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Human Arenas

, Volume 1, Issue 3, pp 231–248 | Cite as

Women’s Constructions of Childhood Trauma and Anorexia Nervosa: a Qualitative Meta-Synthesis

  • Jennifer Malecki
  • Paul Rhodes
  • Jane Ussher
Arena of the Body

Abstract

A meta-synthesis was conducted to explore women’s constructions of anorexia nervosa and childhood trauma. Following a systematic review of the literature, six studies were isolated and synthesized within a material-discursive-intrapsychic framework to produce five taxonomies: “objectified and controlled bodies,” “the abject body,” “embodied emotions and self-harm,” “medicalizing the body-as-object,” and “embodied meanings and new possibilities.” The women’s experience of anorexia, their bodies, and shifting subjectivities was a response to the materiality of childhood abuse. The women discursively constructed anorexia nervosa as a means of negotiating bodily distress associated with trauma and renegotiating their identities to produce a cohesive, embodied self. This meta-synthesis has implications for further research that elucidates how women make meaning from the transformations of their embodied subjectivities.

Keywords

Trauma Anorexia nervosa Women Embodiment Feminism 

The association between childhood sexual abuse and anorexia nervosa (anorexia) has long been the preserve of feminist theorists who were amongst the first to raise the issue of abuse in the development of eating disorders (Wooley 1994). Their pioneering work set in motion a body of biomedical and psychological research that established higher rates of childhood trauma in all forms of eating disorders (Eds) that develop at an earlier age, with higher rates of comorbidities, suicidality, and a more severe form of the disorder (see Molendijk et al. 2017 for a comprehensive review). The establishment of causal links between trauma and the development of eating disorders is important; but beyond causal mechanisms, it is vital to define how different etiological pathways contribute to the development and maintenance of anorexia (Piran 2010).

Research of this kind is critical to developing targeted prevention strategies and effective treatment and care pathways, yet the translation of trauma-informed treatments into mainstream practice has been slow with limited or no reference to the management of trauma in guidelines for evidence-based practice for eating disorders (Hay et al. 2014; National Institute for Health and Care Excellence, (NICE) 2017). The guidelines acknowledge the complex social issues that are present in ED’s, but give no guidance on how to manage the issues. Feminists have been successful in bringing cultural and gendered aspects into scholarly and popular accounts of eating and body management practices (Brown and American Psychological Association 2008); however, the shift towards biomedical paradigm has resulted in a disproportionate presence of biomedical factors within the literature and the narrowing of cultural and social issues into women’s “idealization of thinness” (Bordo 2003; Holmes et al. 2017). Social and cultural analysis has been parsed along aspects of “body image” disturbance (Katzman and Lee 1997), leaving the meanings expressed by women in their body management practices as a neglected area of research (Malson 2009).

Research examining the way broader sociocultural issues identified in the body-image paradigm brings welcome relief to a field taking a sharp turn towards biomedical explanations of women’s distressed relationships with their bodies. Nevertheless, the cultural and social contexts that define traumatic experiences in early childhood and shape the development of anorexia in later life may have little to do with poor body image (Moulding 2015). The assimilation of body-image discourse into western culture (Katzman and Lee 1997) and its wholesale acceptance as a causal factor in eating distress may be doing some women more harm than good by overlooking the broader context of women’s distress. Childhood abuse and anorexia are unavoidably influenced by cultural symbolic constructions of gender and structurally sanctioned gendered abuse that encapsulate women’s concerns (Lester 2007, 2013). In Western countries, women are far more likely to be diagnosed with anorexia than men; for every male diagnosed with anorexia there are eight females (Keel and Forney 2015; Steinhausen and Jensen 2015) and more likely to experience posttraumatic stress disorder and revictimization (Tolin and Foa 2008; Koenen and Widom 2009).

Women’s experiences are reflexive of feminine cultural and symbolic meaning that deserve much more than providing visibility to select aspects of women’s lived experiences. In positioning any one aspect of women’s subjective experience, such as the idealization of thinness in women over other aspects, risks relegating women’s embodied experiences as extraneous to their sexual subjectivities, overlooking the role of language within cultural practice, or nullifying or excluding aspects of materiality such as power inequalities or childhood trauma that is increasingly being shown to reside at the heart of women’s distressing experiences with their bodies and all forms of eating distress (Trottier and MacDonald 2017; Ussher 2000). What is needed is a multidimensional analysis that incorporates factors at the corporeal/material level, the discursive level, and the intrapsychic level (Ussher 2000). Feminist approaches to anorexia and to childhood trauma are informed by an array of theoretical frameworks that converge on a share understanding that the complex cultural and social structures that shape inequalities in gender and power relations also underscore women’s experience of their body and sense of self (Brown and American Psychological Association 2008). Feminist approaches deeply resonate with women affected by trauma by conceptualising self-starvation and other body practices, as forms of embodied management and embodiment (Brown and American Psychological Association 2008; Malson 2009)

