiologica: Or a Treatise of Consumptions 2nd edition (London, 1720), pp.8-9, in R. M. Bell, Holy Anorexia (London: University of Chicago Press, 1985)
  6. ibid
  7. Anon., ‘The Medical Adviser’, The Penny Satirist, iss.43 (London, 1838)
  8. ibid
  9. Victorian Literature and the Anorexic Body, p.2, Noted by Samuel Ashwell, in A Practical Treatise on the Diseases Peculiar to Women (Philadelphia, PA: Lea and Blanchard, 1845)
  10. Anon., ‘The Medical Adviser’, The Penny Satirist, iss.43 (London, 1838)
  11. T. Laycock, A Treatise on the Nervous Diseases of Women (London: Longman, Orme, Brown, Green and Longmans 1840), p.73, in A. Krugovoy Silver, Victorian Literature and the Anorexic Body (Cambridge: Cambridge University Press, 2002)
  12. W. Gull, ‘Anorexia Nervosa’ (apepsia hysterica, anorexia hysterica), Transactions of the Clinical Society of the London 7 (1874)
  13. E.L. Bliss and C.H. Hardin Branch, Anorexia Nervosa: Its History, Psychology, and Biology (New York: Paul B. Hoeber, 1960)