It’s National Eating Disorders Awareness Week. And the theme this year is “Let’s talk about it.” Talking about eating disorders isn’t necessarily comfortable. Or pretty. Last week I wrote about women having all of their feelings, including anger, and having the right to assert their boundaries. This means a woman has the right to say no. She has a right to say no to unsolicited comments about her appearance and her body size.
When women aren’t allowed to directly express these boundaries or when there is trauma such as sexual assault, an eating disorder can become unconscious expression. For example,
- Binge eating or starving can become I’m going to make my body sexually unattractive so I can be protected from ever having to go through the trauma of sexual abuse again.
- Bulimia can become I’m going to take this food in, in a violent, self-harming way, and then I can get rid of it. I can get the trauma and the pain of the assault out of me.
- Anorexia can become I’m going to show you that you CAN be too thin. I’m so thin that I’m smaller than the 12-year-old girls on model runways that your culture says are sexually attractive or coveted.
At the most basic level, women have the right to say no to abuse and feel safe from sexual and physical assault. But when a woman’s right to say no is laden with cultural ambivalence and minimizing, abuse and rape occur at an alarmingly high level. And rape culture thrives.
No Means No.
Violence against women is still frighteningly common. Here are just a few scary statistics:
- 22% of surveyed women reported they were physically assaulted by a current or former spouse, cohabiting partner, boyfriend or date in their lifetime. (National Violence Against Women Survey, November 2000).
- Approximately 1.3 million women are physically assaulted by an intimate partner annually in the United States. [i]
- Of the American women surveyed who said they had been the victim of a completed or attempted rape at some time in their life, 21.6 percent were younger than age 12 when they were first raped, and 32.4 percent were ages 12 to 17. [ii]
I see many of these women in my practice. (No, not all women recovering from eating disorders have a history of abuse. Eating disorders have a complex and multifaceted etiology.) Sexual assault among women is very common though more common than you may think. Among my colleagues, we talk about how the statistics are more likely to be one in three women.
One in Three
Due to survivors being reticent to report it, the statistics reported are often much lower than the actual numbers. The shame of the abuse is still often carried by the survivor. When assault perpetrated against a woman is blamed on the woman, or not believed, or minimized, there is little incentive to speak up. We need only look at the news of the past few weeks to find evidence for this. And when convictions for three sexual assault felonies, such as in the 2016 Stanford rape case, get reduced from 14 years in state prison to 6 months in county jail, there is little incentive for survivors to pursue legal action.[iii]
If one in three women has been sexually assaulted in their lifetime, that means it is highly likely that you, your spouse, your sister, your mom, your child, your friend, or your colleague has been sexually assaulted. The experience of sexual assault is not limited to women of particular socioeconomic status, ethnicity, or religion. I am probably preaching to the converted here, but just to name a few basic educational points about sexual assault:
- Sexual assault is an act of violence, not sex.
- Sexual assault is not caused by what a woman wears, drinks, or doesn’t drink, or whether she is “in the wrong place at the wrong time.”
- Sexual assault is not consensual. If a woman is unable to consent, that is non-consent. If a woman says stop, then that is non-consent. If a woman has said yes in the past, but is saying no now, that is non-consent.
- Sexual assault can leave long-lasting impact of the survivor, including but not limited to Depression, Anxiety, PTSD, Flashbacks, Self-Harm, Suicidality, Eating Disorders, STD’s, and unwanted Pregnancy.[iv]
I could go on and on about the work to be done in healing “rape culture.” I am grateful for the education and advocacy work[v] being done currently. And I am grateful for the January 2017 Women’s March “Pink Pussy Hat” movement reclaiming women’s bodies and rights as their own. I am grateful for every survivor doing their healing work. I am grateful for every woman and man who says “No, this is not ok” to rape culture. And I am grateful for 19-year-old Nina Donovan writing her “I Am a Nasty Woman” poem and Ashley Judd reading this poem at the Washington DC Women’s March. In Donovan’s poem she writes:
“I am not as nasty as racism…homophobia, sexual assault, transphobia, white supremacy, misogyny, ignorance and white privilege.”[vi]
Feminism today is being called to become intersectional, addressing the places where misogyny, racism, and socioeconomic status intersect, and where they don’t. Stay tuned for the next post on how eating disorders do not just affect straight, white, adolescent women. And, in the meantime, what can you do? You can be an ally. You can talk about it. Talk about eating disorders and that recovery is possible. Talk about how rape culture is not okay. Be an ally: for yourself, for others. Healing is possible. You are not alone.