The purpose of this analysis is to examine the available qualitative literature about anorexia and childhood trauma through the synthesis of material, discursive, and intrapsychic (MDI) aspects of women’s lived experiences. The MDI approach is a form of critical realism that considers the material/body as an essential element of lived experience. The material level of analysis accounts for societal and corporeal aspects of women’s experiences that extend beyond the formulations of normative femininities captured by the body-image paradigm to include women’s embodied subjective experiences (Malson 2009). Discursive factors are the broader sociocultural and linguistic factors that define women’s experiences of their bodies, and intrapsychic factors cover broader psychological aspects, such as emotional responses to the trauma or dissociative experiences that impact on women’s expression and experience of ‘symptoms’. Critical realism offers an alternative to the biomedical or “body-image” paradigm as it acknowledges the “real” in the physical realm such as the materiality of malnutrition, or through the interplay of culture and language in its various representations, such as in gender or social class (Bhaskar 1989). Critical realism avoids unhelpful divisions created within anti-empiricism constructionist debates between the mind and body. Importantly, critical realism holds an analytical position compatible with a meta-synthesis by acknowledging that researcher constructed findings, the target of a meta-synthesis, exist in the real world and can be subject to synthesis.

The challenges identified in the earliest feminist analyses and throughout this introduction continue to remain a research priority (Trottier and MacDonald 2017). In this article, we argue that there is room to develop this work further by cultivating new ideas and paradigms. A meta-synthesis of qualitative data provides a medium to advocate for new ideas and has the potential to reach new conceptual understandings of anorexia that can account for the relationship between trauma narratives in their context. A meta-synthesis integrates findings from multiple qualitative studies and reframes them into a new descriptive explanation of womens’ lived experiences (Sandelowski and Barroso 2007). To our knowledge, no reviews of qualitative research examining women’s experiences of anorexia in a context of abuse have been published. The guiding research questions asked: (a) how do women make sense of their body, anorexia, and the early trauma? and (b) How do the intrapsychic, material/societal, and discursive processes following childhood trauma influence the development of anorexia?

Method

Search Strategy

The studies were located using an electronic database search of Web of Science, PsychINFO, PubMed, Medline, ProQuest, Cinahl, and Scopus (2000) on literature dated 1978–2016. The search strategy minimized search parameters to ensure all relevant studies were captured, adjusting terms only to accommodate individual database without altering word meanings. A search containing key words and MeSH headings using Boolean AND/OR operators on childhood abuse, trauma, anorexia nervosa, and eating disorder yielded 3424 documents. Subsequent manual searches were performed using reference lists.

Selection of Studies/Participants

The main influence on study selection was the population of women under study. Purposive sampling techniques were used to reflect participants that met the objectives of the study. Participants’ ages ranged from 14 to 64 years with an illness lasting between 1 and 30 years. The numbers and types of traumas are outlined in Table 1. The final sample of women was drawn from England, Canada, and Australia and represented diverse cultural backgrounds including middle-eastern, eastern European, and Aboriginal. All social classes from socially disadvantaged and middle-class through to socially privileged backgrounds were represented in the original studies. The studies were retrieved and reviewed (see Fig. 1) by following the outline Sandelowski and Barroso (2007) and included the following criteria: (a) peer reviewed and English language; (b) published or unpublished articles; (c) articles reporting qualitative methods sampling, data collection, data analysis, and interpretation; (d) female participants aged over 14 years at the time of the original study; (e) who identified historical childhood abuse and developed anorexia; and (g) purposeful sampling technique. Exclusion criteria: (a) poor or no representation of participant experience or (b) quantitative methods.
Table 1

Material intrapsychic discursive aspects of anorexia nervosa following trauma

Study

Aims

Sample size

Design

Eating disorder and trauma

Material discursive intrapsychic

Original themes

Taxonomies

1. Dawson et al. 2014

Exploring recovery from severe and enduring anorexia nervosa.

8

Narrative inquiry

Anorexia nervosa—5

sexual—5

Material intrapsychic

Unready to change tipping point active pursuit of recovery Reflections and rehabilitation.

Objectified and control, transforming the self, medical gaze and embodiment. Embodied meanings and new possibilities

2. Lamoureux and Bottorff 2005

Exploring recovery from anorexia nervosa

9

Grounded theory

Anorexia nervosa—8

Sexual—8a

Intrapsychic material discursive

Seeing the danger, inching out of AN tolerating exposure without AN, gaining perspective by changing mindset, discovering self as good enough

Objectified and control, embodied emotions, and self-harm. Medical gaze and embodiment. Embodied meanings and new possibilities.

3. O'Shaughnessy et al. 2013

Exploring the development and recovery from anorexia nervosa.

4

Narrative inquiry

Anorexia nervosa—3

Emotional—2

Sexual—1

Intrapsychic material

Fearful/threating world, perspective of other, tangled relational experiences, eventsnot storied, lonely story.

