A Longitudinal Study of Eating Disorders among College Women: Factors That Influence

Recovery
Author(s): Sharlene Hesse-Biber, Margaret Marino and Diane Watts-Roy
Source: Gender and Society , Jun., 1999, Vol. 13, No. 3 (Jun., 1999), pp. 385-408
Published by: Sage Publications, Inc.

Stable URL: https://www.jstor.org/stable/190261

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 RESEARCH REPORT

A LONGITUDINAL STUDY
OF EATING DISORDERS
AMONG COLLEGE WOMEN
Factors that Influence Recove

SHARLENE HESSE-BIBER
Boston College
MARGARET MARINO
Northeast Health Systems
DIANE WATTS-ROY
Boston College

This study provides insight into factors that determine whether women in the college population
exhibit eating-disordered behavior during their college years recover during their postcollege y
The study assessed changes in the eating patterns of 21 women across a six-year time period, fr
sophomore year in college to two years postcollege. Eleven of the women get better during theirpostco
lege year, whereas 10 of the women continue to struggle with disordered eating. The major differ
between the two groups revolve around the relationship between autonomy and relation. Women who
better negotiate the tension between autonomy and relatedness and are more likely to have higher
esteem based on a more positive self-concept; this, in turn, leads to healthier relationships withfoo
body image. Two factors that appear to influence this negotiation include (1) one's history of chr
physical or sexual abuse and (2) the quality offamilial messages aboutfood, body image, relationsh
and autonomy.

Eating disorders abound on college campuses. Research studies consisten

reveal that between 4 and 9 percent of female college students meet the criteria
the clinical eating disorders of anorexia nervosa and bulimia (Drewnowski, Y
and Krahn 1988; Pope et al. 1984; Pyle et al. 1991). Furthermore, studies indic
that between 60 and 80 percent of college women engage in regular binge eat
and other abnormal behaviors that fall short of the criteria set by clinical sc
Many college women who are at normal weights continue to express a strong d
to be thinner and to hold beliefs about food and body image that are similar to t

REPRINT REQUESTS: Sharlene Hesse-Biber, Department of Sociology, Boston College, 140 Co

monwealth Avenue, Chestnut Hill, MA 02467-3807.

GENDER & SOCIETY, Vol. 13 No. 3, June 1999 385-408

? 1999 Sociologists for Women in Society

385

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386 GENDER & SOCIETY / June 1999

of women who have actual eating disorders (Gray and Ford 1985; Hesse-Bibe
1989; Zuckerman, Colby, and Ware 1984).
A number of researchers have concluded that instead of viewing eating disord
as a discrete category, anorexia nervosa and bulimia may be the extreme end
continuum of a person's relationship to food and their body (Hart 1985; Hes
Biber 1989; Hsu 1990; Striegel-Moore 1992; Zuckerman, Colby, and Ware 198
At one end of the continuum, individuals express bodily satisfaction and a desire
maintain healthy eating habits. The other extreme is marked by excessive wei
loss and/or cycles of binge eating and purging by fasting, vomiting, laxative abu
diet pills, and excessive exercise. A wide range of attitudes and behaviors relate
food and body image exist in the "gray zone" all along the two ends of the con
uum. Limited research has been done on those in the gray zone or as referred to
Shisslak and Crago (1994), those with "partial syndrome Eds" the population w
exhibits problematic eating patterns that are not severe enough to be classifie
clinical disorders. Yet, as discussed by Lachenmeyer and Muni-Brander (1988
there is a serious need to do more research on this population.
A college campus is an excellent place to learn more about the gray zone of e
ing disorders since eating disturbances and body image distortions are comm
among college women. Many young women arrive at college with a healthy b
image and normal eating habits only to be tipped into the gray zone. Through
research, we explore factors that precipitate the tipping effect that college can h
on women's struggle with their relationship to food and body. Yet, we do not
there. We are also interested in the long-term influence that being in the gray z
during college can have on a woman's postcollege life. What factors influenc
whether women get out of the gray zone and into healthier relationships with fo
and body at least two years after they leave college?
Psychological and sociocultural theories addressing the etiology of disorder
eating abound. Research grounded in a more psychological perspective sugge
that the gray zone exists as a reaction to a range of stressful life events, includin
woman's ambivalent relationship to her mother (Chernin 1985; Orbach 1986; P
and Rodin, 1991) or father (Maine 1991), family dieting and history of obes
(Steiger et al. 1995); the struggle for self-concept (Baird and Sights 1986; Hess
Biber and Marino 1991; Stein 1996; Timko 1987), control issues (Bruch 19
Siegel, Brisman, and Weinshel 1988), a predisposition toward addiction (Woo
man 1982), the need for perfection (Levenkron 1983; Siegel, Brisman, and Wein
1988), and physical and/or sexual trauma (Root 1991; Wooley and Lewis 1988
Research focused on more sociocultural explanations for eating disorders su
gests that eating problems are greatly influenced by the pressures women exp
ence to conform to socially constructed female gender roles that empha
extreme thinness as a symbol of femininity (Bell 1985; Bordo 1988; Boskind
White and White 1983; Brownmiller 1986; Brumberg 1997; Garrett 1994; He
Biber 1996; Wolf 1991; Wooley and Wooley 1980). Furthermore, sociocultura

