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Anorexia nervosa (AN) is an eating disorder most commonly affecting adolescent women (Russell 1970, 132). The diagnostic criteria for anorexia is defined by the Diagnostic and Statistical manual of the American Psychiatric Association 4th ed (DSM-IV) as excessive dieting or exercise leading to extreme weight loss, a refusal to gain weight, disturbance in body shape perception and amenorrhea (American Psychiatric Association, 1994). It has been suggested that the psychopathologies behind AN arise from within a cultural framework, namely the Western culture (Bordo 1993, 141-145). The Western ideals of beauty and portrayal of a slim body type in relation to attractiveness and healthiness have perpetuated a 'culture of thinness' and 'fat-phobia,' from which AN manifests from extreme measures taken to achieve these conceptions (Bordo 1993, 146-149). Furthermore, in recent years AN has become a transcultural disorder, affecting non-Western cultures influenced by Western culture such as the Chinese, Fijians and African Americans. Mass media has enabled widespread access to Western culture, resulting in a global culture phenomenon that has increased the incidence of eating disorders such as AN worldwide (Simpson, 2002, 66-67). In addition, cultural assimilation as well as cultural clash in those who must balance their traditional culture with the modern Western culture has been shown to contribute to a predisposition towards AN, as a result of self-conflicts and unstable self-identity (Shuriquie, 1999, 355). Finally, some have advocated for a more culturally sensitive definition of AN, which currently is thought to be Western-centric in its definition. Proponents advocate the consideration of individual sociocultural factors, notably unrelated to the culture of thinness, contributing to the development of AN within the context of local biologies (Simpson, 2002, 68-69). Thus AN must be analyzed from within a transcultural framework, one which encompasses the influences of the Western culture on perceptions of the body as well as considers the specific cultural context, which sheds light on causes of AN.
Anorexia is considered a Western culture-bound phenomenon as a result of the current sociopolitical demands placed upon women in regards to the ideals of beauty, body shapes, and feminism (Derenne and Beresin 2006, 257). The term culture-bound denotes a restriction of a phenomenon within a particular cultural group due to specific social, political, culture and psychological factors from within that culture (Prince 1985, 197-198). As most American women are preoccupied with their weight, AN could simply be an extreme manifestation of the nation-wide preoccupation with weight and body image (Lake 1999, 83-84). Historically, the concept of the ideal female body was fluid, changing with the political and economic climate, which affected cultural values and thus attitudes toward female bodies. During the colonial era, strong, fertile, able-bodied women were favoured, as they would be capable of assisting with chores as well as bearing many children to increase family size. Times changed in the 19th century with the introduction of a more comfortable lifestyle, when the waifish look became popular and women sported short hair, pants and a slender, androgynous look that symbolized feminism and liberation. Since then, there has been a cultural trend towards thinness, with famous models such as Twiggy becoming household idols, culminating in today's nation-wide obsession with 'weight-watching,' 'calorie-counting' and 'dieting' (Derenne and Beresin 2006, 258-259). It is the mass media portrayal of the ideal thin female body as attractive, desirable and healthy that has further perpetuated the 'culture of thinness,' targeting particularly vulnerable women - young adolescents and teenage girls. Coincidentally, pre-teens, teenagers and adolescent females have the highest incidence of AN (Borzekowski 2005, 289). Recently, the incidence of AN has increased in pre-teen and teenage girls, as they are often the main target audience for a variety of media, which present unrealistic expectations of their body shapes (Borzekowski 2005, 290-291). Fashion magazines often depict thin women as desirable and healthy, television ads promote the latest technological invention that helps a woman lose weight and the Internet offers countless websites with tips on 'eating healthy,' keeping off the 'fat,' appetite suppressants and '0 calorie' dietary supplements. Particularly notable are the 'pro-anorexia' websites that proclaim AN to be a lifestyle choice, offer advice on weight management, effective dieting strategies and community support encouraging AN (Derenne and Beresin 2006, 258-259) . This bombardment of social and cultural expectations to be thin in order to be attractive has predominated Western culture since the 19th century and has not only grown, but crossed cultural boundaries through communication via mass media to affect other cultural groups (Shuriquie 1999, 356-357). Thus, it is reasonable to conclude that the psychiatric problems behind AN may be described as a set of particular symptoms that arise from within a cultural framework - the Western culture of thinness.