Objectified and controlled bodies. Embodied emotions and self-harm.

aDenotes authors of the original study confirmed trauma was mostly sexual abuse

Fig. 1

Search and retrieval process

The preliminary reading of 3424 titles from the data base search found that 3356 documents were ineligible for inclusion due to misalignment of the research aims and objectives with this meta-synthesis. The remaining 68 documents were reviewed in detail, and a further 57 documents were deemed ineligible due to the following factors: focus on epidemiology, insufficient detail, theoretical study, study sample outside of criteria, or ambiguous clinical description. The authors of the final 11 documents were contacted by email finding that five failed to meet the inclusion criterion, leaving six studies for inclusion in the meta-synthesis.

Key Definitions

Childhood trauma was defined as emotional abuse, sexual abuse, and physical abuse that occurred before the age of 16 years and prior to the development of anorexia. Emotional abuse was defined as symbolic acts used to maintain power over children, such as verbal insults, bullying, rejecting or isolating, and/or a pattern of failure over time to provide emotional nurturance and security. Physical abuse was defined as any physically aggressive act that causes pain, suffering, or distress. Sexual abuse was defined as engaging a child in any sexual activity evidenced by abuse of power and exploitation regardless of whether physical violence occurred (Goldsworthy, 2015). Anorexia nervosa was defined as the persistent restriction of food intake, intense fear of weight gain, and disturbance in weight or shape.

Critical Appraisal and Rubric for Assessing Quality

This study utilized various strategies to optimize validity: (a) second authors possess expertise in the area, (b) discussions with second authors about interpretative techniques, and (c) and to evaluate the findings. The initial screening of titles identified irrelevant articles for exclusion. The remaining articles were compared against the inclusion criteria, then critically appraised for rigor based on established protocols for utility and trustworthiness in the Critical Appraisal Skills Programme checklist (CASP 2014) and the comprehensive outline formulated by Sandelowski and Barroso (2007, please see Chaps. 3,4,5, and 7) as well as using the following rubric for assessing quality: (1)clear statement of the aims of the research, (2) is the qualitative methodology appropriate, (3) was the research design suitable, (4) was the recruitment strategy appropriate, (5) was the data collected in a way that addressed the research issue, (6) have the relationships between researcher and participants been addressed, (7) have ethical issues been considered, (8) was the data analysis sufficiently rigorous, (9) is there a clear statement of findings, and (10) how valuable was the research? Five studies were allocated into category A, as they met 9 or greater on the CASP item scale and were deemed low risk of bias. A single study was rated 8 on the CASP scale and category B with moderate bias (see Fig. 1).

Meta-synthesis

A meta-synthesis can complement existing research by isolating and linking individual accounts across multiple studies to help build a theory of process that can bridge the gap between the materiality of abuse and the way anorexia discursively and materially defines subjective experiences within a relational context.
  • The first stage of the analysis involved line-by-line readings of the studies to familiarize ourselves with the theoretical frameworks and the participants in their social contexts.

  • The next stage, a taxonomic analysis, separates text into its constituent elements using a similar method to axial and selective coding in grounded theory to show the conceptual range within the findings (Strauss and Corbin 1998). The objective was to identify conceptual relationships from the original studies that were either evident in the original studies and reported, or not expressed but implicit in their findings (Sandelowski and Barroso 2007).

  • Detailed readings of the findings, discussion, and conclusion sections of the original studies yielded an expansive list of abstracted statements, for example, “fearful from environmental threats” or “alone and alienated.”

  • The statements were transcribed into print and organized onto concept maps by screening for semantically related patterns of convergence and divergence. The list of abstracted statements was compiled according our interpretation of the way they related (see Tables 1, 2, and 3). For example, “self-transformation” appeared in various forms and contexts (self-development, self-aware, self-differentiation, self-reflection, self-esteem). Because the original authors placed importance on the liminality of women’s “self” and the influence of sense of self on embodiment, it was thought to form the basis of other taxonomies, therefore either a type or a consequence of “self.”

  • The final level of interpretation, a reciprocal translation and synthesis of in vivo and imported concepts, involved the comparison of taxonomies and the imported concept. The objective was to draw conclusions about the findings and review them against the material-discursive-intrapsychic framework (Ussher 2000). Self-transformation and control will be elaborated to show how a material-discursive-intrapsychic framework can strengthen the analysis. Taking “control” at the level of materiality is to consider factors, such as gender and power inequalities that are inherent in abusive contexts. A discursive analysis considers the way women construct the language of control and the related symbolic meanings about the body (Lupton 1992). Finally, intrapsychic processes most closely relate to psychological domain, such as emotional responses to control and the way it is manifested in the material body. When any one aspect is viewed in isolation, it will necessarily exclude either “internal” or “external” aspects of women’s experiences.