[iii] “Telling the Story of the Stanford Rape Case” by Marina Koren, The Atlantic, June 6, 2016
[iv] RAINN.org RAINN stands for the Rape, Abuse, and Incest National Network and is the nation’s largest anti-sexual violence organization. RAINN operates the National Sexual Assault Hotline 800-656-HOPE
[vi] Ashley Judd reciting Nina Donovan’s “I Am A Nasty Woman” poem at the January 2017 Women’s March https://www.washingtonpost.com/video/politics/ashley-judd-recites-i-am-a-nasty-woman-poem-at-march/2017/01/21/93205bc6-dffd-11e6-8902-610fe486791c_video.html
I recently gave a talk for parents on Eating Disorders and what parents wanted to know most was: How do I prevent my child from developing an eating disorder?
Here are five things you can do (and some you can be conscious of NOT doing) to assist with preventing your child from developing an eating disorder:
- 1. DON’T Diet.
Diets don’t work. This has been proven again and again. Here are a few scary statistics:
*95% of all dieters will regain their lost weight in 1-5 years (Grodstein, Levine, Spencer, Colditz, & Stampfer, 1996; Neumark-Sztainer, Haines, Wall, & Eisenberg, 2007).
*80% of 10-year-old girls in America have dieted to lose weight. (Bates, 2016)
Women who were put on diets as young girls are more likely to struggle with obesity, alcohol abuse and disordered eating as adults. (Keel, 2014).
*35% of “normal dieters” progress to pathological dieting. (Shisslak, Crago, & Estes, 1995).
- 2. DO eat intuitively.
Intuitive eating can be summarized by: relying on internal cues for hunger and satiety, eating for physiological rather than emotional reasons, having no dietary restrictions/unconditional permission to eat, and body size acceptance (Tribole, and Resche, Intuitive Eating A Revolutionary program that Works, 1995, 2012). Listen to your own hunger and don’t restrict. Give yourself permission to enjoy eating!
- 3. Take care of your own body image.
Be mindful that you are your child’s mirror. You may be tempted, as I saw in a humourous newspaper wear a “Mom’s Bathing Suit as One Giant, Body-Ecclipsing Ruffle.” You many gaze disgustedly in the mirror at your postpartum muffin top. Postpartum body image and ageing can be brutal. However, don’t allow yourself to buy into the culture’s message around self-worth being tied to “getting your postbaby body back in shape.”
A) Your postpartum body will never be the same shape. You grew a baby in there.
B) Your worth is bigger now. You have been changed by life. Try and embrace and radically accept that. Be proud of your tummy like your child is proud of theirs. You are beautiful because of the life you have lived and your body reflects that: all the scars, stretches, and wrinkles. A wizened tree does not Botox itself to look like a skinny leaf-sprout. Be the tree that you are proudly (or, on a bad day, good-enough).
- 4. Follow the “Division of Responsibility” when feeding your child.
Briefly, the division of responsibility is: The parent is responsible for What, When, and Where you eat. The child is responsible for How much and Whether they eat. This is based on Ellen Sattyr’s work. To see a handout on this, click here
I know it can be hard to trust that your child WILL choose to eat vegetables. But it CAN and DOES happen. See this amazing transformation in my own little one, who used to only eat anything soft and white. Notice how one carrot and two bits of pepper have grown into a plate almost entirely filled with vegetables!
(By the way, DO respect sensory sensitivities. If your child prefers soft texture, make soft texture food and gradually without a fight and making it fun introduce other textures.) And, remember: there are no bad foods. Kids need carbs and fat, and so do you. They help you have enough energy, they feed your brain.
- 5. Allow all feelings in your family (especially uncomfortable ones like anger, fear, and shame).