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 Hesse-Biber et al. / EATING DISORDERS 387

theorists emphasize the variations in disordered eating by class, race, and

as they attempt to understand why anorexia and bulimia are most comm
middle- and upper-class Caucasian populations (Akan and Grilo 19
Shisslak, and Estes 1996; Hesse-Biber 1996; Root 1990; Thompson 1
Research findings suggest that Black women express greater satisfac
their bodies, fewer weight-related concerns, and more positive self-im
compared with Caucasian women (Abrams, Allen, and Gray 1993; Fish
1994; Rucker and Cash 1992) even though on average, Black women and
to weigh more than their Caucasian counterparts (Abrams, Allen, and G
Emmons 1992). Theorists suggest that because Black women are more
about their weight, they are at a decreased risk of anorexia and bulimia
Root 1990; Rucker and Cash 1992). The Black women who are at greate
developing an eating disorder are most often younger and have higher rat
cation (Pumariega et al. 1994) and are more influenced by white, middl
ues (Abrams, Allen, and Gray 1993; Hsu 1987; Rucker and Cash 1992).
Both the psychological and sociocultural perspectives on the gray zone
dered eating and distorted body image provide useful insights to this s
own theoretical perspective draws on both as we explore the influence
concept has on disordered eating and the influence that sociocultural f
on self-concept. According to Erikson (1968), during adolescence, people
construct a more authentic self-concept and identity. A crucial factor in t
opment, as suggested by Erikson (1968) and later explored by Koff an
(1990), involves having a positive body image. Erikson's (1968) work p
that body image affects self-concept. In our research, we will explore
that self-concept has on body image while considering the way that this r
is mediated by and through culture.
For the purposes of this study, self-concept is defined as "the set of b
images we all have and hold to be true of ourselves" (Sanford and Dono
7). When we assess our self-concept positively or negatively, the asses
often referred to as our self-esteem. Self-esteem is "the measure of how much we
like and approve of our self-concept" (Sanford and Donovan 1985, 7). It is "the
level of global regard one has for the self as a person" (Harter 1993, 101). Research
suggests that women who have low self-esteem often have problematic eating pat-
terns and distorted body images (Beren and Chrisler 1990; Brouwers 1988; Hol-
leran, Pascale, and Fraley 1988; Koff and Rierdan 1990; McCanne 1985; Mintz and
Betz 1988; Sanford and Donovan 1985; Segal and Figley 1985).
A person's self-concept is greatly influenced by how well he or she is able to
negotiate the inherent tension between a sense of relationship with other people and
a sense of autonomy from them (Lerner 1988; Prozan 1992; Stern 1991). Psycho-
dynamic theorists (Bruch 1973) assume that the resolution of this conflict rests on a
push toward separation and autonomy, and not relationship. More recent research
on the connection between eating disorders and autonomy confirms this

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388 GENDER & SOCIETY / June 1999

relationship (Beattie 1988; Strauss and Ryan 1987). For example, in a study by
derick and Grow (1996) of 71 college women, problems with autonomy led to b
a reduction in self-esteem and an increase in eating-disordered attitudes an
behaviors.
In contrast, psychoanalytic feminists propose that a healthy self-concept is
based on a pull toward relationship, not autonomy (Chodorow 1978; Gilligan 1982;
Miller 1976). According to Steiner-Adair (1986a, 1986b), adolescent girls are hin-
dered by cultural beliefs that place greater importance on separation and individua-
tion at the expense of relationships. Belenky et al. assert, "It is clear that many more
women than men define themselves in terms of their relationships and connection
to others" (1986, 8).
Our research will explore whether women's self-concepts and, in turn, self-
esteem, are affected by the way they navigate relationship and autonomy in their
own lives. Working within the purview of attachment theory (Ainsworth et al.
1978) and relational theory (Batgos and Leadbeater 1994; Hart and Kenny 1997),
we suggest that strong and stable relationships foster rather than stifle indepen-
dence. Our research will also explore sociocultural factors that influence a
woman's ability to develop "a sense of connectedness to others, balanced by a sense
of our separateness from them" (Sanford and Donovan 1985, 46).
This study is unique in that we consider the longitudinal changes in women with
eating problems to better understand how shifts along the continuum occur over
time. In light of the paucity of longitudinal research with this population of women,
this study follows a group of 21 women who exhibit distorted body images and dis-
ordered eating patterns during their sophomore and senior years in college to better
understand whether eating patterns change for women from college to two years
postgraduation. We are interested in learning more about what happens to women
who experience eating-disordered behavior in college after they leave the college
milieu. Considering the gray zone of disordered eating and distorted body image is
important because it may hold valuable insight into factors involved in the preven-
tion and recovery from eating disorders. Through our research we explore which
lifestyle and developmental factors are associated with recovery and which put
women at continued risk.

METHODOLOGY

Design of the Study and Procedures

The sample was drawn from an original population of 144 wo

pated in a longitudinal study of eating patterns at a private Ne
(Hesse-Biber 1989). The current study consists of data collecte
graduate women. The original population of 144 women complet
during their sophomore and senior years of college. Each o

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 Hesse-Biber et al. / EATING DISORDERS 389

contacted two years after they graduated from college and out of the total s
144 women, 28 agreed to be interviewed. This analysis focuses on the 21
(out of 28) who were in the gray zone during college as opposed to those r
7 who were clinically diagnosed with an eating disorder or who exhibite
pletely healthy relationships to food and body image.
Potential participants were identified by matching their code numbers
original list of names obtained in the initial study. Letters asking for volu
continue a project on eating patterns of alumni were sent out to potential
pants. People who responded were contacted by telephone by the primary
gator. Twenty-one postgraduate women agreed to participate in a confiden
depth interview two years after they graduated from college. The 21 women
analysis, like the original population from which the sample is drawn, sho
siderable homogeneity in terms of demographic data and early family histor
were all Caucasian, middle-class, and of Christian religious background. W
did not specifically ask respondents about their sexual orientation, our in
did touch on issues that involved personal relationships, which all appeare
heterosexual. A majority of their parents (76 percent) were married, 19
were divorced or separated, and one parent was widowed. All of their f
worked full-time outside of the home and a majority (85 percent) of their
did not work outside the home until their children were at least school-age a
then, most maintained part-time jobs or jobs that catered around school da
During the time of the in-depth, postcollege interviews, all of the wom
between 22 and 24 years of age, they were all single, and none of them had
The in-depth interviews were conducted using an interview guide and th
between two and three hours. They covered a wide range of psychological,
mental, developmental, and sociocultural factors. To analyze our qualitativ
we employed grounded theory (Glaser and Strauss 1967) to sort through im
themes and connections in our interviews; we let our data speak to us in an e
generate new theory from our research rather than becoming overly connec
hypothesis testing and replication of past studies.
After the interview the participants answered a short questionnaire. Th
tionnaire enabled us to gather demographic information as well as some of
that help us to rank participants on two different continuum scales that we
measure eating habits-the Eating Habits Scale and the Changes in Eating
Scale. The scales allow us to assess changes in eating patterns across a six-y
period, from the sophomore year in college to two years postcollege. Ea
was designed using a continuum approach. Continuum measures were emp
give a more accurate depiction of eating patterns in a normal population si
concentrate less on ascertaining whether a measure fits a given clinical s
and more on the existing range of attitudes and behaviors.
The first continuum scale, the Eating Habits Scale, is based on a scale cr
Hesse-Biber, Clayton-Matthews, and Downey (1987; Hesse-Biber 1989, 19
consists of five categories: normal eaters, normal dieters, presyndrome, at r