Table 2

Material intrapsychic discursive aspects of anorexia nervosa following childhood trauma

Study

Aims

Sample size

Design

Eating disorder and trauma

Material discursive intrapsychic

Original themes

Taxonomies

4. Moulding 2015

Exploring ED’s in the lives of women who experienced trauma.

14

Narrative inquiry

Anorexia nervosa—9

Sexual—7

Physical—2

Emotional—7

Material discursive intrapsychic

The emotional impact of abuse. Linking emotional abuse to the eating disorder. Recovering from an eating disorder.

Objectified and control, abject bodies. Embodied emotions and self-harm. medicalizing women and embodiment

5. Weaver et al. 2005

Exploring recovery in context of family, community, or society.

12

Feminist grounded theory

Anorexia nervosa—12

Unknown—8a

Intrapsychic material

Not knowing myself, losing myself to AN obsession, finding me, informed self-care, celebrating myself

Objectified and control, embodied emotions

6. Conti 2015

A longitudinal study (10 years) gaining insight into women’s anorexia nervosa

9

Narrative inquiry

Anorexia nervosa—4

Physical—1

Sexual—3

Intrapsychic discursive material

Traversing between narratives of control and “there’s something wrong,” positioning experience in relation to AN, personal agency, the moral construction of AN, a different way of looking and speaking.

Objectified and control, identity, medicalizing women and embodiment, embodied meanings and new possibilities

aDenotes author of the original study confirmed trauma but were unable to define the trauma type

Table 3

Results from critical appraisal (CASP).

 

Study 1

O'Shaughnessy et al. 2013

Study 2

Dawson et al. 2014

Study 3

Lamoureux and Bottorff 2005

Study 4

Weaver et al. 2005

Study 5

Moulding 2015

Study 6

Conti

1

Yes

Yes

No

Yes

Yes

Yes

2

Yes

Yes

Yes

Yes

Yes

Yes

3

Yes

Yes

Yes

Yes

Yes

Yes

4

No

Yes

Yes

Yes

Yes

Yes

5

Yes

Yes

Yes

No

Yes

Yes

6

Yes

Yes

Yes

Yes

No

Yes

7

Yes

Yes

Can’t tell

Yes

Yes

Yes

8

yes

Yes

Yes

Yes

Yes

Yes

9

Yes

No

Yes

Yes

Yes

Yes

10

Yes

Yes

Yes

Yes

Yes

Yes

Total

9

9

8

9

9

10

Results

Taxonomies

The synthesis identified the major taxonomies as: “objectified and controlled bodies,” “the abject body,” “embodied emotions and self-harm,” “medicalizing the body-as-object,” and “embodied meanings and new possibilities.”

Objectified and Controlled Bodies

The objectified body refers to the surveillance, critiquing, and abuse of women’s bodies (Fredrickson and Roberts 1997), and control refers to the extreme bodily practices used in response to the objectifying experiences. Women’s experiences of being positioned as an object of abuse undermined their feminine subjectivities. The experience socializes girls and women to accept surveillance of their bodies and responsibility for the actions of others. The women coped with the objectifying experiences in a multitude of ways. They internalized the experiences and engaged in self-objectification practices, such as monitoring and controlling their bodies “as a teenager the only thing I could control was my body” (Dawson et al. 2014, p. 500), (Tiggemann and Williams 2012). Many of the women constructed their bodies as damaged, unsafe to inhabit, or inadequate, which posed a threat to their wellbeing and feminine identities which invited them into subject positions invoking control. They responded by exerting severe dietary control and relentless self-objectification practices “the only thing I could control was my body.” Control in this context was not structured around obtaining cultural versions of thinness/beauty. It was referring to the rigorous practices they used to control “others” behaviors. Their embodied practices conveyed attempts to shape their outcomes through their efforts to transform the embodied selves (Burns 2009). Lester (1997) proposed that women are acutely aware of the materiality of their bodies, as it intersects with the social environment. In the prevailing social context, being female does define women’s experiences and the choices they make about their bodies. In a context of abuse, a small body occupies less physical space and becomes less likely to attract heterosexual attention offering protection from further abuse. In this sense, women are producing bodies constructed as resistant to abuse and experience their choices as agenic “the control of abstaining from food and the high I got gave me a … huge sense of power” (Anna) (Lamoureux and Bottorff 2005). By reconstructing their selves into femininities that embody strength and self-discipline invites distance from normative prescriptions of passivity and weakness that have previously defined them. The thin body was not driven by a relentless pursuit of the thin ideal, rather it holds a fantasy of power, a thin body equates to control, perfection, independence and mastery “… fulfilling my dream” (Katie) (Conti 2015, p. 6), (Burns 2009; Mensinger et al. 2007). As the material effects of a body yielding to starvation gradually took effect, their discourse signaled a shift in personal agency “… your mind is just taken over” (Lamoureux and Bottorff 2005, p. 176). The women were attempting to hold multiple versions of their selves in a contested social space between controlled and uncontrolled. They were positioned to look for ways to transcend opposing ways of being (Saukko 2009).

