The Left Atrium · De l'Oreille Gauche
CMAJ 1999;161:551-4
Starved for understanding
Wasted: a memoir of anorexia and bulimia
Marya Hornbacher
HarperPerennial, New York; 1999
298 pp. $19 (paper) ISBN 06-093093-4
I read Marya Hornbacher's memoir Wasted at the same time as I read two other books about the lives of women: Margaret Negodaeff-Tomsik's Honour Due and Jenny Walton's Packing for a Woman's Journey. Honour Due is the biography of Dr. Leonora Howard King, a Canadian-born physician who spent 47 years practising medicine in Imperial China in the late 19th and early 20th century and who was the first Western woman to be made a mandarin. Jenny Walton is the pseudonym of Nancy Lindemeyer, the editor of Victoria magazine.
These books tell an interesting tale about this century, especially when read together. Leonora Howard King exemplified the devotion and service that Victorian women strove to achieve in their day-to-day lives. Nancy Lindemeyer's gentle account of a hopeful woman's life is full of the optimism typical of the 1950s and '60s. But there is nothing genteel or gentle about Marya (pronounced Mar-ya, we are reminded) Hornbacher's no-holds-barred account of a young woman's struggle with an eating disorder in the 1980s and '90s. As the 20th century ends, the number of Western women who are dissatisfied with a normal body weight is increasing. And here's a paradox: although the number of anorexic women rises, obesity is also becoming more prevalent. For all the progress made by women in the last hundred years, it would appear that we have also regressed to the point where we cannot even nourish ourselves properly.
Although Hornbacher has written this book for the general reader, there is a great deal that physicians can learn from it. While many physicians may believe that they see few cases of eating disorders in their practices, we are reminded many times that these diagnoses are easy to miss. Even those of us who work with people with eating disorders will regularly be fooled by one ruse or another in a patient's efforts to kill herself by starvation. This entire book is a humbling reminder of our collective inadequacy in the face of this disease.
I found this book a vivid rendering of the intrapsychic changes that occur as an unhappy, unhealthy mind heals. Hornbacher's unremitting honesty makes for compelling reading. Her subject is herself and her self-loathing. Nor do her intimates escape her harsh scrutiny: her parents, psychiatrists, mental health workers, friends and lovers are all dissected. In the end, the reader has to credit all these people and Hornbacher herself with tremendous inner strength. Again, a reminder for physicians: more people than the patient have to change before we can expect to find a solution to an eating disorder.
This is a book that reads more easily in some places than in others. I struggled with some parts of the text while, elsewhere, I couldn't turn the pages fast enough. By the end of the second chapter, I realized that it was not writing style or awkward phrasing that made some parts difficult. They were difficult because I found the subject matter emotionally draining. I suspect that this will be true to some extent for any reader. For this reason, Wasted could be recommended in particular to mental health workers who would like to learn more about their own "blind spots" in treating patients with eating disorders. This book can also help us all to better understand the phenomenon of counter-transference.
I am writing this review at the Eastern Ontario Swimming Association's Long Course Championships. My 14-year-old daughter is competing, and this provides me with a unique opportunity to observe the attitudes of young men and women toward body size. There are few signs of anorexia among these well-muscled young athletes. Nonetheless, recalling Hornbacher's preoccupation with exercise at one point in her illness, I ask my daughter's coach about eating disorders among swimmers. He was once a member of the Canadian swim team. He asks me, "Are you still reading that book?" I have been bringing the book to practice for the past week and it has attracted a lot of attention from the team. These adolescents are familiar with eating disorders and are very willing to share their views. As I listen to them, Hornbacher's warning is in my mind. I wonder if there are any afflicted in the group. As I chat with the coach at warm-up, I realize that Wasted had taught me something no textbook had. I have learned to be extremely careful when assessing appetite and ruling out eating disorders. I have learned that, despite this vigilance, I am bound to miss this diagnosis from time to time.
Leonora Howard King's life story is an inspiring tale of courage; Nancy Lindemeyer's is persistently positive. Marya Hornbacher gives us the insight that will enable us to be both courageous and optimistic.
Gail Beck, MD
Dr. Beck is a psychiatrist practising in Ottawa and is chair of the OMA's Committee on Women's Issues.
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[Contents]
Room for a view
Letters to a claims adjuster
The following is excerpted from a letter sent in response to an insurance company's request for information about a patient who had filed a claim for disability payments. Details have been changed to protect the patient's privacy.
Dear Claims Specialist:
Re: Ms. ——
Your claim no ——
I have been a family physician to Ms. —— since her first pregnancy, ten years ago. She has generally been well. In the second year of our relationship she came for seven one-hour sessions of counselling; our discussions related to her experience of hardship in her earlier life in —— and to the frustrations she was experiencing in her own work as a counsellor. She showed no signs of psychopathology. I believe she benefited from the work we did and proceeded in her life with new enthusiasm and understanding. She had a second child one year ago.
This spring her husband became ill with suspected tuberculosis. Ms. —— brought herself and her children for testing; she and one of her children were found to be converters and began a nine-month course of medication. Her husband was later found also to have lung cancer. He returned to ——, where he died a short time later. Ms. —— travelled to —— for the funeral. On her return to Canada, I was able to confirm that she was in good physical health, in spite of her earlier exposure to tuberculosis.
