“A LOT OF PEOPLE THINK EATING DISORDERS are based in vanity,” says Professor of Psychology Ruth Striegel-Moore. “Bulimia is ‘the stupid thing vain women do.’ But they’re really disorders of identity.”
That crucial insight lay well in her future when Striegel-Moore, as an undergraduate, accompanied her mentor on a visit to a hospital ward for patients with eating disorders. She listened in amazement as a patient described the episode that led to admission: During the night, while her family slept, this girl got up and ate all the pastries her mother had baked for a family celebration the following day.
“We’re talking 10 or 12 different cakes and pies and tortes,” says Striegel-Moore. “She ate them all in one sitting, vomiting in between. It was such an extreme example, so compelling both in the sheer volume of food and the underlying hostility to her family, that I found it really intriguing. I wondered what lay underneath this behavior. I was hooked.”
Most people are familiar with the symptoms of bulimia nervosa, an eating disorder in which an individual ingests huge quantities of food followed by forced vomiting. Princess Diana’s bulimia became the stuff of tabloid headlines in the ’90s as the “fairy-tale princess” struggled to maintain a public image despite unhappiness in her marriage. Yet the term hadn’t even appeared in the Diagnostic and Statistical Manual for Mental Disorders, the handbook of diagnostic categories used by health professionals in the United States to define psychiatric disorders, until 1980, when Striegel-Moore was a graduate student.
As an intern at New York’s Bellevue Hospital and then director of the Yale Eating Disorder Clinic in the mid-’80s, she worked directly with eating disorder patients just as the field was beginning to attract serious public attention. Public scrutiny, however, underscored how little scientists understood about the causes and social dimensions of this problem.
“Researchers knew that childhood obesity was a significant factor in developing an eating disorder,” says Striegel-Moore in her rapid-fire speech with the hint of a German accent, her first language. “But that turned out to be just one piece of the puzzle. Eating disorders often are treated far too simplistically.”
In 1987 Striegel-Moore joined the Wesleyan faculty, which in retrospect was a critical move for her development as a scientist. Deprived of a setting that offered day-to-day contact with patients, she ventured into then-uncharted territory: the study of large populations in communities to glean information about the prevalence and characteristics of eating disorders. Few scientists attempt these studies because of the expense and labor involved. Through her work and that of collaborators, a picture has emerged of eating disorders as a complex familial and societal problem.
Along the way, Striegel-Moore’s reputation grew rapidly. She has received several million dollars in federal funding, served as president of the Eating Disorders Research Society, president of the Academy for Eating Disorders, and a visiting professor at Harvard. She has participated in numerous professional commissions and editorial boards. In 2002 she won a major national award for her research from the Eating Disorders Coalition for Research, Policy, and Action.
“Ruth has had an extraordinary impact on the field of eating disorders—in research, treatment, advocacy, and advancing careers of young people,” says Dr. David Herzog, professor of psychiatry at Harvard University. “She’s been uniquely able to develop collaborative efforts across the globe to engineer outstanding studies.”
Among the questions she has posed are: Why women? Why adolescent women? Women are three times as likely as men to suffer from an eating disorder. Approximately 15 percent of young women have disordered attitudes and behaviors about eating and food.
Eating disorders, Striegel-Moore points out, are inextricably linked with the formation of feminine identity. One need not look farther than the nearest magazine rack or television to know that in the U.S. culture, thinness and beauty are central features of the female sex-role stereotype. Studies have shown that women who eat smaller meals are perceived as more feminine, and women will adjust their eating behavior to project a favorable impression.
The pursuit of beauty affirms a woman’s own sense of femininity. Young women differ in the extent to which they feel pressure to conform to this stereotype, but girls who are insecure are likely to focus on physical appearance as a concrete, easily understood way to build identity. It’s also a terrible trap.
“For most girls, the contemporary beauty ideal is biologically unattainable,” Striegel-Moore writes. “Efforts to create an adequate sense of self by pursuing an adequate physical self are doomed to failure and are likely to result in a potent source of social anxiety.