Abject Bodies

In the course of making meaning about their bodies, women produced threatening outcomes for their embodied subjectivities (Malson 2009). Bodies constructed as disgusting or threatening were positioned in state of abjection (Kristeva 1982; Warin 2010). Abjection refers to their embodied, visceral, and emotional reactions to their own bodies or food following abusive experiences (Warin 2010). The parts that women considered abject were distanced, breaking down the distinction between what they experienced as “me” the body-subject and “not me” the body-as-object (Lester 1997; Merleau-Ponty 1962). In removing or distancing aspects from felt experiences, women could cope with materiality and the emotions of abuse and avoid “others” power to control. They were finding a way of refiguring their identity (Alcoff 2006). Identity in this sense implies a constitutive relationship between the self and the other, as well as the social community. Taken together, their embodied experiences challenge the idea of selfhood as fixed natural occurrence, with the countervailing idea that inter-subjectivity is experienced in relationship with the objectifying other in social contexts (Butler 2011).

Anorexia produced a mixture of complex constructions of the body, as both part of the self and not belonging to the self. Within this fluid dynamic, anorexia fulfilled a multitude of roles constituted in a space between the subjective self and the body. Anorexia was discursively constructed as an identity replete with thoughts and a speaking part “It’s huge and it’s a real self-perpetuating thing …” (Katie), (Conti 2015, p. 12) holding court over women’s subjectivities (Malson 1998). Anorexia was positioned by the women as a benevolent guardian, a friend for lonely women, or it could secure a place in a group setting. Continued membership of belonging to the group “anorexic” relied on strict adherence to rules grounded in moral territories between women whose identity was taken up by “… actually being the symptoms (Katie)” (Conti 2015., p. 8) and others who “adopt the symptoms consciously.” (Katie) (Conti 2015., p. 8.) to produce an artificial model of anorexia. In some contexts, the “anorexic voice” performed defensive functions of mitigating the harmful effects from attacking one’s self, or minimizing rejection or shame in interpersonal situations (Pugh and Waller 2017), or conversely, the voice was positioned as powerful and subjugated women’s subjectivities. In positioning, themselves within the various narratives required recognition of possessing the qualities necessary to locate themselves within those gendered frameworks. Seeing the world from that position with a commitment to the moral system circulates in the wider culture of being positioned as an “anorexic” (Davies and Harré 1990).

Dissociative experiences are common in eating disorders and in trauma (Brown et al. 1999; Hund and Espelage 2006). They are recognized as the psyche’s response to trauma and characterized by a disruption to an integrated consciousness, identity, and embodied experiences. Severe traumatization resulted in a discontinuity between the felt body experiences and the “self” (Sack 2010). The more severe experiences of body-as-object occurred as dissociative experiences in the context of violence and manipulation associated with severe sexual abuse. Dissociative experiences are characterized by a disruption to an integrated identity and embodied experiences. For example, “… I was hearing voices, self-harming a lot … I was diagnosed with dissociative identity disorder (Louise)” (Moulding 2015, p. 1466). In this account, dissociative experiences helped to maintain safety by distancing awareness from the material body and aversive intrapsychic sense of being “out of control” (Louise) (Moulding 2015, p. 1469).

Embodied Emotions and Self-Harm

Emotions are anchored in the body and enable a person to understand the meanings of other objects and to “feel” located in their social world (Stanghellini and Rosfort 2013). Abusive events in childhood disturbed women’s ability to affirm their self through their embodied emotions. The emotions fear, disgust, sadness, and self-loathing were described across studies; however, women most commonly positioned their bodies as shameful. The emotional meaning attached to negative self-representations and abuse-related emotions were reproduced in the body through food behaviors. For example, shame, self-loathing, and punishment attached to sexual abuse “I wouldn’t eat, but, you know, I wouldn’t let myself sleep in a bed, because I wasn’t worthy of sleeping in a bed” (Louise) (Moulding 2015., p. 1469.) Starvation and binging were constructed as a form of self-punishment after being positioned as responsible for the abuse. The emotion shame was particularly aversive and specific to discourse structured around blaming women for not fitting into traditional feminine identities (Moulding 2015). Abuse was rarely described in isolation with most women describing multiple interpersonal traumas, “growing up I was sexually abused … there was a lot of violence … there was a lot of manipulation from my father …” (Louise) (Moulding 2015., p. 1466.) Accounts involving sexual abuse or multiple abuses gave rise to punishing regimes of starvation, bingeing, and purging constructed in discourse reminiscent of the violence of abuse. For Kristeva (1982), food loathing is probably the first form of abjection that invokes an “I” who wants nothing to do with food, “I expel myself, I spit myself out, I abject myself within the same motion through which I claim to establish myself.” (p. 3). Food can cross the boundary into the pure body defiling it with impurities (Warin 2010). Importantly, food constitutes the corporeal body when ingested and broken down and must be expelled (Churruca et al. 2017). The abjection of food, the body, or the self is a culmination of all the experiences of abuse causing a disruption of the boundaries between the self and others.