Low tolerance for negative affect has been shown to be one of the factors contributing to eating disorders. What does this mean? It means, in order to create an environment where your child will not feel they have to hide or stuff parts of themselves in order to be loved, you have to allow discomfort. Anger is a tough one. Most people error in one direction (rage at others) or the other (blame self and stuff into depression). Work on expressing anger at the level of irritation before it gets too overwhelmingly big. Have weekly family meetings. If you get in a fight with your partner, make up and show your child you have made up so they can see people re-unite after being mad at each other. When your child is mad, don’t withdraw your affection. Notice: “I see you are mad. I’m going to help you. I love you even when you are mad. You can hit the pillow, but not me. I’m going to stay with you until we work this out.” Allow fear. Allow insecurity, embrace imperfection. When someone makes a mistake in our house, we say “Yay! I made a mistake!” This is not my natural inclination. The natural inclination with shame is to hide it. Sweep it under the rug quickly! Pretend-like-you-know-what-you-are-doing-before-you-get-in-trouble-or-someone-sees-that-you-are-a-fraud! Don’t do this. Turn toward your own and your child’s imperfections and growth edges. Growing requires failing, and failing, and failing before succeeding. Support your child in practicing new skills. When your little one is learning to walk and falls down, you say “Hooray! Try again!” Continue to do this with yourself and your little one. Again and again.
It is possible to prevent eating disorders. And it is also possible to build a strong protective factors so that if your child develops one, they can recover with more ease. Do what you can. Eating Disorders are complex and develop from a unique and individual interplay of many factors. Eating disorders are no-one’s fault, but everyone’s responsibility. Prevention and recovery are possible.
The short answer? “It’s complicated.”
The longer answer: Genetics and temperament both play a strong role in the possibility of Depression or an Eating Disorder developing, but do not determine it.
The hopeful answer: Even if your child develops an Eating Disorder or Depression, it is possible to recover.
In this post, I will look at some of the risk factors that can lead to an Eating Disorder or Depression.
Eating Disorders: Are they inherited?
Eating Disorders develop as a combination of genetic vulnerability combined with temperamental traits and a facilitating environment. Some (but not all) risk factors named in Carolyn Costin and Gwen Schubert Grabb’s book 8 Keys to recovery from an Eating Disorder (W.W. Norton, 2012) that can contribute to developing an eating disorder include:
- being overweight or dieting as a child
- having a mother who diets or has an eating disorder
- early menstruation
- being bullied or teased
- engaging in sports or activities with a focus on appearance or weight (for example ballet, cheerleading, ice skating, wrestling, gymnastics, modeling)
- a history of childhood abuse
In a 2000 study in the American Journal of Psychiatry, results showed that anorexia nervosa has a heritability of 58%, but the authors were unable to rule out the contribution of environment. However, they did conclude that genetic factors influence anorexia and contribute to comorbidity of anorexia and depression.
Along with genetic links being discovered with both anorexia and binge eating, certain temperamental traits tend to foster the birth of an Eating Disorder. Ovidio Bermudez, in presenting at Eating Disorder Recovery Services conference* this past year discussed the following temperament traits as those at risk of developing an Eating Disorder:
- Anxiety, Depression, or OCD
- Low stress tolerance
- Low distress tolerance
- Sensitivity to real or perceived injury
So in other words, if you have a sensitive child who struggles with tolerating “distressing” feelings such as sadness, anger, or shame and you (or a family member) struggle with Depression, Anxiety or OCD, the ground is fertile for the seed of an Eating Disorder to sprout.
What about Depression?
At least 10% of people in the U.S. will experience Major Depressive Disorder at some point in their lives. According to statistics, two times as many women as men experience major depression. (There is a lot to be said there in terms of mis-diagnosis of symptoms, gender bias, and who reaches out for support to mental health professionals, that can affect these statistics, but that is for another blog.)
According to two Stanford doctors writing about genetics and brain function, genetics play a strong role in causing Major Depression (Levinson, Douglas F. M.D. and Nichols, Walter E. M.D., Professor in the School of Medicine Department of Psychiatry and Behavioral Sciences, Stanford, 2015). They write:
- The heritability (or percentage of the cause due to genes) is probably 40-50%, and might be higher for severe depression.
- The situation is a little different if the parent or sibling has had depression more than once (“recurrent depression”), and if the depression started relatively early in life… the siblings and children of people with this form of depression probably develop it at a rate that is 4 or 5 times greater than the average person.