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390 GENDER & SOCIETY / June 1999

problem eaters. Each woman in the study received an eating-habits score th

placed her at one of five points along the continuum from normal to problema
during three different points in time: sophomore year, senior year, and two y
postgraduation. Because we only focus on women in the gray zone, this scal
enabled us to discern between women who had healthy relationships with food (i.
women who never dieted and did not exhibit behaviors or attitudes associated with
an eating disorder) and their body, women in the gray zone, and women with cli
cally diagnosable eating disorders. See Appendix A for a complete overview of
scale.
The second continuum scale, the Changes in Eating Habits Scale, measured
changes in individual eating patterns from the sophomore year to the senior year in
college and from the senior year to two years postgraduation. The Changes in Eat-
ing Habits Scale was designed to be a flexible and inclusive longitudinal measure
that captures the myriad of ways in which women's eating patterns could change.
Each woman received two scores for changes in eating habits: from sophomore-
senior year (time 1) and from senior year-two years postgraduation (time 2). See
Appendix B for a complete overview of this scale.

RESULTS

Using the eating-habits scores and the scores for change in eating ha
explored how eating patterns for women who were consistently in the
during college changed from college to two years postgraduation. We fo
distinct patterns. Eleven women "get better": Disrupted eating patterns
return to normal in the postcollege period, and 10 women "remain
Although their eating habits improved after college, they continue to ex
dencies toward disordered eating and distorted body image.
The "get better" group-Corrine, Polly, Nan, Virginia, Sharon, Patty,
Brooke, Hillary, Gretchen, and Jill (all the names in this study have been c
protect confidentiality)-"get better" from sophomore year in college to
postgraduation. During both their sophomore and senior year, eight wom
group engaged in behaviors associated with category 2 ("presyndrome"
Eating Habits Scale such as binge eating, purging through fasting, use of
and/or excessive exercise. Three women in this group engaged in behavio
ated with category 4 ("at risk") on the Eating Habits Scale, which includ
eating and purging through fasting, use of laxatives, excessive exercise,
and vomiting. By their postcollege years, all of these women had relinquish
behaviors and exhibited healthy attitudes and behaviors toward food a
image; they no longer binged or used any extreme weight loss methods nor
obsess about their body image.
The "remains at risk" group-Tara, Joan, Courtney, Lynn, Becky, Eliz
ence, Tina, Mary, and Rory-"remain at risk" after two years postgrad

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 Hesse-Biber et al. / EATING DISORDERS 391

During both their sophomore and senior years, six women in this group e
behaviors associated with category 3 ("presyndrome") on the Eating Habi
such as binge eating, purging through fasting, use of diet pills, and/or exces
cise. Four women in this group engaged in behaviors associated with categ
risk") on the Eating Habits Scale, which includes binge eating and purging
fasting, use of laxatives, excessive exercise, diet pills, and/or vomiting. Dur
postcollege years they continue to have difficulties with food and body im
Three of the women who get better and four of the women who remai
were at serious risk (category 4 of the Eating Habits Scale) of developing
cally diagnosable eating disorder while in college. Eight of the women wh
ter and six of the women who remain at risk were at moderate risk (category
Eating Habits Scale) while they were in college. On the basis of these data, it
cult to differentiate the women who get better from the women who rema
when considering their scores on the Eating Habits Scale during college
The next section of this article uses information from the postcollege
interviews to gain a better understanding of some of the factors that diffe
the 11 women who get better from the 10 women who remain at risk. W
ticularly interested in exploring whether the agentic and relational aspect
concept and self-esteem differentiate the women who get better from th
who remain at risk.

Self-Concept across Time: Those Who Get Better

A healthy self-concept is based on the ability to successfully negotiat

omy with relationship. An inability to adequately resolve this normative
can lead to low self-esteem or a "disavowal" of the self-a renunciation and devalu-
ing of one's perceptions, abilities, feelings, and needs.
A pattern emerged for the 11 women in the get-better group. In their early devel-
opment, up until the time they left for college, both relational and autonomous vari-
ables were balanced and intact. Women in the get-better group consistently
describe feeling successful in the relational realm as they recount having close rela-
tionships during their high school years, either with their parents, friends, or both.
Examples of this include the following:

Corrine: I was always very close to my family... and I liked to know that my family was
close by ... I liked to know that I could go home when I wanted to.
Virginia: I had basically a lot of friends and your typical best friend and close-knit groups.

Individuals in the get-better group also describe success in the autonomous realm as
they discuss their academic and athletic successes:

Hillary: In high school I was very athletic. Three sports every year: swim, play basketball,
and then track-for four years. I excelled in swimming.

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392 GENDER & SOCIETY / June 1999

Patty: I always did well... I used to get straight As all the time. In grammar school I got
straight As all the time. In high school I was always on the Dean's List.

