Eating Disorders among Orthodox Jewish Women: same or different?

By Caryn Gorden, Psy. D.

Eating disorders among Orthodox Jewish females are a major and continuous cause for concern.  Despite inconclusive data on whether the rate of eating disorders among Orthodox Jewish women and teens is higher than its incidence in the general and larger Jewish population there is concurrence that until recently these eating disorders remained under-reported and often unaddressed. Currently there is increasing awareness and greater numbers of women seeking treatment. 

Eating disorders among observant Jewish women and teens are both the same as and different than they are in the larger Jewish or general population. They occur for many of the same complex reasons and present with the same signature features.  

Cultural Difference

What distinguish eating disorders in the Orthodox Jewish population are unique cultural and religious elements. These aspects may intersect with other existing vulnerabilities and increase a woman’s risk of developing an eating disorder. These factors include: the mixed and contradictory obligations embedded in the religion, the importance of food, the significance of family, the shidduch (matchmaking) phenomenon and the traumas of the Holocaust.  

Mixed messages and incompatible expectations

Nothing intrinsic to Orthodox Judaism causes an eating disorder. However, the underlying mixed messages and incompatible demands to observe a traditional, spiritual way of life while functioning in a modern, secular world may serve as fertile ground for putting some females at risk. This may be truer now because the recent shift of orthodoxy to the right demands an increased, effortful negotiation of the gulf between this traditional culture (with its circumscribed gender roles) and a contemporary  existence (where gender and sexuality are significantly more fluid).

For example, Jews are taught to celebrate and take pleasure in their bodies, yet the many restrictions regulating this enjoyment send another message. There are laws dictating the modest clothing women are permitted to wear, married women must cover their hair when in public and women are allowed only limited contact with men, including when they can be physically intimate with their husbands. 

The observant female’s attempt to reconcile the contradictory expectations can at the very least generate conflict but more worrisome, can catalyze her asceticism, body shame and sexual discomfort which often underlie an eating disorder.

Perfectionism and Desperation

Jews highly value education, and professional and economic achievement, which can lead to greater contact with the secular culture. However Orthodoxy privileges a good shidduch (match), marrying young and having many children, skillful domesticity and physical appeal while in modest dress–values and expectations that may be felt as paradoxical and impossible to fulfill.

My patient, Elana, struggles with this dilemma. A thirty year old, high powered attorney and mother of 4, she relentlessly strives to meet the demands of her law firm, while also attending to every detail of her children’s lives, preparing large meals for Sabbath company and staying thin and physically desirable. Elana suffers from perfectionism and a belief that she must always be in control. This manifests in her relationship to food—initially Elana restricted herself to eating only “healthy food” but eventually developed full-blown anorexia punctuated by weekly “Sabbath binges.”

Susan, an academically successful seventeen year old, responded to the impossibility of fulfilling both traditional and modern gender roles by silencing herself and protesting against these irreconcilable pressures.  Her anorexia and the related loss of menstruation and fertility were a communication of her failed attempt to live in these incongruous worlds as well as a desperate solution to her problem: In this state, she could not be expected to pursue pre-med at an ivy-league university, while also marrying young and quickly having a large family and home to manage.

Food as a prime medium for acting out

Food plays a prominent and preoccupying role in Orthodox Jewish life because of its link to religious practices and the demands of preparing for and feeding large families. Like other essential elements of Judaism food is layered with contradictions. It is a source of joy, embedded in many familial and communal traditions and rituals such as the Sabbath and holiday meals.  Yet there are many rules surrounding preparing and eating food such as Kashrut (keeping kosher), blessings before and after meals and fast days. Food’s distinct role in the Orthodox Jewish population makes it a prime vehicle for playing out unspoken conflicts and confusion. The religious regulations regarding food that demand strict observance can serve as the scaffolding for the rigidity, control and deprivation that characterize restrictive anorectic eating.