I last saw Ms. —— six weeks ago, at which time I noted that she was still working out her grief reaction and displaying depressive features. This seems appropriate under the circumstances. She is a single parent of two children, and her health and that of her children has been at risk. It is natural for her to feel depressed, confused, angry and afraid. It is natural for her thoughts to dwell on her health and on her ability to provide for her children. The life she had been building has been grievously distorted, and she is doing the only reasonable thing any mother could do in these circumstances: she is drawing back, allowing herself time to grieve, and making herself a resource and comfort for her children. For her not to take the time to work this through is a direct route to later problems and illness. It is my assessment that she is unable to fulfil the requirements of her job, and that as a major part of her treatment she should be at home.
Ms. —— has not received any psychiatric medication or referral from me. She has a social network in the community, from which she has sought support and understanding. I expect that she will be able to return to work in the New Year.
Please advise if I can provide any clarification or information.
Sincerely,
Russell Springate, MD, CCFP
The following is excerpted from a second, unsolicited letter sent to the insurance company after the patient's claim was turned down.
Dear Claims Specialist :
Re: Ms. ——
Your claim no ——
I am writing to elaborate on the circumstances of Ms. ——'s recent disability. I was surprised to hear that her claim was denied. The major points of contention appear to be that she did not see a psychiatrist, was not placed on psychiatric medication and was not seen by a medical practitioner for ongoing counselling and review. The rationale would seem to be that she did not manifest the typical medical model of illness. Therefore she could not really be sick, and therefore could not really be disabled.
Ms. —— did seek counselling, but it was from friends and family. She managed to put the needs of her family foremost, and held herself together long enough to get to ——, bury her husband, comfort her children and come back home. This did not happen without tears, confusion and sleeplessness. It was not an easy process. She continues to do the emotional work required to process these events. I fail to see how she can provide her own clients with the comfort and guidance required in her own work when she herself is tearful, afraid and confused. Surely the issue here is disability, not illness behaviour. I feel strongly that Ms. —— is unable at this time to meet the demands of her job. I also feel that she has appropriately employed medical and nonmedical help as required. With every due respect for the complex task you do, I believe a review of the decision would best serve all involved in this case.
Thank you for your consideration. Please write or call if I can clarify any points or issues.
Sincerely,
Russell Springate, MD, CCFP
The patient returned to work in due course. No disability payments were awarded.
Russell Springate is a family physician in Toronto.
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[Contents]
One thousand words
"When preparing the formula have everything you require near at hand. It is of the utmost importance that every utensil be scrupulously clean. Wash your hands well before preparing the formula." From E. Couture, Canadian Mother and Child, Ottawa: 1939. p. 130.
(photo: Eugene Michael Finn / National Archives of Canada / PA-163732)
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[Contents]
Lifeworks
Poisoning the well
Recently mounted at Ottawa's SAW Gallery "in support of" the World Conference on Breast Cancer (see page 584 in this issue), the installation A Collective Cleansing by Brooklyn artist Cynthia Cox presents breast cancer not as a discrete pathology but as one symptom of a far-reaching societal malaise. A degradation of human relationships has "inadvertently" resulted, in the artist's view, from the degradation of nature. In this work, breast cancer is not explored as the odyssey of an individual woman, but as a tragic retribution for the failure of modern society to take responsibility for the human and ecological implications of industrialization and consumerist culture.
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The central component of the installation is a 9-minute video interpretation of Aeschylus' The Suppliant Maidens. In the Greek play, the 50 Danaids, daughters of the king of Argos, are punished for the coerced murders of their cousin-husbands by being condemned to pour water endlessly into a broken cistern. In Cox's video, a row of women pour water from jarringly bright plastic buckets into a pool of water. The video is mirrored in a rectangular pool of water installed in front of the screen. The only other light in the main room of the installation comes from strings of tiny white bulbs that illuminate a row of elbow-high shelves along the wall. Here are displayed casts of resected breast and testicular tissue and enlarged transparencies of stained cancer cells.
At one point in the video, the camera zooms in on a bucket that floats unnaturally high in the water, reminding the viewer that the women are engaged in a seemingly hopeless task of restoring a contaminated resource. The women are barebreasted, but any idyllic references are deconstructed: some of the women have undergone radical mastectomy. The artist's statement also points out that "In many parts of the industrialized world, women are advised not to breastfeed as their milk is too toxic." Nonetheless, Cox writes, the "Roman bath" provides a "reflective opportunity": it "stands for the numerous natural elements that we are systematically affecting, and as a metaphor for cleansing."
The combined preoccupations of environmentalism and breast cancer patient advocacy have a potent synergy. Evidence of an association between exposure to environmental toxins and the rising incidence of breast cancer is becoming more alarming. Epidemiologic corroboration aside, one cannot help but reflect that breast cancer more than any other neoplastic illness has metaphoric and mythic resonances capable of evoking a radical response. Despite recent exercises in consciousness-raising in areas such as prostate cancer and childhood leukemia, breast cancer remains the area of oncology capable of generating the greatest political charge.
Anne Marie Todkill
Editor, The Left Atrium
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© 1999 Canadian Medical Association
