Article Highlight: Vol. 41, Issue 1, “‘Hunger Hurts, but Starving Works.’ The Moral Conversion to Eating Disorders”

This week we’re highlighting Gisella Orsini’s “Hunger Hurts, but Starving Works.” The Moral Conversion to Eating Disorders article. Orsini suggests that eating disorders are the result of moral self-transformative processes. Women in Malta and Italy with anorexia, bulimia, and binge eating disorders are thus actively and deliberately engaged with cultural moral values embodied in thinness and the control of bodily needs and pleasure. Thus, the more control over hunger, the higher the level of satisfaction and the degree of moral conversion achieved.

Orsini begins by discussing the history of eating disorders within the Diagnostic and Statistical Manual of Mental Disorders (DSM), highlighting that the explanations of onset, classification, and treatment has often been, and to a large extent remains, unclear. Yet before the medical category of “eating disorders,” behaviors which would now be considered symptoms of pathology had different meanings, often characterized as holy behavior or as a wonder of nature. Medieval European nuns often adopted strict starvation practices in order to reach unity with Christ. Pre-Victorian and Victorian era “fasting women” were admired by the rest of society and were considered curiosities by scientists and doctors. Orsini narrows the modern gap between the biomedical construction of illness and the self-perception of patients through an understanding of the narratives of people with eating disorders and framing it as a process of self-transformation.

Between 2012 and 2014, Orsini conducted comparative qualitative research in Malta and Italy. Even though the prevalence of eating disorders was relatively similar between the two countries, the social reactions to eating disorders were markedly different. The Italian government considers eating disorders to be a “social epidemic, which leads to serious problems in terms of public health.” Malta, by contrast, has almost no concern with eating disorders at the public level as well as a lack of public and private treatment institutions. Both countries aligned with the international trend of eating disorders being mostly female.

In framing eating disorders as a moral conversion, on the basis of the interview narratives she collected, Orsini suggests that eating disorders could be considered as the body becoming a physical symbol of an attempt to redefine their lives. Yet the biomedical approach views the behavior of people with an eating disorder as stemming from a mental condition. Orsini states, “anorexics, bulimics and binge eaters actively and deliberately adopt behaviors in relation to food and their own bodies in order to morally improve themselves.” All of Orsini’s participants sought to dominate their bodily needs in order to improve themselves morally. Furthermore, all recalled negative moral feelings, such as guilt and shame, when their behavior was not in line with their moral values of purity and control. In this way, moral values became moral imperatives.

Yet not all people with eating disorders reacted to their diagnosis’ pathologization in the same way. Anorexics tended to be the most resistant to their newly achieved satisfactory personhood with illness. Bulimics and people with binge eating disorder, on the other hand, tended to experience relief at being labeled “ill,” identifying more with their condition as a disorder rather than a moral conversation.

Orsini states that although the main objective of people with eating disorders is thinness, this thinness is simply the end result of several behaviors that aim to ameliorate one’s self in highly moral terms. The process of a moral conversion requires an individual to adopt views, attitudes, or patterns of behavior that are generally thought of as morally better than their previous views. Orsini then further divides the three discussed eating disorders into levels of conversion: achieved moral conversion for anorexia nervosa, attempting moral conversion for bulimia nervosa, and rejecting moral conversion for binge eating disorder.

In the case of anorexia nervosa, Orsini presents the circumstances of Elisa, a 28-year-old woman in residential treatment in Italy. Elisa’s narrative of transforming her body from being “sinful and dirty,” to a “pure and sinless body” through her anorexia is an example of an achieved moral conversion. Yet she was forced to abandon her new perspectives and values in order to live. Elisa had to decide if the costs of her anorexic beliefs justified the benefits, leading to a painful moral choice.

For bulimia nervosa, Orsini discusses that people who are diagnosed with bulimia after having had a history with anorexia can be said to have lost the ability to practice the core values associated with anorexia, even though they still consider such values (such as controlling hunger and thinness) to be core values in their lives. Orsini’s participants who were not diagnosed previously with anorexia often spoke of their daily frustrating struggle to control their hunger; while they are unable to totally control their eating, the compensatory behavior of self-induced vomiting, laxative use, or over-exercising was still an attempt at thinness. This continuous attempt to control their hunger, followed by “repairing the damage caused by their moments of weakness,” is an example of how they are attempting moral conversion.

Finally, for Orsini, binge eating disorder is seen as a case of rejecting moral conversion. While the people in Orsini’s research diagnosed with binge eating disorder still described thinness and control over food as a core value in their lives, unlike the anorexics and bulimics, people with binge eating disorder did not believe they deserved to ameliorate themselves. Their self-transformative process can be understood as a form of self-punishment as well as a statement of their perceived failure in being the person they want to be.

Michelle, a 34-year-old Maltese woman, spoke of her body as a sign of failure after gaining a significant amount of weight during and after pregnancy. Orsini states Michelle never referred to her body in aesthetic terms, such as “ugly,” but instead as a mark of her inabilities and moral dissatisfaction. She states, “If I was slimmer, if I am slimmer, I would be a better person” (p. 134). For Michelle, bingeing was a manifestation of her moral failures.