The challenges of separating and staying connected to family

The importance of family is a central and abiding principle. Maintaining the legacy and ties to previous generations is so essential, that observant Jews consider parental disrespect a sin against God. Yet marrying and creating a large family is similarly fundamental to Judaism. The universal challenge to stay connected to one’s original family yet separate so that one can develop a self-identity and create one’s own family may be a source of intensified conflict. This is particularly evident in enmeshed mother-daughter relationships, which are often a hotbed for the development of an eating disorder. 

The eating disorder often communicates the struggle of merger and separation and concretizes the wish for a boundary and demand for control. Jewish educators note that for many teens who spend a gap year abroad studying in Israel the transition and abrupt separation from family for the first time may be mediated by the eating disorder.

The Shidduch may generate body image dissatisfaction

The importance of making a good shidduch shapes the lives of many young women, and creates an indelible timeline. The trend is to date briefly prior to an engagement, quickly marry and then begin having many children. The common underexposure to the opposite sex can, however, create fear and an avoidance of physical intimacy. A resulting eating disorder can function then as a solution to overcoming the conflict regarding physical desire.  

The shidduch process has morphed for some into a shopping expedition with a list of necessary “attributes” and the “shidduch resume” has become a common occurrence. My patient Sarah was therefore nonplussed when Jonathan’s mother asked the matchmaker, what size dress Sarah wore and even “What size does Sarah’s mother wear?” suggesting that anything larger than a size 4 might lower Sarah’s chances to marry her son. The pressure to make a good shidduch, and overvaluing a thin bride can objectify young women and foster body dissatisfaction, that may further the development of an eating disorder.

History of Persecution and Holocaust Trauma

Though sparse research exists exploring the correlation between Holocaust exposure and disordered eating in the Jewish population, particularly among the children and grandchildren of survivors (Zohar, Giladi & Givati, 2007), there are many anecdotal examples and clinical case studies that buttress the link between these two variables (Grubrich-Simitis, 1984; Rabinor, 2002).  

The unfathomable emotional and physical horrors visited on the survivors resulted in their dissociation of experience, where traumatic memories remain incomprehensible — unsymbolized, unspoken and disconnected. The survivor’s inability to develop a coherent narrative, served as fertile ground for intergenerational transmission, and for their offspring’s reenactment, of this trauma history. The transmission may have occurred both through the attachment relationship and parenting as a result of the adaptive strains that accompanied the parents’ survivorship (Kestenberg, 1982,; Bar-On et al., 1998,; Scharf & Mayseless, 2011) as well as through the children’s unconscious identification with the previous generation and their (known or unknown, spoken or unspoken) history (Auerhan & Laub, 1984,; Faimberg, 2005).  Similarly the long-term biochemical shifts resulting from trauma are thought to have been transmitted intergenerationally even at the prenatal stage or during infancy and early childhood when maternal behavior influences a child’s hormonal and metabolic processes (Yehuda & Bierer, 2009).

The unmourned persecutory and Holocaust traumas of previous generations rendered many from subsequent generations affectively dysregulated, psychically concrete, somatically encoded, relationally enmeshed, and unwittingly identified alternately with the helpless victim and/or unmerciful aggressor. These same psychodynamics and vulnerabilities are often identified as facilitating or underlying patterns of disordered eating.  

Affective Dysregulation

A child’s affect tolerance is developed through exposure to the internalization of the parent’s regulatory capacity. The traumatized and affectively dysregulated parent’s inability to organize and contain their child’s affective experience often results in the child’s failure to modulate and express strong affect “[o]ne generation’s trauma leads to the next generation’s lack of affect tolerance” (Wilson, 1985). 

The psychoanalytic literature, which clearly establishes a link between empathic failures and eating disorders (Bromberg 2001; Sands 2003; Ferguson 2011), views the dysregulation of affect as the crucible for the development of disordered eating.  The absence of a self-regulating experience of human relatedness and its potential for reparation results in the individual’s necessary reliance on her own physiological and affective states. The outcome of this protracted self-reliance is the dissociation of psyche from soma, thought to be at the heart of eating problems (Bromberg, 2001; Farber et al., 2007). Where there is inability to self-regulate affect, the eating disorder functions as a self-regulatory Other, as a failed attempt to ward off or control anxiety and as an anesthetic, relieving the patient from her intense and overwhelming feelings. For example, compulsive overeating becomes a way for patients to “stuff down their feeling” while maintaining the imperative for verbal silence (Rashkin, 1999).