In college this balance gets upended for the get-better group. Disruptions oc-
curred in the more autonomous aspects of their lives. All of the women in the get-
better group report feeling less academically or athletically accomplished during
their college years. They report feeling as if "they could not compete" like they
could in high school. They also describe some confusion and discomfort about aca-
demic decisions that they had to make. Examples of this disruption include the
following:

Jill: Sophomore year was a really hard time for me for making decisions, like what I
wanted to major in, and I felt like the world would end if I didn't make the right
decision.
Patty: I didn't work my freshman year. I hated it because I was flunking. I wasn't pre-
pared. I did not have the proper study habits when I came here. And I had nobody to
teach me the proper study habits. The first couple of things I got a zero.
Brooke: In college I don't think I felt up to par. I sort of looked around at people and how
much better they were than I was.... It just seemed that everybody was on the ball at
school. I didn't feel that I was anything really special.

However, as a group, many of the relational aspects of their lives remained

intact. They quickly "fit in" and maintained satisfying friendships with both sexes.
As stated by two respondents:

Sharon: I regard college as four of the best years. I made the best friends and had the most
fun really.
Polly: I wasn't homesick at all. The new experiences and meeting new people and every-
thing just kept me so busy and interested in things that I didn't have time to get
homesick.

By the time the get-better group leaves college they had developed healthier means
of coping with the difficulties in their lives. By two years postcollege all of the
women worked in professional capacities and reported career stability and
satisfaction.

Sharon: I'd say right now I'm about the happiest personally in my life than I have been in a
long time. I feel like everything has kind of clicked and I've hit my stride. I'm getting
ready to go back to school and teaching . . . and I'm really looking forward to
that... it's turned out really excellent. This is going to be the start of my third year and
I really love it.
Virginia: I am a pediatric nurse. I love children and I've always wanted to do that.... The
next thing I want to do is work in the neonatal intensive care unit.
Monique: I'm a little more confident now ... I want to get my MBA. I would like to
advance where I work. I just got a review and hopefully I'm getting a promotion which
will give me more responsibility here which I would really like.

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 Hesse-Biber et al. / EATING DISORDERS 393

In addition, the relational aspects of their lives continue to remain intac

all described having satisfying friendships, intimate relationships with m
were in the process of renegotiating more reciprocal relationships with th
ents. As stated by two respondents:

Sharon: I've gotten used to the new relationships I have with my friends now. It
much that I miss the intense ones ... because we are still really good friends
come to accept the new phase we've entered in our lives.
Brooke: I write a lot to my friends in school and call them. And I enjoy them on th
because I really like Boston and the people that I have here because these frie
have been for years and are really close.

Self-Concept across Time: Those Who Remain at Risk

A different pattern emerges for the remains-at-risk group. Like the ge

group, in early development the women in the remains-at-risk group report
experiences in the autonomous realm as they describe academic and athlet
cess. Examples of this include the following:

Tara: I would say that I was a good student. I was a studier. I almost resent how
studied. I would study continuously.... Morning, noon, and night. That w
priority.
Joan: I was a good student, very good student, I would say. I did well. I enjoyed school for
the most part.... Sports were important to me. I liked doing sports.
Eliza: I was smart and I was the brightest one in the class, all the teachers' pet.
Florence: I played a lot of tennis ... and then studying because I did pretty well in high
school.
Mary: All the way up to college I got straight As. Because of that I was always ostracized.
Not only was I the fat kid but I was the smart kid too. Nobody wanted to be around me.
I had glasses. All the things that you don't have when you are that age.

However, in contrast to the get-better group, the remains-at-risk group describes

tension in the relational aspects of their lives during their high school years. They
describe feelings of isolation and discontentment with their relationships with fam-
ily and friends, as expressed in the three following quotes:

Courtney: I always never fit in because I felt it took me a long time to develop a good
friendship... I thought that kids were mean to each other growing up. It's just tough
years. I didn't enjoy those at all.
Eliza: It seems as if I didn't have that many friends. A lot of people thought I was snobbish
and I could understand that. I knew I was shy. I was more to myself.
Florence: I didn't have a close girlfriend and I wasn't very close to my sisters and broth-
ers. I was sort of a loner type, outgoing but yet not close... I had a few close friends. I
never dated or anything. So it was really difficult to see all the other girls have friends
as boys and I had a really hard time with that.

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394 GENDER & SOCIETY / June 1999

In college, the remains-at-risk group reports disruptions in both autonomous

functioning and relational abilities. Like the get-better group, all of the remains-at-
risk group felt less academically and/or athletically accomplished. Three women
provide clear examples:

Rory: Well I wanted to be a doctor. Freshman year they threw chemistry, biology, and cal-
culus class at you. It was so competitive that I didn't do well, so I thought, this isn't for
me.

Tara: Academically I thought college was very hard. I remember going to

lab-Three 3-hour labs. It was a big commitment.
Florence: College, I had a hard time with it. I was always a perfectionist... I alw
to do better than what I can do. I always want the 100 and everything always h
perfect so to speak.

In addition, a variety of relational factors were reported as problematic. M

the women in this group reported not having satisfying friendships, not "fi
and dating less. Expressing her difficulty in making friends, one respondent

Becky: I would love to have some outgoing, pretty friends but I never had that. T
always very average... But they never went out. I was thankful for every party
go to. I didn't dare go alone. I didn't know how to make other friends.