Gendered expressions of emotions were found across accounts in what Moulding (2015) constructed as “particular discourses, social practices, and social contexts” (p. 1467). The meanings of food in the context of trauma were closely linked to embodied emotions. For example, male surveillance of girls developing bodies induced intense shame that continued to be reproduced in adulthood through social relationships. In other socially situated contexts, women described fear-based emotions within the context of schoolyard bullying, chronic traumatic invalidation in the home environment, or sadness and grief from bereavement (O'Shaughnessy et al. 2013). Painful abuse-related emotions that were deflected through food-related psychological defenses, such as avoidance or minimization, could not find recourse. For some women, the unresolved trauma and contempt for the body merged into self-injurious or suicidal behaviors. Within this context, women positioned their body as abhorrent, an object worthy of punishment “… there is a strong connection to self-harm … a kind of like self-hate” (Louise) (Moulding 2015, p. 1469) and the focal point of emotional distress. The scarred body signified private meanings about the body that could not be spoken about, or conversely signified an act of resistance “see what you did to me” (Cally Ann) (Brickman 2004; Weaver et al. 2005, p. 194).

Medicalizing Women and Embodiment

Constructions of the body-as-object in the context of the medical system were evident throughout the studies. This occurred in the context of a diagnosis and was signified by the discourse the women used to refer to their bodily practices from the first-person perspective of being engaged in the world from within one’s own body to a third person perspective or body-object distanced from their bodily subjective experiences to identify as “the anorexic.” For many women, diagnosis conferred medical legitimacy to their bodily distress, “they didn’t give me any alternative to it …you’ve got no choice but to listen” (Katie) (Conti 2015, p. 10); however, it also required conceding “control” to something constructed as all powerful and a loss of personal agency, “it’s huge, and it’s a real self-perpetuating thing” (Katie) (Conti 2015, p. 12.) Several women were not ready to “surrender” to a diseased or disordered state, “I’d read the list of symptoms … search for something in the list that would tell me I was OK” (Kelly) Conti 2015, p. 171), or willing to be labeled “I’ve really tried to fight having that label and get quite resistant to anyone that wont to kind of put that label on me because… I just don’t, I don’t see myself as a sick patient or anything anymore” (Lisa) (Conti 2015, p. 175). The majority reported the wearing down of fully experiencing lived-sensory body, which ultimately led to alienation from their body and a loss of personal agency. In either case, women were positioned by biomedical discourse as the body-object, “…you have to have a classic set of symptoms, before you can be classified as having it” (Conti 2015., p. 171) or positioned in denial if they could not distinguish what part of their subjectivities was “anorexic” or did not want to yield “I surrender” to the more powerful medical perspective “… it was pounded into me—it’s all part of the illness. It was really hard to distinguish what I was and what I wasn’t and to be able to look beyond it.” (Kelly) (Conti 2015, p. 173.) In refusing to yield to the persuasive medical position, the women were in the unenviable position of being “in need of containment” because they lacked insight, or by surrendering, they were positioned as “sick” and in need of help. Unsurprisingly, there were multiple accounts of treatment experiences that failed to help “treatment felt like banging my head on a brick wall” (Dawson et al. 2014, p. 499) driving a disconnect between client and therapist “participants felt alienated and misunderstood ….” There were many accounts where women responded with “defiant resistance … well screw you. I’m not doing that, it became more about the ‘us’ and ‘them.’” (Dawson et al. 2014, p. 499.) For most women, a clinical formulation positioned women within a disorder giving them no other alternatives for their embodied distress “… I’d already failed and was told by a psychiatrist and nurses that there was no hope. Recovery seemed impossible.” (Dawson et al. 2014., p. 499)

