Chapter 9

The Pressure To Be Perfect

1. Discuss the impact of group pressure in the development of eating disorders among young women.

by Eric Goodman

Ashley returned for her sophomore year at Miami University in Oxford, Ohio, excited about living off-campus in a group of nine women. They'd rented two adjacent apartments, five girls upstairs, four down, and had planned to do everything together. Two of the women, Jen and Leslie, were Ashley's close friends from high school. They'd met the others freshman year, forging friendships over dining hall meals, hitting the uptown Oxford bars (with fake I.D.'s) and sharing late-night snacks when the bars closed down.

As the year began, the group did almost everything together. Monday nights, they'd catch the bargain movie in town. They spent a weekend in Cincinnati, an hour away, stayed in a hotel and shopped. Wednesday and Thursday nights, they'd gather in the family room of the upstairs apartment (where Ashley lived) and watch Melrose Place and Rescue 911, scarfing bowls of no-fat nacho-cheese-flavored airpopped popcorn.

In most ways, theirs was a typical group of undergraduate women living on their own, but under the surface there was trouble waiting. Ashley, who loved to cook and had hoped the others would take turns in the kitchen, soon realized that food and eating disorders were going to be a problem, just as they had been a terrible problem for her friends in high school. Of the 20 girls she'd hung out with then, 17 had developed eating disorders. One had had two heart attacks.

Leslie, who lived downstairs, had developed anorexia their junior year in high school and bulimia senior year and had gotten help, but freshman year at Miami her problem was so much worse that she had to leave school early and spend part of the summer in a hospital. Supposedly, the therapy had worked. Leslie's parents arrived with her at the beginning of sophomore year and stocked the kitchen. They asked Ashley to try to make sure that Leslie didn't get too stressed out-their euphemism for her eating disorder.

In the first days and weeks of the semester, Ashley found herself bringing up the subject of food avoidance with her friends because she was nervous about what the year might bring. She told stories about her high school friend who had the heart attacks, emphasizing how stupid she thought it was. Everyone agreed it was really stupid, girls doing that. They totally couldn't deal with it either.

In this way, in denial, September slipped by. But by the first Sunday of October-the third time Ashley had cooked lasagna from scratch and the third time almost everyone invited had an excuse for why she couldn't eat ("I had too big a lunch"; "I'll sit with you while you eat") Ashley had to admit the group was in trouble.

To the students who love it, Miami University is sometimes known as J. Crew U. Miami, named after the Miami tribe of Native Americans (and not the city in Florida), is the crown jewel of the Ohio state education system. Medium-size (14,000 undergraduates) and extremely competitive academically, Miami looks and feels like a private university at public university prices. A tradition of academic excellence helps attract a regional student body that is remarkably homogenous: suburban, conservative, upper middle class and 94.3 percent white.

With almost everyone coming from the same background, undergraduates feel enormous pressure to fit in. There's one way to look, one way to be: ultraslim, ultratoned. Women need to dress in clothes that are expensive and coordinated. They should belong to the right sororities and make A's in their classes. (If they're at Miami, they most likely earned A's in high school.) While not all Miami women conform to this image, a remarkable percentage do, and it's an ideal shared at similar schools across the country.

Also shared at schools nationwide is an epidemic of eating disorders. Though shocking to anyone who is not an undergraduate, the scourge is old news to students. At Miami almost every female undergraduate I interviewed said she knew of someone who had died of an eating disorder. Simple bulimia-vomiting after eating-was common; it wasn't even worth mentioning.

I had always believed what I'd read-that eating disorders resulted from individual psychological problems: an unhealthy competition between mother and daughter; a brother treated preferentially; low self-esteem, in all its many permutations, carved on the victim's own body.

But the more students-and experts-I interviewed, the more I was struck by an inconsistency in logic. How could individual psychological problems produce a national epidemic? I had to conclude that at Miami (and by extension at many other universities), many young women with a predisposition to eating disorders (and other habit-forming behaviors) developed them partially, or even primarily, in response to the pressures of their immediate environment.

Julie Campbell-Ruggaard, Ph.D., is a full-time member of the Student Counseling Service at Miami University. In addition to providing individual counseling, she coordinates therapy groups for women with body-image problems and the eating disorders that often ensue. Campbell-Ruggaard estimates that 1,500 of Miami's women undergraduates-about 20 percent-meet official clinical guidelines for eating disorders. Three quarters of those, she estimates, or 15 percent of Miami women, are bulimic: 5 percent are anorexic. In addition, Campbell-Ruggaard believes another 30 to 40 percent of Miami's women show enough symptoms to fit a second, less serious clinical category known as disordered eating, meaning that they overdiet but haven't dropped to 85 percent of normal body weight. Also in this group are women who haven't met the official clinical standard for bulimia: bingeing and purging twice a week for three months.