Unlike the get-better group, these women reported that throughout thei
years, they were isolated from meaningful relationships. Many experien
mendous ambivalence about separating from their families. As stated b
women:

Joan: This emotional side was really overriding... I didn't know what wa
like someone was pulling the rug from under me. My family was the bas
tion, and it was like they were pulling that rug from under me.
Mary: My parents were telling me I had to go away to school. And I said, "
go," because I was scared. There was so much. I just felt in the middle of

In the postcollege period, the sense of disharmony in relational a

realms continues. Unlike the get-better group, these women report
flict in their parental relationships as well as dissatisfaction with frie
timate relationships with men. Examples of this pattern include th

Becky: There is a part of me that would love to find something to do h

much going on around here, but I won't do it alone and there is no one
don't have any friends... I'm really insecure... I feel like I'm a total lo
talk to anyone. And I know I'm more boring because of it.
Eliza: People like me but I don't think they'd like me if they really got
the outside I get along with everyone at work and even my own friends,

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 Hesse-Biber et al. / EATING DISORDERS 395

with me when we're going to go out and have a drink and have fun... I don't think they
would like to spend some time with me because I am boring.
Rory: You go to a bar and there are men there.... And you just don't date. It's just ver
hard. And the type of guys you meet in bars are not the type you want to associate with

Dissatisfaction was also reported in the autonomous realm. Half of this group
worked temporary jobs and the other half was not yet in their chosen careers. Lack
ing meaningful and stable employment, many reported feeling unsettled and
chaotic:

Courtney: I'm really depressed and I'm working as a temp and I'm working in secretary
positions. And I feel like the rest of my life I am going to be a secretary. Loser!
Joan: When you graduate, you're kind of thrown out into a void and you had to sink or
swim. It was a tough transition for me.... What I wanted to do with my life, that was
always a big thing. I haven't been happy with any of my jobs.
Tara: I haven't gotten used to working ... I haven't beaten the system yet. I think I will
eventually figure out some routine. There is no routine in my life right now, at all.
None... so it's really hard for me to plan anything.... In my life right now, I'm trying
to get my feet on the ground.
Rory: I don't want to stay at my job. Probably in June I'll start looking for another job. I
thought about going back to school and becoming a teacher. I think I should have done
that in the beginning but I am not really sure.

Although the get-better group was able to strike a balance in their postcollege
years between important relationships in their lives and their own independence,
the women in the remains-at-risk group had greater difficulty with this task. This
central difference is exemplified in their responses to the question: "Now that you
have left college, what do you value for yourself?" In their words, the women re-
vealed a final confirmation of a theme that had been present since childhood: The
women who more quickly learned the task of feeding themselves had evolved in
their capacity to value both relationships as well as independence. All of the women
in the get-better group emphasized the importance of both relationships and career
satisfaction, attachment, and autonomy. As stated by one woman:

Brooke: I value being intelligent in a certain area and knowing what I am doing. But as a
female I really enjoy having a relationship and being able to share things.... The com-
bination is pretty nice.

On the other hand, when the women who remain at risk answered the same ques-
tion, a majority of the women said that they valued independence over relationship:

Tara: I'll take care of myself, not the whole world.

Florence: I count on myself and I don't have to worry about anyone else. And that is the
way I like it.

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396 GENDER & SOCIETY / June 1999

Courtney: I always wanted to go out on my own. My mother wanted to do things f

me... I kind of broke away from that... I am a very independent person. I don't li
having roommates. I like to do things on my own. It's on my own terms and not som
one else's.

Lynn: Right at this very moment I concentrate on my job more than anything else.
Because that is really it for right now.

For the remains-at-risk group, independence was often valued at the expense of
relationship. This difference between the get-better and the remains-at-risk group
reiterates a consistent theme: When relationships are integrated with agentic activi-
ties, there was less difficulty with disordered eating and body image.
It appears then, that for the remains-at-risk group, an early disruption between
relational and autonomous functioning continues from childhood throughout the
postcollege period. For the get-better group, the disruption in this delicate balance
appears most prominent at only one time period, the college years.
When asked to describe their overall opinion of themselves, there are stark con-
trasts between the two groups. This disruption in the negotiation of agency and rela-
tionship affects the women's feelings about their self-concept-their self-esteem.
During their postcollege years, women in the remains-at-risk group express
extreme self-doubt and a diminished self-esteem with regard to their ability to con-
tend with both autonomous and relational aspects of their lives. They feel unsettled,
anxious, and insecure and they tend to describe themselves as people who worry
excessively. Several examples illustrate this pattern:

Joan: Probably what disappoints me about myself is my lack of self-confidence. And an

inability sometimes to really tell my friends what I think without worrying about what
they are going to think because I say what I say ... I am a big worrier.
Florence: I worry about time, like getting things done on time or being on time. When I'm
late, it gets me very tense. I am concerned about things happening in my life.
Becky: I'm really insecure. I'm like two different people... I feel like I am a total loser
and I won't talk to anyone.

In contrast, women in the get-better group express a distinct sense of confidence

in their own ability to make good decisions about the autonomous aspects of their
lives and they worry less about the repercussions of their career choices. As stated
by a number of respondents:

Patty: I used to be a worrier but I don't think I am anymore. I've seen so many things that I
used to worry about and I've just adjusted to it.
Jill: I am less of a worrier now, thank God... I think I'm confident, more confident than I
ever was... I'm someone who likes who I've become. I am just happy with myself.
I like the person that I am. I think I'm a nice person. Of course I notice my flaws but I
think I'm a decent human being.
Monique: I am more settled with my life... I am a little more confident now... I'm more
open now and more accepting of myself now too.

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 Hesse-Biber et al. / EATING DISORDERS 397

Brooke: I find myself to be a sincere person, open and honest and happy with w
now... I feel like things are really going my way. I feel that way and I'm h
where I'm at.

Two factors may provide insight into why the women in the get-better group when
compared with the remains-at-risk group are more able to negotiate their indepen-
dence and their relationships thereby maintaining a higher self-esteem.

Autonomy and Relationship: Factors Influencing the Balance

Through using our grounded theory methodology on the interview, we found

two factors that seemed to significantly influence a woman's ability to deal with
tension between autonomy and relationship: sexual assault and familial message.