The origin of AN may have arisen from Western cultural values, but there have been an increasing number of reports of eating disorders such as AN in non-Western populations, challenging the notion that AN is a Western culture-bound syndrome. This trend is attributed to the exposure of non-Western cultures to Western culture via mass media. One study has shown that Hispanic and South African girls exhibit AN, influenced by their exposure to Western media, suggesting that AN transcends cultural and socioeconomic boundaries (Nasser 1994, 26-27). It was previously believed that the mentioned group of people were 'protected' from modern Western influences, due to their traditions of embracing larger, full-bodied women. Yet, a study conducted by Becker (Becker 2002, 509) found that the women of a group of islanders hailing from the South Pacific Ocean, the Fijians, have been heavily influenced by the Western culture of thinness. There were no reports of eating disorders in the Fijian population until 1995, when an international television station was broadcasted for the first time, depicting Western media. Three years later, reports of dissatisifation with body image, attempts to control weight such as dieting and self-induced vomiting were heard, suggesting that these Fijian women were significantly affected by the Western cultural ideals of the perfect body and perhaps could not distinguish between the idealism and concepts of perfection that television presented and reality. Despite a tradition of favourably viewing full-bodied women (Becker 1995, 27-29), a few years of exposure to Western cultural and perceptions of beauty have negatively impacted the Fijians. Anthropologists have studied the reasons behind the heavy influence of Western culture and have suggested that less developed, non-Western populations such as the Fijians regard the values portrayed by Western culture as symbols of socioeconomic progression, high social status and social acceptance (Shuriquie 1999, 358-360) and thus strive to emulate and assimilate Western culture values within their local cultures. Streigel-Moore points out that even African American groups within the United States have shown increasing incidence of AN, stemming from a desire to participate in the 'white world' (Striegel-Moore 2003, 1326-1328). Similarly, a study conducted by Nasser on the prevalence of AN in teenage Egyptian girls in Cairo indicated that traditional Egyptian values of larger, fertile women have not conferred protective effects from the assimilation of Western conceptions of the ideal body type via mass media in young Egyptian women (Nasser 1994, 28-30). These findings highlight a phenomenon known as global culture, where the world is connected via media, allowing cultural values to be readily accessible by other cultures across the globe (Banks 1992, 867). In this instance, global culture has contributed to the rising incidences of eating disorders such as AN, which has ultimately become a transcultural disorder that is not limited by cultural boundaries.
In addition to the global cultural phenomenon, some have argued that those immigrating to the West from non-Western cultures experience cultural clash, leading to greater risk of psychiatric disorders such as AN (Lee 1996, 21-23). Studies have indicated that those who are assimilated into Western culture are less impacted by media-driven concepts such as dieting and maintaining a slender frame than those who choose to maintain their own cultural values while living in a Western culture. Culture clash occurs when an individual adopts two cultural systems, which are often in conflict. Mumford and Whitehouse have shown that Asian girls in the United Kingdom that have not acculturated struggle to balance their beliefs and attitudes at home, where their traditional culture dominantes, and at school, where there is pressure to conform to the norms of the Western culture (Mumford and Whitehouse 1991, 222-225). Unfortunately, the unrealistic expectations of body shape is often taken as the norm in individuals affected by this cultural clash, leading to increased vulnerability to the negative influences of Western culture on body image and subsequently increased susceptibility to AN. These findings interestingly point to the influence of a non-Western culture within the context of Western culture not as protective, but exacerbative of eating disorders.
Although the phenomena of global culture and culture clash demonstrate the extensiveness and impact of Western cultural values on the rest of the world, it has been argued that attributing the cause and symptoms of AN solely to the sociocultural influence of the West may be inaccurate. The culture of thinness may be pervasive, but it is not the sole explanation for AN. Simpson claims that the prevailing biomedical definition of anorexia as a psychiatric disorder characterized by fat phobia and a distorted perspective on body image is itself a cultural construction within the confines of the Western culture (Simpson 2002, 66-70). This suggests a need to adopt a culturally-sensitive definition of AN, one which stems from within the context of local biologies rather a universal framework. Fat-phobia is currently the defining characteristic in AN, but there have been accounts of those with an eating disorder very similar to AN, except for the obvious lack of fat-phobia. Simpson presents reports of Chinese women suffering from AN who do not report fat-phobia. Rather, they attribute chronic epigastric bloating and a loss of appetite to their disinclination to eat (Simpson 2002, 68). In another case, a woman refuses to eat after being separated from her boyfriend, citing abdominal discomforts and a disinterest in food (Simpson 2002, 68). These psychosomatic symptoms are a result of somatization (Kleinman 1989, 57), where the illness symptoms of AN manifests from social problems, rather than any dissatisfaction of body shape. Psychosomatic symptoms are commonly reported in the Chinese population and contribute to the etiology of AN, although they are not included in the DSM-IV criteria. Furthermore, some women from conservative religious fundamentalist backgrounds have been cited to abstain from food, as a result of their beliefs about food, the body, femininity and spirituality (Simpson 2002, 68). Similarly, Mogul discusses a case where an anorexic patient refused food and fasted to the point of emaciation due to a religious belief that attainment of the highest spirituality and freedom from materialism came with a rejection of the temptations of food (Mogul 1980, 51). Thus, explaining AN within a Western cultural framework establishes a limited perspective of the disorder that does not take into account the personal, sociocultural factors within local biologies that contribute to various forms of AN.
Ultimately, AN is not a universal disorder, but a transcultural disorder. AN should not be viewed within the confines of any one culture, but rather understood to be a cross-cultural phenomenon. Essentially, AN is a psychiatric disorder with multi-factorial causes, requiring the incorporation of the Western cultural preoccupation with fat-phobia and unrealistic body shape expectations and the cross-cultural psychological and sociocultural reasons within local biologies to arrive at a holistic and culture-sensitive definition.
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