Campbell-Ruggaard says, "When I make a presentation to a group of women, I no longer ask, `Who knows someone with an eating disorder?' I ask, `Who doesn't? '"

When Ashley tries to figure out what went wrong in her group, she thinks of the diet most of them went on the summer after freshman year. They wanted to lose what's referred to as the freshmen 15: the extra weight many first-year women gain. Ashley's hometown friend Jen, who hadn't gained much weight freshman year, was the most visibly transformed. She'd spent the summer with her parents, worked nine to five, exercised every day after work, then went home to a quiet evening.

"When Jen came back to school, you could fit your finger around her waist," Ashley remembers. "She was a small girl anyway, but everyone went like, `Wow, Jen, you've really lost a lot of weight.'"

"Marian, another roommate, had also lost weight, but she was very insecure and when she heard people saying someone else was really skinny, she became like, `OK I need to work harder so people will start complimenting me.'"

Jen says that as the year got underway, she wasn't consciously aware she'd set off the weight and appearance competition. In high school, after all, she and Ashley had been the good girls, almost the only normal eaters in their group of 20 friends. Back then, she'd been the first to recognize that Leslie was anorexic.

When Leslie became seriously bulimic again in college, Jen felt she couldn't deal with Leslie's problem anymore-perhaps because at Miami, for the first time, she'd began to worry about her own weight and appearance. That was why she'd dieted the summer after freshman year, telling herself that, unlike her friends in high school, she would lose weight healthily.

Returning for sophomore year ten pounds thinner. Jen hoped Leslie would be unaffected; after all, Leslie had been in intensive therapy over the summer. Maybe seeing Jen obsessed with working out and what she ate was just too much for Leslie. Maybe there were other reasons. But within weeks, Jen suspected that Leslie was making herself throw up in the bathroom. Jen told no one.

And who could she have told? Jen says she suspected that Marian, and possibly Carrie, a former cross-country runner and, ironically, a nutrition major, were also making themselves throw up.

Jen recalls, "Everyone would say, `Oh, I look fat,' and change clothes at least ten times before going out for a night."

The most stressful days in their household, Ashley recalls, were when formal dances came around. "Four girls starved themselves so they would fit into smaller dresses. The worst thing you could do was try something on in front of its owner, who wore it all the time, and then say, `Oh, this is too big for me.' "

And then there was the food in the fridge. Except for what Ashley bought, there wasn't a gram of fat in either shared kitchen. Their meals-on-the-run were minimal. Salad with no-fat dressing. Lean cuisine or bagels with melted fat-free cheese, dipped in ketchup. "It was ridiculous. Even if you wanted something that wasn't fat-free, say peanut butter, you wouldn't bring it home. It's not that someone would point or laugh, but there was definitely a group effect," says Jen.

For this group, as for many others, the unspoken eleventh and twelfth commandments became: Thou shalt eat no fat and Thou shalt never admit to enjoying food. According to Charles Murkofsky, M.D., a psychiatrist who runs the Program for Managing Eating Disorders, an innovative outpatient program in New York City, "In an environment with such social pressure to conform, there's an operative ethic that says, `If you need to eat, need to give in to the food, you have failed in some way. Eating is immoral, and you demonstrate your excellence by not giving in.' "

According to Campbell-Ruggaard, women at Miami with eating disorders most frequently major in psychology, exercise science or dietetics, thereby transforming their entire college experience into the study of what they put in their bodies. That was the case with Carrie.

Although no one in the household had known prior to sophomore year, Carrie, too, had struggled with bulimia in high school. As a junior, she says, her developing body upset her. She loved being tall and thin and hated the 20 pounds her changing body added. Several times a week senior year, she'd binge and purge with a teammate. "There was a competition between us, both in athletics and in weight loss. We both wanted to be the number-one runner, wanted to get into the number-one college. It was also real bonding. No one else knew about it. We'd eat a lot together and make ourselves throw-up."

According to Susan Klebanoff, PH.D, a clinical psychologist specializing in the treatment of eating disorders and an associate of the Eating Disorder Resource Center in New York City, "When women binge and purge together, it probably diffuses conscious levels of shame. They tend to think so-and-so is doing it, then it's OK for me. I've treated young dancers from ballet schools who were referred by a teacher when they were too weak to keep up in class. These girls would say to me, `Everyone does this, so why am I here?' "

Senior year in high school, Carrie began having shaking spells during races and learned she'd developed a pituitary imbalance. She stopped bingeing and purging, told herself that her behavior had been just a phase. Six months later, during her first semester at Miami, Carrie discovered what many bulimics do: Bulimia is habit forming and can be obsessive; it's not easy to quit. She began purging again, got caught by a fellow student in one of the dorm bathrooms, felt enormously ashamed, perhaps because she no longer had the sanction of a partner, and switched to abusing laxatives.