Starvation 

Of the entire bodily trauma that Holocaust victims endured, the most ubiquitous was severe starvation. Subsequently, many survivors were preoccupied with food and eating. Their offspring may then unconsciously identify with their ancestors’ previous emaciated condition and enact the same physical and psychic state by starving themselves or by secret binge eating. Additionally, the survivor guilt experienced by those victims who lost family members yet survived may be lived out by the next generation(s) who silently tell this story through their ravaged bodies (Farber et al. 2007; Jackson & Davidson, 1986). Their anorexia, which comprises a “deadened” state, is a compromise formation for the feelings of guilt over being alive. 

The survivors’ history also often included experiences of desperate hiding, of having to either escape or retreat. The symptoms of anorexia can simulate this physical withdrawal. The hiding is enacted through the disappearance and invisibility the anorectic feels as she is shrinking, as well as the way she may conceal her body in baggy clothing. The bulimic or compulsive overeater may similarly obscure her shame and greediness by eating in secrecy and shrouding her unacceptable feelings in the layers of protective fat.

Identification with the Aggressor

Like their earlier ancestors, offspring of survivors often alternately act out the paradox of survivorship (special for surviving yet degraded for being victimized, (Auerhan & Laub, 1984), as well as the oscillating and contradictory self-states of victim and aggressor. The anorectic offspring may play out this history by condensing both sides of this dyadic interaction. Through starvation (or bulimia) the offspring operates self-destructively, being both aggressor and victim to herself, and though she remains alive (survives) despite the starvation, in her profound loss and mourning she is lifeless and dead in life. 

In identifying with the aggressor, the offspring may enact not only the sadism of her ancestors’ persecutors, but also introject their ethnic hatred and anti-Semitism. This is illustrated by the offspring’s (often unconscious) self-hatred of her Jewishness, which among other genetically predisposed traits is stereotypically represented through her “zaftig” Jewish body, which she wishes to control and alter into a thin non-Jewish profile. Moreover, by striving for and achieving perfection, she unconsciously hopes to avoid criticism and anti-Semitism.

Particular issues related to treatment, recovery and prevention

Similar to the disorder, the treatment and recovery process with eating disordered Orthodox Jewish females is both the same and different than it is for the general population. A therapeutic relationship that privileges the patient’s experience of being seen and known (often absent from the young woman’s psychic development) is an essential ingredient to recovery for anyone with an eating disorder (Gorden & Kofman, 2015). Additionally, although important in any treatment regardless of the issue, sensitivity, privacy and trust are particularly critical factors in the treatment of the orthodox eating disordered female. For my patient Rachel they are especially important due to her close (at times intrusive) family ties and the stigma she believes could impact her shidduch potential if her disorder was known.

Accordingly, Rachel initially wanted a therapist outside of the Orthodox community so as to safeguard her privacy. However, she also required someone culturally sensitive, who possessed a solid understanding of the role Orthodox Judaism occupies in her life or at least a therapist with a keen curiosity, respect, and willingness to collaborate with her rabbi or another psychologically minded religious figure. My being culturally informed was subsequently essential in clarifying whether some issue Rachel presented was an expression of a religious imperative or a reflection of the restriction and rigidity of the disorder. Appreciation of the role Judaism played in Rachel’s life likewise allowed me to use and rely on religious values and rituals regarding self-care of the body that were ultimately helpful in furthering Rebecca’s treatment and recovery.

As Jewish Orthodoxy continues to shift to the right, modern technology and globalization is infiltrating and impacting every aspect of daily life. This consequent collision of traditional and modern culture presents young women with irreconcilable demands. Mixed messages regarding body image and gender role expectations have increased women’s conflicts and the desperation of their solutions.