Embodied Meanings and New Possibilities

Women’s identities were forged in social conditions that imposed restrictions on their ability to achieve subjectivity. During periods of liminality, the women undergo a process of detachment from an earlier fixed point. These periods of “betweenness” are accompanied by symbolic behaviors, such as dietary control, abjection, or suicidality/self-harm, or the object of medical attention. The liminal persona is characterized by their emotional, physical, or intrapsychic states, as they transition into a new state that is defined by name and cultural symbols “the anorexic” (Turner, 1967). At certain critical moments, that were often punctuated by a life-crisis, the women described reflecting about the powers that had previously defined them. Women signaled a shift as they engaged in biographical meaning-making and constructed themselves as being in an embodied state of “in-self,” “I needed to know that I was more than my weight … more in self” (Fiona) (Lamoureux and Bottorff 2005, p. 185). Constructions of body-as-object that had previously disrupted women’s embodied states gradually faded as women negotiated their identities and developed new values that included prioritizing “looking after me now…having value in just who I am in this very moment” (Fiona) (Lamoureux and Bottorff 2005, p. 180). Many sought out responsive, trusting relationships that conveyed validation, and sensitivity or ended abusive relationships. For other women as memories of abuse gradually unfolded its role in their distress became apparent, “I started to become aware that anorexia wasn’t a choice—it was a reaction,” “As a teenage girl the only thing I could control was my body because I had no power …” (Dawson et al. 2014., p. 500). Women’s constructions shifted into states of “body-subject,” characterized by the discourse “I” or “me.” Such changes are not premised on the notion that one’s real, true, or perfect identity waits to be discovered or that such changes were contingent on medical treatment. Certain conditions opened a space for the reconfiguration of identities to occur, and importantly, women have a large part in this reconfiguration (Lester 1997). As the visible and acknowledged identity intersects with the social world, it impacts on the way women experience their interior world or subjectivities (Alcoff 2006).

Discussions and Conclusions

The Embodiment of Trauma

In medical and psychological analysis, anorexia is represented as psychopathology of food restriction, fear of weight gain, and disturbance in self-perceived weight or shape. The problem with this framework is the conspicuous absence of the role of the body in shaping women’s experience of anorexia and trauma. In line with the findings by Young (1992), this synthesis found that women’s experience of anorexia is a problem of embodiment. The application of the concept of embodied subjectivity (Merleau-Ponty 1962) to the analysis of trauma and anorexia can offer a holistic approach to the bodily distress. Embodiment in this sense is the aspect of the “self” as it is experienced through the body and engaged in the world (Young 1992). Women are both object and subject in their body, their situation, and in the world through mutual engagement (Merleau-Ponty 1962). An embodied individual has a subjective sense of living from within their body and being-in-the-world (Merleau-Ponty 1962). Anorexia can disrupt an embodied experience leaving the “self” constructed as a dichotomy of oppositions between the object “the anorexia” and the subjective self. These studies show that anorexic bodies performed a multiplicity of self-constructed identities that women used to negotiate the objectified-self and subjective-self after trauma. In understanding the multiplicity of ways, women “do” embodied identity requires looking beyond the effects of self-representation to the layering of meaning through their connections with other bodies (Budgeon 2003).

Embodied Emotions

The women’s accounts described links between the material aspects of emotions found in victim blaming discourses and the intrapsychic experience of embodied control and relational aspect of the self. Emotions are therefore embodied, essentially linked to the “felt” inner experiences and to the relational aspect of the self. The emotionally expressive body is a vehicle for communication and meaning making in our everyday interactions (Williams et al. 1998). When natural adaptive emotional experiences are subjugated and wronged during abuse, they were experienced as alienating and in need of transformation. Especially emotions experienced in the context of pain from physical or sexual trauma. The corporeal realities of the body are central to women’s experience, when emotions and somatic pain are entwined and the body emerges as a separate objectified “thing” to be controlled. For many women, it marked the breakdown of the boundaries between the subject and the object. Management of the body and emotional experiences demonstrated the difficulties women experienced when confronted with trauma. When women are consumed by strong emotions and thoughts but have no determinable safe location for the body within the symbolic order of meaning (Kristeva 1982), anorexia seems to provide a safeguard and a way to overcome trauma.

Gender

Anorexia was discursively constructed as a reaction to abusive events that are framed by gender. Considering gender identity and the way in which gender intersects with socially situated power in social relations was essential to this analysis (Fallon et al. 1994; Moulding 2015; Tannenbaum et al. 2016). The gendered victim-blaming discourses and practices were central to specific emotions (Moulding 2015). The emotions of abuse, shame, disgust, guilt, and sadness were located in discourses of self-loathing and unworthiness. Shame associated with sexual abuse or in victim-blaming discourse was particularly aversive and played a significant role in women’s suffering. Body objectification in adolescent girls has been found to arouse increased body shame and more rumination about the body and depressive symptoms (Grabe et al. 2007). Research looking at whether the body is associated with traumatic emotions following childhood sexual abuse found that shame, guilt, and disgust are associated with more trauma-related areas (pubic area, buttocks, inner thighs) on their body (Dyer et al. 2015). The results of this meta-synthesis found that embodied emotional experiences are important to women who survived childhood abuse. The interrelationship between the traumatic event, the body, and embodied emotions inform what women do with their bodies and how they manage their distress.