Sexual assault. The first risk factor involves the incidence of physical and sexual
trauma among the women in the study. Within the get-better group, three women
reported a single episode of sexual assault in college. They reported being sexually
assaulted by a male acquaintance and in two of these cases the women were able to
intervene in the assaults by calling for nearby help. Four women who remain at risk
reported experiencing traumatic sexual and/or physical abuse by boyfriends, rela-
tives, and physicians. In contrast to the get-better group, the women who remain at
risk experienced more unresolved issues with regard to the type of physical and/or
sexual assault they endured.
In the remains-at-risk group, the assaults were more chronic. Two women stated
that the abuse began in childhood. One woman reported being physically abused by
her doctor during a four-year time period. Two other women reported repeated sex-
ual and physical assaults by a man they were in an ongoing relationship with while
they were in college, and one woman reported being sexually abused by both her
father and her boyfriend.
There were some similarities for both groups. In all cases, the attackers were
adult males and their attackers were known to them. But there were important
differences. Having a history of being assaulted did not differentiate the women
who get better from those that remain at risk. However, the nature of the assault
as well as how it was processed did differentiate the groups. While the women in
the get-better group experienced one discrete episode, the women in the
remains-at-risk group experienced chronic assaults within the context of an
ongoing relationship.
Given that the nature of the assaults was somewhat different, it is not surprising
that the groups were differentiated by the way the women processed the attacks. By
the time of the research interview, the get-better group appeared to have more reso-
lution around the event. The women who were assaulted in the get-better group
were clear in their attribution of blame; it was not their fault.

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398 GENDER & SOCIETY / June 1999

Brooke: He was really pushy and I really resented it... he thought that I was going to have
sex with him and I was very shocked. I was in my house and my family was here and it
was a very easy situation to get out off. He was just a very pushy person.
Hillary: You could say he was trying to rape me, but I managed to get away from him... I
was like, "Get out of my room." One of my residents called the police on him because
he was making so much noise.

In addition, for the women in the get-better group, the assaults were not kept a
secret. Each woman told at least one other person about the attack shortly thereafter
One woman in this group describes the steps she took to change her behavior in or-
der to increase her own safety:

Polly: I just don't go off with three strangers late at night anymore. And I don't get drunk
That's the thing. [I] don't get real drunk in public. If I get real drunk now, I go home.

It appears that the women in the get-better group do not blame themselves for the
violations they endured. This level of resolution did not appear to be present for th
women who were assaulted in the remains-at-risk group. For them, despite th
detailed accounts of the assaults, there seemed to be a pervasive "cloud" about
whether the attacks constituted abuse. One woman notes, "Sometimes I think I am
wrong about it. Maybe he didn't molest me." They also voiced a sense of confusio
about their own culpability in the events:

Eliza: He got very violent... I told him to go away but he wouldn't.... But it was my
apartment. I did go with him. He had done it before ... so maybe I was to blame in
some ways?
Mary: He [boyfriend] would pressure me to do things that I didn't want to do. He was
really very sexually abusive. I didn't know that then. There were things I just said,
"no" and there were other things that I said, "I'll go along with it," and then afterwards
I would just feel awful.

And unlike the women in the get-better group, the women in this group did not have
any support system to cope with their pain.

Eliza: Well it is not a thing you discuss, especially if you have a family.... They would
have pulled me right out of school and locked me in my room for life.
Mary: He [father] would always want me to come downstairs with him and watch TV and
lay on the couch with him. And I would do that and he would touch me all over. I just
didn't understand ... we told her [mother] about it before we told my grandmother.
She just couldn't deal with anything at the time.
Becky: If I told (my mother) that I think I was molested, she'd say, "Oh, come on." She
wouldn't believe me. She'd say, "What did you do to earn it?"
Courtney: I never said anything to anyone about it. It was a bad experience when I got him
out, you know. And I just kept quiet about it... I just never said anything because I
didn't want to cause an issue.... I just didn't want to tell anyone because I don't know
how I would have confronted it or dealt with it.

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 Hesse-Biber et al. / EATING DISORDERS 399

At the time of the research interview, women in the remains-at-risk grou

were assaulted appeared to have less resolution about the trauma. As stated
woman, "I know that all this stuff affected me a lot.... As a matter of fact...
was a senior in high school I started having anxiety attacks .... I think it h
with that."

Familial messages. The second risk factor involves the messages that the
received from their parents and siblings. A number of the women in the sti
group described the ways that, while growing up, their families exhibited
emphasis on physical appearance with particular concern for the impor
being thin. Examples of the tension sparked by this emphasis on physical
ance include the following:

Joan: My brothers and sisters would go around and make pig noises.... My da
say, "You need to lose weight." And I'd try and I'd be successful.
Becky: My brothers would mention to my mother and she would say, "Tommy thi
are getting fat" and then she'd say, "Maybe you should stop eating so much." He [
commented a lot. Never bad. Always good. He'd say, "You look good, you lost w
He was always commenting on pretty young girls. So I knew it was important
that I look good too. I wanted him to see that I could be as pretty as all the girls
commenting on. I wanted him to be proud of me for that, and I knew he was
Eliza: She [mother] was very critical. I was always the fat one and she was the t
She always made sarcastic remarks. You know, just something like, "You bette
what you eat. You're going to get fat. You look chunky there." She said, "thin
all my life.... That I have the fattest thighs in the world. I'm the fat one. I'm
daughter.
Florence: I was sitting at the table and he [father] would just turn to one of the girls... and
he would say, "You're getting a little fat belly."
Mary: My dad used to call me fat. I wouldn't have noticed on my own... I was three years
old when my dad was calling me fat.

In contrast, all of the women in the get-better group reported that their parents never
placed emphasis on issues concerning weight and/or appearance.
Parents of all the women sent very clear messages about the appropriate negotia-
tion between autonomy and relation. In the get-better group, women often viewed
their mothers as people who valued both their primary role as caretaker and their
special strength or competence beyond their role as nurturer. For some women this
came from seeing their mothers work outside the home. For others, it had to do with
her personal qualities that went beyond traditional expectations for women. In
short, their mothers were seen as people who were competent and who affirmed
multiple roles for women. When asked what was important to her mother, one
respondent described the following:

Sharon: Her children. Her house in the suburbs and her husband and stuff... her inde-
pendence, her ability to stand on her own and make her own decisions.