“The people who struggle with these problems feel bad about who they are,” she says. “They try very hard to be good, and they latch on to outer appearance to demonstrate their goodness. Wanting to be thin is not really a vanity; it’s their vehicle to respect. In this culture we associate obesity with laziness, any number of negative personality attributes. If you’re fat, you’re bad.”
To make matters worse, she observes, we live in a culture where fast food is almost always within easy reach by car (who would ever think of walking?) and school cafeterias tempt students with soft-drink machines. Small wonder that obesity in young women and men is a national crisis.
Of course, not every insecure young woman is destined to engage in binge eating or develop life-threatening eating disorders. In a Congressional staff briefing—Striegel-Moore travels often to Washington as an advocate for more support of research and treatment—she clarified specific risk factors among adolescent and young adult women (the causes of eating disorders remain unknown). Childhood sexual abuse is a major risk factor, as are a history of dieting and obesity. A family history of substance abuse or depression figures in. So does familial criticism and teasing about weight, perfectionist personality traits, and elite athletic performance. These are only vulnerabilities, she stresses. There is no formula to predict who will experience an eating disorder.
Colleagues see her work on risk factors as particularly important because early intervention is a key to success in treatment. Absent early intervention, eating disorders are more likely to become chronic.
As a fuller picture of these disorders began to emerge, one curious fact remained. Psychologists perceived eating disorders to be limited mostly to white women. This view came about partly because women of color rarely show up in treatment centers, and partly because the most commonly observed eating disorder, anorexia nervosa, is very rare among black women. Yet scientists would learn that eating disorders transcend ethnic lines, thanks largely to Striegel-Moore.
“My work is saying, ‘Wait a minute, anorexia is only one of several eating disorders—and not all sufferers are found in a doctor’s office!'” Black women display other eating disorders: binge eating and bulimia.
The route to that discovery lay outside the clinic. Patients in clinics choose to be under medical care; they can afford it and want treatment. By conducting community surveys, Striegel-Moore uncovered many individuals who had never sought out treatment. Her most significant work to date has been a massive survey of nearly four million individuals, conducted through a large national health insurance database. Results showed that eating disorders remain untreated in a majority of cases. Her community studies have lent further support to this observation. Women of color are particularly reluctant to seek medical help; perhaps as few as one in 20 do so.
She attributes this reluctance to several factors. Some women of color are put off by the paucity of black or Hispanic therapists. Many also say that eating disorders are a “white woman’s problem,” so admitting to this problem feels like selling out. Some don’t know that effective treatments for eating disorders exist. Finally, health care professionals are less likely to recognize an eating disorder among women of color because the belief persists that they are relatively immune.
But the same cultural trends influencing white women are felt in other ethnic communities.
In an editorial for the Journal of Pediatrics published last year, Striegel-Moore noted that, “The thin beauty ideal increasingly applies across ethnic groups. Print and television media that target primarily ethnic minority women have been shown to promote the thin ideal in much the same ways as do media with a predominately white target audience.”
“Clearly, the cultural messages about the importance of thinness are learned by girls and boys,” she adds, “and by children of different ethnic groups.”
Harvard’s Dr. Herzog says her studies of binge eating in ethnic populations have been a “landmark.” Nonetheless, much more remains to be done. Just how many black or Hispanic women in the United States suffer from eating disorders is not known because there is no nationally representative data. In fact, says Striegel-Moore, there is no nationally representative data concerning the exact prevalence of bulimia or binge eating for any U.S. population.
In the classroom, she has a dramatic way of showing that ideas about weight are a cultural phenomenon.
A colleague comes to her class in a realistic fat suit designed to make her appear as though she weighs 250 to 300 pounds. She begins to give the class a lecture about how we have to stop discriminating against fat people—”and she uses that term,” says Striegel-Moore—then leaves the room under some pretense. She returns as a normal-sized person, and the students “are blown away.” They admit they weren’t taking her seriously when she spoke about not discriminating against overweight people. They are culturally predisposed to view the fat lady’s obesity as her own problem—one brought on by laziness.