The summer after freshman year, Carrie, told her parents about her problem and saw a therapist. But when she returned to Miami, she moved in with the group, and her troubles started all over again.

"I was abusing laxatives again," says Carrie. "The three of us who were bulimic wouldn't talk about it in threes, but sometimes I'd have a conversation with one or the other. If one of us said, `I'm having a really bad day,' that meant you were struggling with thoughts of food. If I was tempted to `be bad,' which meant having a couple of cookies at night, I wouldn't eat them unless someone else was doing it with me."

Even members who didn't struggle with food issues were affected. "It was always tense," Ashley recalls. "Who was working out more? Who was eating less? When I went to the grocery store, I would find myself putting fat-free stuff in my cart, then I'd ask myself, Why? It tasted so bad, I couldn't even stand to look at it, but there it was, in my cart."

According to Devra Braun, M.D., a psychiatrist who is unit chief of the Inpatient Eating Disorders Service for New York Hospital-Cornell Medical Center, Westchester Division, "There are peaks for the onset of eating disorder at ages, 14 and 18, which roughly correspond to a girl's body changing and to the stress of going away to college. The typical pattern is they start out dieting, a very restrictive diet, then one day they can't stand not eating, so they binge-and then purge." 

At Miami, Campbell-Ruggaard reports that most of her clients are sophomores and juniors who have struggled with eating disorder for two to four years before seeking help. "All kinds of reasons bring them in. Heart problems because of anorexia, and/or bulimia. Teeth stained from stomach acid. Burning in their esophagus. For others, it's a sexual experience, wanted or unwanted. A sudden drop in GPA."

Klebanoff compares women who share an eating disorder with each other to a dysfunctional secret society. "Something about sharing secrets bonds people together. Trying to quit threatens the group and is perceived as betrayal."

One client of Campbell-Ruggaard confessed to members of her sorority that she had an eating disorder and that it was an agony for her to attend functions where food was served. Six or seven sorority sisters admitted they'd had the same problem. Their solutions: They would all sit together at functions eating Doritos cheese dip, with the tacit understanding that they'd slip away and purge.

For the most part, Ashley's group didn't discuss the obsession that was consuming them. "It was a taboo issue," she says, "Either the girls didn't want to admit they had a problem or they didn't want to deal with other people's problems. When it was discussed, we were always talking about someone else, hush-hush, behind her back."

Melinda, a 20-year-old junior who's not part of Ashley's group, had a similar experience with women afraid or unable to deal with each other's problems. In high school she was a competitive gymnast and had several friends with eating disorders. "As a gymnast, there was a great deal of pressure to be thin. Gymnast thinks the thinner you are, the higher you jump. One friend would make herself throw up any time she ate until she could no longer control what would make her throw up. One morning she was in the bathroom, brushing her teeth. She started to throw up, but there was no food in her body. She couldn't stop the contraction, and she had a heart attack and died. She was 16."

Even with this horrific firsthand knowledge, Melinda was shocked by what she encountered at Miami freshman year: "I'd say 20 percent of my dormmates had some level of eating disorder. By October, one girl was too weak to walk back from class. We all knew why, but no one talked to her about it. Her parents took her home."

"If you saw someone becoming addicted to a serious drug, you'd know something needed to be done. But purging is so common here, you become inured. You live with girls who are absolutely starving."

Over time, undergraduates who don't have eating disorders grow angry at those that do. Melinda admits, "I'm really annoyed with my friends who say, `That has three grams of fat in it, I won't eat it,' when all they're eating is 500 calories a day. I become so furious I refuse to give them the attention they're looking for."

Campbell-Ruggaard adds that quite a few women come into counseling enraged at roommates with eating disorders because they constantly steal normal eaters' food, then use it to binge and purge. Almost worse than anger are the jokes. One quip that made the rounds last spring: When sororities have events catered, all they really need to order are wooden spoons.

Men tend not to react as directly, or as angrily. Since more than 85 percent of all bulimics and anorexics are women, few men have experienced this problem personally. Nor do they seem inclined to intervene. If their girlfriends are "looking good," most men don't question how they got that way.

Sheila, a first-year Miami student from Wisconsin, had a typical experience. Just five feet tall and a dancer, she battled anorexia and bulimia in high school. While living abroad as an exchange student during her junior year in high school, her weight dropped from 120 to 80 pounds, but she managed to pull out of the cycle and returned home weighing 104 pounds. The first thing her father said when she got off the plane was, "Wow, you look great. Losing that weight helped."