In conclusion, Orsini reiterates that only viewing people with eating disorders as having a physiological or psychological dysfunction underestimates the active role their conditions and cultural meanings of their behaviors. Through her analysis of the narratives of people with an eating disorder in Malta and Italy, she reveals how anorexics, bulimics, and binge eaters deliberately engage in a number of practices aimed at losing weight in order to improve themselves in moral terms. Their actions are further divided into an unofficial moral hierarchy, wherein anorexics embody an ideal moral-selfhood.

Article Highlight: Vol. 41, Issue 1, “‘They Treat you a Different Way:’ Public Insurance, Stigma, and the Challenge to Quality Health Care”

This week we are highlighting “They Treat you a Different Way:” Public Insurance, Stigma, and the Challenge to Quality Health Care by Anna C. Martinez-Hume, Allison M. Baker, Hannah S. Bell, Isabel Montemayor, Kristan Elwell, and Linda M. Hunt. The authors argue that stigma is a public health issue which should be addressed in Medicaid policy. Even though Medicaid eligibility is expanding to include more low-income adults, issues within the social context of public insurance and the experience of stigma may result in increased disparities in health care.

In this article, the authors examined the experiences of stigma when using public insurance as described by a group of low-income individuals eligible for Medicaid in Michigan and how such stigma influences their health-seeking behavior. Social scientists have long been concerned with the impacts of stigma on an individual’s social identity. Sources of stigma affecting health care experiences may include race, class, gender, and illness-status, all of which have serious consequences for health status. Underutilized care, delayed care, forgoing tests, infrequent check-ups, and lower quality of life have all been linked to health care stigma.

Patients in this study often reported stigmatization based on having public insurance, or no insurance, and reported feeling ignored, disrespected, or overlooked. As patients experience low satisfaction with their health care providers, the result is often missed follow-up appointments, changes in their providers, and reluctance to access necessary services. The authors discuss that groups who experience stigma in the health care system are most likely to be individuals who enter into the system as already stigmatized patients.

Racial categories within health care structures also distinguish between types of people, often leading providers to unknowingly treat some patients differently than others. The authors discuss how providers are taught through their medical training, published articles, and clinical guidelines to presume racial and ethnic groups share genetic, socio-economic, and cultural characteristics. These assumptions ignore complex social problems and highlight the multidimensional processes of differential treatment in health care.

Understanding the intersectionality of personal attributes, such as race or illness-status, and public insurance status can improve the appreciation for how experiences of stigma are compounded. Clinical encounters which manifest stigma have important health consequences for patients.

From their research, the authors explore participants’ stories about being treated differently while receiving Medicaid coverage and focused on two central stigma themes: receiving poor quality care, and experiencing negative interpersonal interactions.

One example of receiving rushed or poor quality of care comes from a woman named Destiny. She recounted her experience of taking her son to a clinic:

“The wait was an hour long…and then they were very quick with us, they didn’t take their time to ask questions…It’s like they weren’t patients, they were just another number, you know, to get them out the door, and the next one in… [The doctor] just sent us on our way without even fully understanding what the problem was… [My son] had a really bad cold or bronchitis and I told the doctor before he’s allergic to amoxicillin, penicillin, and he actually wrote him an amoxicillin script. It was in his file. He didn’t even read through his file.”

Mistreatment by staff or health care personnel based on public insurance status included shaming, being disrespected or ignored, not being believed, or being patronized. Shannon described her negative interpersonal interactions:

“When we had Blue Cross and Blue Shield, we were treated much differently even by the receptionist. People treat you differently. They look at you differently… I sometimes don’t want to pull out my green [Medicaid] card when I’m in the line at the pharmacy…the lady in front of me has a Blue Cross Blue Shield card and the way they talked to her or interact with her…is much different than when I roll up with my green card and my cardboard [Medicaid health plan] card. It’s ‘here, sign this, birth date, co-pay, have a great day.’”

These stigmatized experiences often lead to discontinuity of care and even resistance to returning to these facilities for care. The authors consider an especially concerning story from Carrie, whose stigma experience is amplified by her HIV-positive status:

“My doctor asked me to swab myself one time when I was being tested for STDs… How the hell can you work in infectious disease and you don’t want to swab me? Like okay, I can do that. But how humiliating is that? I’m switching doctors…I just don’t want to go. I want to be able to sit down and talk to somebody about what’s going on with me because I’ve been missing medicine, and that’s serious. It’s a serious thing, and they’re so callous to it.”

As the authors’ research elaborates, Medicaid use has long carried a stigma in the United States as a symbol of waste and excess of the welfare system. This carries with it a set of assumptions about the individuals who rely on these resources. The social construction of low-income individuals who enroll in Medicaid characterizes these people as lazy, willingly unemployed, less educated, and ultimately, undeserving. Inequitable health care received under the stigma of public insurance is fundamentally a public health issue, creating further disadvantages for the health of already vulnerable people.