She pauses, as though deciding whether to continue with the story. “Before the class, this colleague arrived early to meet me at Freeman Athletic Center and share a lunchtime walk with me around the track, something I often do,” she says. “I found myself introducing her to my colleagues here and explaining to them that she was really a thin person but was in a fat suit to speak with my class. I realized I was embarrassed for her.”
Students who take her research-oriented courses learn how to design questionnaires, they conduct in-depth diagnostic interviews, and they critique analyses for weaknesses. Her undergraduate students have conducted more than 2,000 interviews and have coauthored numerous papers. “This is extraordinarily unusual at an undergraduate institution,” she says.
“Some students come in with the idea that it’s going to be a touchy-feely class, that eating disorders are a woman’s problem, so it’s not serious, it’s fluff. Usually by the second or third class, these students are saying, ‘Wait a minute, we’re doing numbers?! This is hard work.’
“But then they love it. Research skills can be learned, like all other skills. I allow students of all majors to take the course. Some students who haven’t thought of themselves as researchers realize they could study a problem in this way.”
When she was a sophomore Elizabeth Pratt ’94 took an advanced seminar with Striegel-Moore that plunged her into a study of eating disorders and substance abuse in adolescent females. Ten years later she is a post-doctoral psychology fellow at the Boston Veterans Administration Medical Center, working with substance abuse and eating disorders in female and male veterans. Striegel-Moore, she says, has guided her at every step of her career and offered a compelling role model.
“Ruth was very inspiring to me as a female scientist-practitioner who seemed to achieve the kind of balanced life I desire. One of my favorite images of her is in slippers talking about her research over a cup of tea in her home while her children were tugging at her elbow—entertaining me and some other undergraduates during the holiday season.”
Shireen Rizvi ’96 admires Striegel-Moore’s commitment to science. Now a doctoral candidate at the University of Washington, working with borderline personalities—whom she sees as similar to those with eating disorders—she says, “What I really love is using science to inform practice. I have a session with a client and use a prescribed treatment protocol that was based on study. I feel secure in what I’m doing, and then I can see the results: I have helped this individual. In the field of psychology, there’s so much fluff out there that can end up doing so much damage. Ruth’s dedication to science is really important.”
“One thing that’s impressive is the number of her students that go on in the field,” adds Katharine Elder, ’96. A clinical psychology intern at the University of Wisconsin, she says that at a recent conference on eating disorders, “I saw so many of her former students whom I’d known from the lab. People don’t drop out of the field after working with her. They keep on going and producing.”
Striegel-Moore is planning another large-scale study to examine why so few people seek treatment. Eating disorders cause intense personal suffering and may produce serious health consequences. The sad irony is that effective treatments can help many of the five million afflicted Americans. Yet her studies of individuals in the insurance consortium database show that only 10 percent of patients with an eating disorder receive treatment. The findings apply across economic class lines, across ethnicities, and across sexes (men with bulimia are particularly reluctant to seek help).
Even among those who do seek treatment, hospital stays—an average of 17 days per year—fall well short of the time needed to fully treat these debilitating disorders. Insurance coverage is woefully inadequate.
Although much remains to be done, psychologists do have a much clearer view of these disorders that some people still blame on vanity. “To understand eating disorders, you have to understand human behavior from many different perspectives,” says Striegel-Moore. “Let’s keep striving for the whole diverse picture and keep trying to recognize its full complexity.
“I think our problem, as a society, is that we still are searching for individual solutions to eating disorders and to obesity, rather than seeking societal solutions.”
WHEN HELP IS NEEDED
Wesleyan students who are concerned about eating disorders show “little to no reluctance to seek help,” according to Dr. Philippa Coughlan, director of the Office of Behavioral Health for Students. She believes the student body is well-informed about these disorders, in part because they have been widely publicized.
“When students realize they have problems that are too big to handle by themselves,” she adds, “they are urged (by a variety of possible sources: friends, resident advisers, faculty, deans, etc.) to come to the Office of Behavioral Health for Students where they can work with a therapist to learn how to cope effectively and ultimately to overcome their problem. When this route is followed, the prognosis is usually very good.
“Wesleyan students take pride in being responsible,” she says. “Seeking help promptly when it’s needed is certainly a good example of their take-charge behavior.”