The summer before starting her freshman year at Miami, Sheila was bulimic and using laxatives. She had a new boyfriend, and most nights, after home around midnight, she'd binge and purge, but she was careful to hide it from him. Since most anorexics withdraw socially, stop menstruating and exhibit a diminished sexual drive, it's primarily bulimics who are in an ongoing relationship. All the boyfriend knew was that she'd had a problem in the past.

After two months at Miami, where she'd been hoping to make a new start, Sheila was using laxatives all the time, and her bulimia was worse than ever. She started seeing a therapist and told her boyfriend about her problem. "He was really upset, both that it was still going on and that I'd kept it from him. But the relationship continued."

Why had her bulimia worsened at Miami? Sheila says she was overwhelmed by the Miami image. "Everyone seemed so gorgeous and polished. People were so skinny and perfect-looking, which made me feel all the other parts of their lives were going to be as great as they looked."

"I was depressed, almost embarrassed by the way I looked. First semester my grades were awful, although they had been A's and B's in high school. My grades were too low to rush a sorority, which really disappointed my parents. I didn't want to be here. I didn't want to get out of bed. I was buying laxatives at the supermarket and using them all the time, bingeing in my room and purging several times a week."

As second semester started, Sheila began to consider transferring to a more heterogenous school. One day, she says, while she was walking back to her dorm after her workout, "My hair was falling out of a ponytail, and some girl I didn't know-I didn't even know her!-slowed down in a passing car and yelled out the window, `Fix your hair, bitch!' "

That helped Sheila make up her mind. She decided to transfer.

If eating disorders are more group driven than has been acknowledged, then recovery must take the group into account. At Dr. Murkofsky's Program for Managing Eating Disorders, a key component of treatment is supervised group meals, which are also a feature of inpatient clinics.

According to Dr. Murkofsky, "We feed them regular restaurant food two meals a day, five days a week. Menus change every three weeks, and patients pick their food in advance. We don't do anything that's branded low-fat, not even diet soda. We're trying to help people destigmatize normal food. While eating normally is the most important goal, the bonding that we see around getting well is incredibly intense."

Dr. Murkofsky stresses that before an anorexic or bulimic can recover, the underlying physiological effects of starvation must be overcome. Citing the classic Ansel Keys study from the 1940s, in which 40 conscientious objectors were fed half the normal calories for six months only to develop crippling obsession with food, Dr. Murkofsky points out, "People don't usually start by bingeing and purging; they start by deprivation and starving. The vulnerable then develop bulimia, but it doesn't happen without a context of significant starvation."

Now, think about the extended diets many women subject themselves to. What are they doing but starving themselves? And with starvation comes depression, food obsessions and, for some, eating disorders. To break the pattern, therefore, people need to eat normally.

By November of her sophomore year, Ashley knew she wanted to live in a healthier, less competitive environment as a junior. The group, she believed, needed to be split up, but old loyalties die hard, and there was the rest of the year to get through, with all its focus on fat-free foods and aerobics and those horrible sounds that periodically emanated from behind closed bathroom doors.

After Christmas, Ashley decided she had to try help Leslie. All the special treats that Leslie's parents had brought in September were still in the kitchen cabinet. Ashley talked to Leslie's visiting parents to let them know she was worried about Leslie. "I didn't know what to do anymore. I couldn't babysit her all the time."

Leslie's parents responded, "OK, we'll talk to her," and they did. "They'd call," says Ashley, "and Leslie would say, `I'm OK, everything's fine.'"

"Her mother would send packages every week. Little gifts, like stationery. And she'd send notes. `We love you, don't stress out. You're wonderful. Sit down when you eat. Don't stress out.' "

By spring, in spite of her doubts, Ashley had agreed to live with her two high school friends, Jen and Leslie, the following fall.

Fortunately, things finally improved. Jen reports, "Leslie went for therapy over the summer, and by the beginning of junior year, she seemed to have things under control. Our environment was healthier. We were one year older, one year more secure about being away from home. And in our new place, our housemates were people who didn't have the same problems. That was lucky."

Ashley echoes Jen's assessment. "Our group had a positive attitude, possibly because of one strong housemate. Her sensibility set a positive aura in the house. Yes, she worked out; yes, she ate healthily. But she didn't starve herself and she looked great. The girls still worried about fat-free foods, but no one was making herself throw up. Some of our other roommates from last year, however, ended up in another really competitive household."

And in those households, and in the group culture of Miami and Universities like Miami across the country, there's no escaping the internal whispers. If only you were thin, you'd be happy, sexy, and popular. Thin is beautiful, and there's only one way to look, one way to be.

There's no escaping those voices. They're in the culture all around us. For these women the struggle is to remember that those voices lie.

Reprinted with permission.

Eric Goodman is a novelist, journalist and screenwriter. He teaches creative writing at Miami University in Oxford, Ohio.

This article originally appeared in Glamour.

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