Sexual Abuse and the Adaptive Nature of Eating Disorder Symptoms
Amy Olson, LCSW
There is much interest in the relationship between disordered eating patterns and sexual abuse, mainly,
the attempt to understand if sexual abuse is a specific risk factor for the later development of an eating
disorder. Studies have yielded vastly different results on this topic, largely influenced by study conditions and
methodological problems. However, in a 1997 review of available literature, Fallon and Wonderlich concluded
the following: (a) There is “…preliminary support for the idea that childhood sexual abuse is a nonspecific
risk factor for Bulimia Nervosa” (p.399), (b) sexual abuse may be more common in bulimic individuals than in
restricting anorexics, and (c) sexual abuse is associated with higher levels of co-morbidity, but not
necessarily a more severe eating disorder.
Of course, not all women with eating disorders have been sexually abused, nor do all women who are
sexually abused develop an eating disorder, but for the practicing clinician, there is enough overlap in these
populations that it is prudent to be familiar with sexual trauma treatment within the context of treating an
eating disorder. This paper will focus on the impact of childhood sexual abuse on disordered eating patterns,
particularly the adaptive function of symptoms. Treatment implications for this population will also briefly be
highlighted.
The Eating Disorder as Adaptive
An eating disorder can be conceptualized as a sophisticated, organized attempt to maintain a sense of
value, protection and tolerable reality after trauma. In any type of trauma there is a sense of loss of control
(of the body, thoughts, feelings or environment) and one subsequently struggles to regain what was lost.
“Disordered eating patterns are, in part, attempts to resist with the body and to define, establish or restore a
sense of self” (Costin, 1996, p. 113). It must be explained to clients, that no matter how senseless or crazy
they view their behaviors, it has helped to manage the overwhelming stress associated with child abuse.
Many theories exist about how an eating disorder helps a woman adapt to chronic post-traumatic stress, but
clinically it is most therapeutic for her to draw her own conclusions about the functional nature of her
symptoms. There are however, common themes regarding the adaptive nature of symptoms, three of which
are be described in greater detail below.
Displacement of traumatic memories
In women with traumatic histories (not just exclusively sexual trauma), there is “…a reciprocal relationship
between their post-traumatic imagery and the intensity of the preoccupation with weight and the desire to
avoid food” (McFarlane, McFarlane & Gilchrist, 1988, p.707). Food preoccupation can provide some sense
of control and alleviate the sense of being a victim or helpless. When attempts to control or manage
disordered eating patterns are made, exacerbation of trauma symptoms such as flashbacks and nightmares
is common (Schwartz & Gay, 1996).
This displacement points to eating disorder symptoms as dissociative disorders. Starvation, bingeing
and/or purging serve to numb intrusive thoughts and feelings both about the original trauma as well as
subsequent troubling thoughts, feelings and interpersonal experiences seemingly unconnected to the
trauma. A woman essentially re-enacts the trauma through disordered eating patterns, but at least maintains
the illusion that she has some control over her body, as she is the one hurting herself this time. Schwartz
describes the double edged nature of this phenomena: “Dissociation, which protect(s) survivors from
suffering the full impact of the trauma, simultaneously prevent(s) them from ever resolving the trauma,
thereby bonding their lives to the trauma” (p.105). After years of disassociating through eating disorder
symptoms, survivors may have little emotion about the trauma itself, leading to the false belief that feelings
about the trauma have been resolved.
Need to gain control over the body
Women with eating disorders, particularly those who have been sexually abused, commonly experience
themselves as separate from their bodies. This separation, or splitting-off, is often underpinned by beliefs
that the body is bad, dirty or invited the abuse. The body may be viewed as the “enemy” especially if any
physical pleasure or comfort was felt during the abuse. Appropriate care and nourishment for the body may
feel like collusion with the body that betrayed them.
To makes ones body small and frail, or large and “well padded” is to ward off further exploitation, and
manage feelings about intrusion, closeness and abandonment. Costin (1997) describes how “selective
eating” can enhance a sense of mastery or control:
An anorexic who maintains extremely rigid control over her body may be expressing
the fear of interpersonal contact. Fear of intrusion or losing control fuels her will to
defy her own needs: “I don’t need food, I don’t need you, I don’t need anybody. (p.
113)
The cost of separation from the body is high, as it impedes the development or maintenance of a healthy
body image. A healthy internal representation of the body can only develop when major caregivers model
adequate respect for the body, interest in its care and protection of its physical boundaries. The absence of
these ingredients leads to poor body awareness, the tendency to confuse emotions with bodily sensations, a
condition known as alexithymia, and frank body loathing.
Turning blame against the body instead of towards abuser
When abuse, neglect and less than nurturing experiences are inflicted upon a child by a trusted caregiver,
particularly a parent on whom the child’s survival depends, there may be an unconscious wish to protect the
fantasy surrounding the caregiver, and therefore ensure survival. It can feel safer to blame one’s own body
for the abuse, believing it dirty and seductive, rather than the abuser.
Feelings of anger or blame towards the abuser, when unacceptable, underpin what Schwartz and Gay
(1997) describe as the “eating disorder ego state” – a reservoir for a client’s anger so that she may continue
to live in a family system that will not confront abuse in an appropriate way. Through a set of rules and beliefs
about food, weight and shape this ego state assists in release of emotions through bingeing, vomiting and
restricting.
Treatment
The complexity of the internal experience for the woman with an eating disorder who is also a sexual
abuse survivor must be match by a well-paced, integrative approach to treatment. Education about the
adaptive nature of symptoms should be provided to patients so they can explore the unique meaning of their
behaviors in an atmosphere of empathy and respect. In addition to standard empirical treatments, expressive
and experiential strategies such as guided imagery, journal writing and art are especially useful when
accessing split off ego states, which often have limited capacity to verbalize. The integration of bodywork into
therapy, such as massage, yoga or tai chi, is corrective for those who feel separate from their bodies or have
little body awareness.
References
Costin, C. (1996). Body image disturbance in eating disorders and sexual abuse. In M.F. Schwartz & L.
Cohn (Eds.) Sexual Abuse and Eating Disorders (pp.109-127). Bristol, PA: Brunner / Mazel.
Fallon, P. & Wonderlich, S.A. (1997). Sexual abuse and other forms of trauma. In D.M. Garner & P.E.
Garfinkle (Eds.) Handbook of Treatment for Eating Disorders (2nd ed.) (pp. 437-449). New York: The
Guilford Press.
McFarlane, A.C., McFarlane, C.M. & Gilchrist, P.N. (1988). Posttraumatic bulimia and anorexia nervosa.
International Journal of Eating Disorders, 7 (5), 705 – 708.
Schwartz, M.F. & Gay, P. (1996). Physical and sexual abuse and neglect and eating disorder symptoms. In
M.F. Schwartz & L. Cohn (Eds.) Sexual Abuse and Eating Disorders (pp.91-108). Bristol, PA: Brunner / Mazel.