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400 GENDER & SOCIETY / June 1999

The mothers of the women in the get-better group affirmed these multiple roles
their daughters. When the women were asked, "What does your mother value
you?" the mothers in this group were seen to be self-actualizing and affirmi
Their mothers wanted them to "be all you can be," without losing sight of relatio
ships. Mothers of the get-better group were seen as extremely supportive of t
daughters' aspirations. The women described what their mothers want for them
the following manner:

Patty: Basically, whatever I wanted for myself... she always trusted my instincts.
Corrine: She never had anything against what I did. She always wanted what I wanted f
me.

Monique: She was always trying to instill in us we could do anything we wanted. She
would support anything we wanted.
Jill: She wants me to be happy. She wants me to live my life according to how I want to
and I think she wants to help me get as many opportunities to fulfill my dreams.

The women who remain at risk received different messages from their mothers.
There was considerable conflict between what their mothers valued for themselves
and their daughters. The mothers consistently tended to value relationship for
themselves. When asked about what their mother valued for herself, a number of
women stated,

Mary: She was a people pleaser and I think the only thing she probably valued was how
she always did things for other people.
Joan: Her role as mother. Her six kids is what she valued most and probably still does
value most, her contribution to our nurturing.
Courtney: She valued just the family. I think that was important. Living in this family
tradition...

Despite valuing relationship for themselves, the women in the remains-at-risk

group suggest that their mothers tended to value autonomy for their daughters.
When asked, "What do you think your mother values for you?" two of the women
stated,

Florence: That I be independent. That I get an education. That was probably the number
one priority, that I get an education and I go to college.
Tina: She wanted me to... be successful. She didn't go to college so she wanted me to go
to college.

Mothers of those in the get-better group taught their daughters positive self-
regard by valuing both their achievements and their relational abilities. The women
in the remains-at-risk group received more mixed messages about relation and
autonomy from their mothers; in turn, they experienced greater role conflict in this
realm.

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 Hesse-Biber et al. / EATING DISORDERS 401

Fathers also had an important influence in respondents' developing sense of

Women in the remains-at-risk group described their relationships with their
in more problematic terms. A number of women in this group described their
as being emotionally or physically absent from their lives. Two women de
their fathers in the following manner:

Lynn: Removed. Not as involved in the day-to-day things that are always there. Th
way he is... He is much more self-concerned ... I guess I would have wante
time from him ... I would have wanted it to be better than it was and in more abun-
dance ... I hardly feel that he was overly concerned about me deeply.... He was sort
of surfacely interested in things.
Florence: If I have a problem I would never go to my father.... He aggravates me a lot.
He's one of those people that when he knows you are tired and cranky, he tries to
annoy you even worse.... The only time basically he would talk to us if he was upset
with us.

For these women, their father's absence was not a benign event. He was missed.
And as mentioned earlier, two women in the group were physically and emotionally
betrayed by their fathers.
For the women who get better, their relationship with their fathers is seen to be
similar to their relationship with their mothers in that their achievements and rela-
tional abilities were positively affirmed. As stated by two women when asked,
"What does your father value for you?":

Brooke: To do well in my work. He's very curious to what I do in school, how people view
me, am I happy there, and am I doing a good job. And also in my future that I have a
stable life. He's always talking about the future and how it will be when I am married
and things like that.
Jill: He wants me to get married [and] he wants me to be successful. He feels I have all of
the brains in my family.

DISCUSSION

The data on eating patterns of the women from this study were cons
the literature in a number of ways. The onset of eating problems has b
mented. Eating problems often begin in adolescence (Drewnowski, Ye
1988; Pyle et al. 1991; Stein 1996; Striegel-Moore, Silbertein, and R
and the first years of college represent a time of particular stress. The
this study support the existence of a continuum of eating problem
women as has been documented elsewhere (Hart 1985; Hesse-Biber 1989;
Striegel-Moore, Silbertein, and Rodin 1986).
Furthermore, there is a consistency in the literature on longitudinal changes in
eating patterns. Although there is no other existing research that has looked

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402 GENDER & SOCIETY / June 1999

specifically at how women in the gray zone during college change once they le
the college environment, in this study, as well as in three other follow-up stu
(Drewnowski, Yee, and Krahn 1988; Hesse-Biber 1989; Norman and Herz
1986), some women get better and others continue to have problems with food an
body image.
This study adds to the literature on eating patterns by documenting the existence
of a continuum across a six-year time period. Specifically, this continuum is main-
tained beyond the college years, at least for eating problems in the gray zone. Previ-
ous longitudinal research has used only dichotomous scales in assessing eating
problems, thus subtle changes in eating patterns in studies using these instruments
may become obscured (Drewnowski, Yee, and Krahn 1988; Norman and Herzog
1986).
Theories proposing the connection between eating problems and the need for
relationship and autonomy are often predicated on an either/or model; that is, either
relationship or autonomy is crucial. Our own theoretical orientation, based on the
voices of the women in this study, supports the findings of relational theorists who
suggest that relationship and autonomy are intricately connected. Our data reveal
that theoretical explanations predicated on this either/or approach tell half of the
story. Relationship and autonomy do not exist in dualism. They have a dialectical
and interdependent relationship with each other. Both relational abilities and agen-
tic qualities were critical to a positive self-concept. As stated by Jacobs, "Good-quality
attachments to others not only do not prevent autonomy, they facilitate it... such
attachments enhance rather than detract from self-determination" (1993, 20).
Through our research, we found that women who had improved eating patterns
appreciated and to some extent achieved a balance between their relational and
autonomous needs. It is evident that academic and career achievement in conjunc-
tion with valued social relationships need to exist in a delicate balance with each
other to promote positive self-concepts. Positive self-concepts lead to higher self-
esteem and healthy lifestyle behaviors. Our study reveals that by two years post-
graduation, the get-better group compared with those who remain at risk had a
much stronger sense of self-confidence and self-esteem, and as discussed in the
beginning of the article, self-esteem is essentially a person's positive or negative
assessment of her self-concept. Women in the remains-at-risk group tended to
express far more insecurities.
In considering factors that may affect a person's self-concept, we found two
important differences between the get-better group and the remains-at-risk group
which involve familial reactions toward body image and independence and relation
and incidence of sexual assault. With regard to familial relations, women in the
get-better group tended to appreciate the need for both the relational and the agentic
because they have access to people who role modeled this for them. It was the
women in this group who had fathers who, like their mothers, were seen to be posi-
tive and affirming of their whole selves. Many of the women in the remains-at-risk
group did not have fathers who were positively accessible to them. Instead of an
affirming male presence, they were often left with either a blank space because of