Bordo (2003) writes a persuasive argument that women with anorexia are not a “victim of a unique and bizarre pathology, but as the bearer of very distressing tidings about our culture” (p. 60). Self-harming the body left a symbolic reminder to themselves and to others that signified their intrapsychic distress (Walker 2009). The boundaries inscribed into the body by self-harm were constructed as an act of protest or an act of communication of their resistance. Their bodily practices and resistance we argue are subversive to dominant cultural forces and important to recognize and validate. A feminist analysis does not pathologise women’s distressed relationships with their bodies (Holmes 2016). It contextualizes and reviews power imbalances to ensure the emphasis is on egalitarian relationships between therapist and women who have already been over controlled by others (Ballou et al. 2008). The regulation of women’s distress has a long history in medical and psychiatric nosology (Malson 1998). In framing anorexia as an illness and applying a diagnostic label may in fact be unhelpful and prolong recovery. An alternative feminist construction positions anorexia as a legitimate response to abuse that forms a profile of representations of women embodied distress. Feminist approaches to treatment are careful to position embodied distress within its social location to help to bring about a cultural shift in discourse from “what is wrong with you” to “what happened to you,” giving women a chance to hear what they want to say rather than being positioned into other’s representations of feminine identities. As this review has drawn out, anorexia represented the various ways women use their bodies to articulate and negotiate their problematic relationships with their selves, their bodies, and their social relations.

Women represented anorexia in multiple ways that were located and shaped by the particularities of individuals. They were shown to actively resist oppression as they strive to make meaning of their femininity, bodies, emotions, and their embodied selves. Their resistance was not actuated by the pursuit of the feminine thin ideal; rather, women’s bodies represented a myriad of meanings (Malson 2009). Their bodies symbolized a quest for control, ownership, and mastery, as they sculpt and refine the boundaries of their bodies. A waifish body exceeds cultural expectations of femininity and signifies to others perfect control with its absence of feminine excesses (Malson 2009). Their bodies also signified the successful production of the body, as a fortified stronghold against possible abuse “proof that the self and the body can be dislodged from one another” (Lester 1997, p. 486).

The effects of trauma were not always located by the women at the time of the event; indeed, some women were unable to connect the abuse to their current distress. Trying to locate anorexia within a specific temporal order may prove difficult, as the process of recovery is variable making it difficult to locate within temporal locations that may not even resemble recovery. At critical points along the life-trajectory and demarcated by a tipping-point (Dawson et al. 2014), women experienced periods of intrapsychic turmoil to make way for new possibilities without anorexia. The periods of liminality can occur in the context of emotionally charged events that positioned women at a threshold of either continued identification with anorexia or taking up a different conceptualization of their “selves.” Such changes are not premised on the notion that one’s real, true, or perfect identity waits to be discovered. Certain social conditions opened a space for the reconfiguration of different embodied subjectivities to occur, and importantly, women have a large part in this reconfiguration (Lester 1997).

The taxonomies identified in this study were comparable to a large meta-synthesis about the processes and struggles involved in the healing from sexual violence involving re-evaluating the self and transforming the self (Draucker et al. 2009). Similarly, a meta-synthesis of treatment for anorexia from the perspective of recovered individuals found impaired identity as a dominant theme, and recovery occurred as an outcome of self-reconciliation and self-acceptance (Espíndola and Blay 2009). This meta-synthesis went further in finding that women’s experience of their embodied subjectivities after trauma is precarious. As Young (1992) noted, to live in the body and view it as essential to identity is unthinkable for survivors of trauma. The aim of this synthesis was to explore women’s intrapsychic, material/societal, and discursive processes following childhood trauma that influence the development of anorexia. The intrapsychic and corporeal material processes of anorexia were constructed to protect the self, to control the self, to annihilate the self, and ultimately to transform the self. The intrapsychic and material aspects cannot be analyzed independently from the familial context where the abuse occurred, or the socio-cultural contexts that constructs females as sexual objects, and facilitates gendered power relations. The body defines women’s experiences and drives the imperative to “cut the ties that bind” them to the past. Anorexia was constructed by the women as more than an obsession with food or the mindless pursuit of a thin body. Women’s experience of anorexia following childhood trauma has profound effects on her developing sense of self, her emotions, and the ways in which her body and femininity are experienced. The conclusions in the study will be impacted by the population under study and the epistemological framework chosen for this synthesis. The abuse was not the exclusive domain of men, at least one mother was complicit in perpetuating abusive patriarchal discourse, and demonstrated how the aversive effects of shame can linger and infiltrate into adulthood.

This meta-synthesis highlighted an absence of trauma informed research and treatment for anorexia, which presents an obstacle for clinicians who are challenged to know how to approach this population. There is a clear need to develop research and treatment pathways that focus anorexia through the lens of trauma and feminist ideologies. Research that acknowledges women’s traumatic lived experiences and validates their embodied and intrapsychic distress and negotiation of cultural discourse. The present synthesis was limited to six studies and should be read as a prelude to further research examining women’s experiences of anorexia following trauma.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.School of Psychology, Brennan MacCallum Building(A18)The University of SydneySydneyAustralia
  2. 2.Centre for Health Research, School of MedicineWestern Sydney UniversitySydneyAustralia

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