In thinking about prevention, it is important to consider eating disorders in the context of cultural/religious factors, while continuing to look at unique biological and psychological issues. As cultural shifts are clearly beyond our control, it is essential to focus effort on ways to broaden and redefine individual female identity and role expectation. Loosening the shackles of traditional gender roles can contribute to the development of Jewish orthodox women’s positive self-esteem, realistic and healthy body image, and a sense of empowerment. By doing so, we can provide observant Jewish women with greater freedom to access their desire, and make choices about how they want to live.

About the author:Caryn Gorden, Psy. D., is a faculty member and supervisor at the Stephen Mitchell Center for Relational Studies and a visiting faculty member at the Eating Disorder Compulsions & Addictions Service of the William Alanson White Institute. She teaches, lectures and writes about eating disorders in the Orthodox Jewish population and the intergenerational transmission of trauma.

References:

Altmann, E. (2009. June). Food, body image and eating disorders in the Jewish community. Paper presented at Renfrew Center Foundation Conference. 

Auerhan, N. & Laub, D. (1984), Annihilation and restoration. International Review of Psycho-Analysis, 11, 327-344. 

Bar-On, D., Eland, J., Kleber, R. J., Krell, R., Moore, Y., Sagi, A.,  Soriano, E., Suedfeld, P., Van der Velden, P., & Van  Ijzendoorn, M. (1998). Multigenerational perspective on coping with the Holocaust experience: An attachment perspective for understanding the developmental sequelae of trauma across generations. International Journal of Behavioral Development, 22, 315-338.

Bromberg, P. (2001). Treating patients with symptoms and symptoms with patience: reflections on shame, dissociation, and eating disorders. Psychoanalytic Dialogues, 11, 891-912.

Faimberg, H. (2005). The telescoping of generations. New York: Routledge.

Farber, S., Jackson, C., Taabin, J., & Bachar, E. (2007). Psychoanalytic Psychology, 24(2): 289-305.

Ferguson, H., & Mendelsohn, S. (2011). Full of your self: How eating disorder symptoms encode a relational history. International Journal of Psychoanalytic Self Psychology, 6(3), 352-376.

Goldman. D. (2010). As generations speak. Psychoanalytic Psychology, 27, 475-491. 

Gorden, C.; & Kofman, S. (2015).  Body and Soul: Eating Disorders in the Orthodox Jewish Population. In: J. Petrucelli (Ed), Body-States: Interpersonal and Relational Perspectives on the Treatment of Eating Disorders, (pp. 186-204). New York: Routledge.

Grubrich-Simitis, I. (1984). From concretism to metaphor-Thoughts on some theoretical and technical aspects of the psychoanalytic work with children of holocaust survivors. Psychoanalytic Study of the Child, 39, 301-319.

Jackson, C. & Davidson, G. (1986). The anorexic patient as a survivor: The denial of death and death themes in the literature on anorexia nervosa. International Journal of Eating Disorders, 5,821-835.

Kestenberg, J. (1982). A metapsychological assessment based on an analysis of a survivor’s child. In: M. Bergmann & M. Jucovy (Eds), Generations of the Holocaust, (pp. 137-158). New York: Basic Books. 

Rabinor, J. (2002). A starving madness: Tales of hunger, hope and healing in psychotherapy. Carlsbad: Gurze Books.

Rashkin, E. (1999), The haunted child: social catastrophe, phantom transmissions, and the aftermath of collective trauma. The Psychoanalytic Review, 86:433-453.

Sands, S. (2003). The subjugation of the body in eating disorders: A particularly female solution. Psychoanalytic Psychology, 20(1), 103-116. 

Scharf, M. & Mayseless, O. (2011). Disorganizing experiences in second and third generation Holocaust survivors. Qualitative Health Research, 21(11), 1539-1553. 

Wilson, A. (1985). On silence and the Holocaust: A contribution to clinical theory. Psychoanalytic Inquiry, 5, 63-84.

Yehuda, R. & Bierer, L.M. (2009). The relevance of epigenetics to PTSD: implications for the DSM-V. Journal of Traumatic Stress, 22, 427-434.

Zohar, A., Giladi, L. & Givati, T. (2007). Holocaust exposure and disordered eating: a study of multi-generational transmission. European Eating Disorders Review, 15:50-57.