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 Hesse-Biber et al. / EATING DISORDERS 403

his absence or a deep negative trace of bodily shame because of this. Furth
this research supports other studies that suggest that women who are raised
lies that are hypercritical of weight issues are more likely to experience di
eating patterns (Keel et al. 1997; Moreno and Thelen 1993; Pike and Rodi
Our findings also support research that suggests that teasing about weight an
image during early childhood can have a detrimental impact on an indiv
body image in later life (Fabian and Thompson 1989). The women in thi
remind us that intrapsychic explanations that are predicated solely on m
daughter relationships do not suffice as an explanation for their experien
porting the existing research that emphasizes the importance of father-d
relationships in adolescent development (Benjamin 1991; Brown 1990
1991; Phare 1992), the women in this study were clear that their fathers w
important in their lives.
Using a psychodynamic lens, alongside Chodorow, Gilligan, and Miller
focus on the mother-daughter relationship, we need to incorporate theor
address the significance that the entire family milieu has in female develo
Perhaps women in the get-better group are describing what Chodorow an
min have proposed as an "ideal resolution": Using Benjamin's (1991) word
the mother and the father represent agents of desire for their children. Usi
dorow's (1978) words: Men need to be involved in child care and women, i
tion to child care, need to have "spheres of legitimate control."
Finally, the women in this study remind us that we cannot forget that dif
with self-concept also come from the culture. It is not enough to say that in
chic conflict generates an eating problem. The balance or imbalance tha
between relationship and autonomy cannot be solely attributed to an intra
process with one's mother and father. Cultural messages about womanh
victimization that include physical and sexual assault can add to the denigr
self-concept. What appears to be emerging, at least from these data, is th
trauma occurred for several women in the get-better group, it appeared to
temporarily contribute to the continuation of an eating problem. For the
who were chronically assaulted, the attacks only complicated an already e
difficulty in negotiating the delicate balance of trusting in relationships a
their ability to act on their own behalf.
This study confirms the existing research that suggests a link between eat
orders and sexual trauma (Fullerton, Wonderlich, and Gosnell 1995; Herzo
1993; Waller 1993) and it raises important questions regarding the relat
between sexual trauma and disordered eating. It was the processing of the ev
meaning attributed to it, that ultimately differentiated the groups. Beckm
Burns (1990) and Sloan and Leichner (1986), studying eating disorders an
trauma, came to a similar conclusion: The characteristics of the abuse, the
tion of control, degree of sexual contact, appraisal of the meaning of the
were seen to mediate the outcome.
Future research would do well to study other racial, economic, and religious
groups. Methodologically, it would be advantageous to repeat this study at critical

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404 GENDER & SOCIETY / June 1999

points in an individual's development, incorporating information from significan

family members and friends, as opposed to the retrospective data collection
employed through the vantage point of one individual.

APPENDIX A
Eating Habits Scale

Category 1 Ideal eaters: never dieted, binged, fasted, used diet pills, diuretics, vomi
used laxatives to lose weight
Category 2 Normal dieters: women who have dieted but have never fasted, binge
diet pills, vomited, or used laxatives to lose weight
Category 3 Presyndrome: women who have binged and have then used more ex
methods of dieting, such as diet pills, fasting, or overexercise, but they
never purged through vomiting or laxative abuse and have little concern
this behavior
Category 4 At risk: women who have binged and have then taken laxatives, vo
and/or have demonstrated more severe behaviors for more than a year
express some concern over this behavior
Category 5 Problem eaters: women who meet the clinical criteria for anorexia nerv
bulimia nervosa.

APPENDIX B
Changes in Eating Habits Scale

Category 1 Remains in normal range: people who were in category 1 and 2 and r
in category 1 and 2
Category 2 Gets better: people who were in category 3,4, or 5, and become catego
Category 3 Still at risk: people who were in category 3, 4, or 5, and remained in 3, 4
were in category 4 or 5 and became category 4
Category 4 Increasingly abnormal: people who were in category 1 or 2 and bec
gory 3 or 4 or were category 3 and became category 4
Category 5 Becomes or remains abnormal: people who were in category 1,2, 3, 4,
became or remained in category 5.

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408 GENDER & SOCIETY / June 1999

Sharlene Hesse-Biber is a professor of sociology at Boston College. She is the director of th

tional Association of Women in Catholic Higher Education (NAWCHE). She is author of A
Thin Enough Yet? The Cult of Thinness and the Commercialization of Identity (Oxford Un
sity Press, 1996). She is coeditor of Feminist Approaches to Theory and Methodology (O
University Press, 1999) and coauthor of A Study of Working Women in America: Split D
(Oxford University Press, 2000). She has published widely in the area of women's studies,
cially the impact of socioculturalfactors on women's body image.

Margaret Marino has worked in thefield of eating disordersfor the past 20 years. Currently,
directs the Eating Disorders Programfor Northeast Health Systems. In addition, she is con
ing to investigate the long-term outcome of people with eating disorders at Harvard M
School. This article is partly based on her dissertation, completed in 1989 at Boston Coll

Diane Watts-Roy completed her doctoral course work in sociology at Boston Colleg
received herMA in sociologyfrom the College of William & Mary. She has a long-standing
est in research on body image and disordered eating. Her other research interests include
cal sociology and gerontology. She recently coedited The Generational Equity Debate,
lished in April.

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