What else contributes to Depression? And what about Postpartum Depression?
Stressful life events (trauma, loss of a loved one, moving/loss of support, having a baby) can lead to depression in and of themselves. When combined with a genetic risk, there is a stronger possibility of developing depression. And having one (or more) episode of depression increases the risk of having future episodes. (Kendler, Thornton, and Gardner, 2001)
While many women experience some mild mood change or “the blues” during or after the birth of a child, 1 in 7 women (and some recent research says 1 in 5) experience more significant symptoms of depression or anxiety. 1 in 10 Dads become depressed during the first year. (Postpartum Support International)
Risk factors for Postpartum Depression
Some women are more likely than others to develop Postpartum depression. The following factors put you at an increased risk:
- Previous history of depression
- History of severe PMS or premenstrual dysphoric disorder
- Medical complications for you or your baby
- Lack of support from family or friends
- A family history of depression or another mental illness
- Anxiety or negative feelings about the pregnancy
- Problems with a previous pregnancy or birth
- Marriage, Relationship, or money problems
- Stressful life events
- Substance abuse
How does Postpartum Depression impact children?
Postpartum Depression and other Perinatal Disorders (Anxiety, OCD, Psychosis) can affect children in the following ways:
- Behavioral Problems
- Delays in Cognitive Development
- Emotional Problems and/or Depression
According to Zero To Three, a research-based resource for federal and state policymakers and advocates on the unique developmental needs of infants and toddlers, untreated Depression can have detrimental effects on children’s functioning and future outcomes (2009).
The mental health of parents can affect young children… infants of clinically depressed mothers often withdraw from caregivers, which ultimately affects their language skills, as well as their physical and cognitive development. Older children of depressed mothers show poor self-control, aggression, poor peer relationships, and difficulty in school.
Unlike adults, babies and toddlers have a fairly limited repertoire of responses to stress and trauma. Mental health disorders in infants and toddlers might be reflected in physical symptoms (poor weight gain, slow growth, and constipation), overall delayed development, inconsolable crying, sleep problems, or aggressive or impulsive behavior and paralyzing fears. Early attachment disorders predict subsequent aggressive behavior. Some early mental health disorders have lasting effects and may appear to be precursors of mental health problems in later life, including withdrawal, sleeplessness, or lack of appetite due to depression, anxiety, and traumatic stress reactions.
So, if you have had or are currently suffering with and through (because it is possible to recover and get through it) an Eating Disorder or Depression, your child does have risk. But that does not mean they are doomed. It means, even more important than ever, that you get treatment and recovery yourself! When I attended Postpartum Support International’s training on Perinatal Mood Disorders, the message that they gave was: There is Hope and You are not alone. It is possible to recover and in recovering yourself, you help build a more protected base from which your child can thrive and grow.
Wade, Tracey D, Ph.D., Cynthia M. Bulik, Ph.D., Michael Neale, Ph.D., and Kenneth S. Kendler, M.D., “Genetic and Environmental Risk Factors Anorexia Nervosa and Major Depression: Shared Risk Factors,” Am J Psychiatry 2000; 157:469–471.
Eating Disorder Recovery Services The mission of EDRS (Eating Disorder Recovery Support), Inc. is to promote recovery and wellness for those impacted by eating disorders by providing support, information, and education to individuals, families, professionals, and the community at large regarding eating disorders and recovery resources. EDRS.net
Ovidio Bermudez, MD Dr. Bermudez has lectured nationally and internationally on eating pathology across the lifespan, obesity and other topics related to pediatric and adult healthcare, and has been repeatedly recognized for his dedication and advocacy in the field of eating disorders. eatingrecoverycenter.com
“Major Depression and Genetics” Douglas F. Levinson, M.D. and Walter E. Nichols, M.D., Professor in the School of Medicine
Department of Psychiatry and Behavioral Sciences (2015) Depression and Genetics
Zero To Three The Zero To Three policy Center is a nonpartisan, research-based resource for federal and state policymakers and advocates on the unique developmental needs of infants and toddlers. zerotothree.org
Link to Depression during and after Pregnancy Fact Sheet
Link to study on teaching sleep with infants to prevent Postpartum Depression:
Link to study on effects of Lexipro on treatment of Postpartum Depression: