Al-Ahram Weekly 30 Sep. - 6 Oct. 1999 Issue No. 449
Published in Cairo by AL-AHRAM established in 1875

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Shattered visions Most people believe eating disorders plague only affluent societies. Most people are wrong. Yasmine El-Rashidi discovers a subculture with its own terrifying rules

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It started as a little game they decided to play -- just for a month, to see who would win. They thought it would be cool and easy -- a change and a challenge. It seemed perfect, for a while.

But the month turned into two, then three, then four. And now, 10 years later, the game is still going on. Only now, it is no longer fun. For it has taken over their lives, in a life-threatening way.

Like many other young women around the world, Nadine and Dalia have eating disorders. Despite the autodidactic expertise they have acquired -- both know full well the medical complications that their habits bring on -- both women say that they are caught in the whirlpool. Aware of the dangers, aware even of their distorted self-image, they are simply unable to stop.

When it started, Nadine was 13, Dalia 14. They were both popular and outgoing, good students and good athletes. But it wasn't quite enough. Predictably, their parents expected type-A perfection; they could accept no less themselves.

Today, Nadine is 23, Dalia 24. One has a BA, the other a master's. One is engaged to be married, the other "seriously committed". It seems like they've come a long way since they were teenagers obsessing about their weight, playing games to see who could lose the most weight by Christmas, or summer, or some big party. But though they are busy making decisions about where to go and what jobs to take, they are also busy obsessing about their weight. The fat they see on their hips is still the most important thing in the world; their days are still plagued by the infernal cycle of bingeing, purging and starving which has almost cost them their lives.

Twisting a faded red hairband through her fingers, Nadine talks about her descent into bulimarexia -- the disease characterised by bouts of bingeing and purging (bulimia) followed by days of starvation (anorexia).

"We saw this programme on TV about eating disorders, and so we decided that anytime we'd eat something fattening, we'd make ourselves sick," she says, her soft brown eyes moving slowly around the buzzing café. "We both needed to lose weight, so we thought we'd see who could lose the most this way. We were completely in control -- we would have never thought it could get this bad."

"This bad" means spending days in a vicious circle, stuffing themselves six, seven, sometimes eight times a day, only to heave it out with purges and huge doses of laxatives. "This bad" means dizzy spells and fainting fits, ulcers and mouth sores. It means not eating a thing for days on end to counteract their days of bingeing.

"It's no fun," Nadine says, her soft voice choked. "It's really no fun at all. Everyone thinks we can just stop, but it's not that simple. It's not about food like everyone thinks. If it were that easy I'd give up in a second. I would never put myself through so much hell."

It is hell indeed to wake up each morning to self-loathing and disgust. Hell to hate getting up, hate getting dressed, and hate seeing friends. And yes, hell to watch friends munch on hamburgers while they sit silently, sullenly, sipping water. It is a private little hell on earth. And like the media, movies and magazines in today's global village, it is one which has transcended borders and "Western" stereotypes, and crashed full-force into the lives of young Egyptian girls. All kinds of girls.

It is a disease with no limits and no restrictions. It grabs the so-called jet-set just as it can the doorman's daughter. And contrary to popular belief, it doesn't just strike the likes of Princess Di, a Western woman with nothing to care about but her waistline, not where her next meal is coming from. As affluence spreads to new social classes, eating disorders have hit Egypt as it has Europe and the States. It has claimed lives, broken friendships, families and marriages. And here, too, it is a silent killer.

"It's a social taboo," says Sherine Khalil, a clinical psychologist at Ain Shams University's psychiatric hospital. "In Egypt, all psychological problems are a social taboo. This is no exception. No one will talk about the problem."

The reaction to bulimia and anorexia is a classic case of denial. The disorder, like the denial, stem from the need to fit in, to be a part of the group. The older generation and their conservative views do nothing to help; it is their views, in fact, their desire to preserve appearances, which Nadine and Dalia believe have prolonged their suffering.

"Of course our families know we have a problem," says Dalia, "but they'll never do anything about it." It's easier to pretend nothing is wrong. If they did admit to the problem, they would be diverging from the norm -- announcing to their family and friends that their children weren't perfect. It would be a social faux-pas.

Dr Somaya Mahmoud, an eating disorder expert and assistant lecturer in psychiatry at Menoufiya University, believes problems like bulimia and anorexia usually start when a child gets "a bit picky about their food" -- which everyone thinks is just part of growing up and worrying about appearances. Often, parents only realise a disorder is serious when it is too late to help.

"There's major denial on the parents' part," Mahmoud says. "Parents don't want to admit that there was a problem that they didn't see. It's about blame, guilt, denial." To admit there is a problem, in other words, is to admit that, as parents, they failed.

"Among Egyptian families, feelings of guilt may be stronger than abroad since family closeness and communication have much higher social value," Mahmoud says. "That's one of the reasons no one talks about problems like eating disorders."

Another problem stems from the fact that few people know the difference between a real eating disorder and the latest dieting fad. Bulimics and anorexics were often abused as children; in all cases, they have practically non-existent self-esteem. And most people have no idea that the life-threatening side effects of eating disorders is devastatingly long, according to health practitioners: reduced thyroid metabolism, difficulty in maintaining core body temperature, delayed gastric emptying, amenorrhea (loss of menstrual cycle), osteoporosis, electrolyte imbalances, seizures, salivary gland and pancreatic inflammation, esophageal and gastric erosion (which can lead to a ruptured esophagus), irregular heartbeat, urinary tract infections, kidney failure and, in extreme cases, cardiac arrest.

Nadine and Dalia know all about the side effects, though. They know it can kill them, and they know people who have almost died.

On one of the on-line eating disorder discussion groups that the two women frequent, a 55-year-old woman sent out a message to the younger women in the group urging them to seek help.

"When I first started, I thought I could do it for a few years to lose weight and then stop," she wrote. "After all, when I looked around, I saw no older women with eating disorders. It was only when I turned 26 and lost my first friend to bulimia that I realised where all those women were. Two years later, I lost another friend. I am lucky to still be alive."

Andrea Goldensohn, a clinical psychologist at the Community Services Association (CSA) in Maadi, stresses the importance of understanding eating disorders. "People need to become aware of the complexity of the issue. They need to realise that it is a problem that is almost invisible to the public eye, yet is very severe, and they need to be educated about the consequences," she says. "These are young women destroying their bodies and destroying themselves." Somaya Mahmoud agrees that eating disorders must be addressed now, before they claim the lives of any more young girls and women.

"There is reason for alarm," she says. "This is a social problem, not an individual one like everyone thinks. We need to get people interested. The figures here are already as high as in Europe and the States."

In the United States, eating disorders claim the lives of at least 1,000 adolescent girls each year. Of an estimated five million sufferers in the US, one in five will die prematurely -- 87 per cent from cardiac arrest. Although many believe that the problem is not as serious in Egypt, a five-year research project undertaken as Mahmoud's doctorate thesis revealed some startling information.

Choosing seven schools, public and private, in Madinet Nasr, Mahmoud chose a random sample of 500 girls (equal to six per cent of the female student population) in the 13-18 age bracket. Questionnaires and clinical interviews showed the following results: "1.6 per cent of the population were bulimic -- the same as international statistics; 0.5 per cent had anorexia -- similar to international statistics; 9.7 per cent had atypical cases of anorexia or bulimia -- exactly like American figures; and over 50 per cent were dissatisfied with their weight and appearance. This is across all [social] classes. Those in the public schools had exactly the same problems in the same proportions [as their private-school counterparts]."

These statistics, however, do not seem serious when compared to the 15 per cent of Egyptians who, Mahmoud says, are dealing with anxiety and depression. But although only 10 per cent of young women suffer from serious disorders, a stunning 50 per cent of the female population do not like the way they look. As new standards of beauty spread in Egypt via fashion magazines, TV and cinema, more and more young girls are coming to believe that controlling their weight will allow them to achieve what they want: marriage, a career, a life with all the trappings touted by consumerist image-mongers. They end up hating themselves, hating their bodies, and hating their lives.

Nadine and Dalia are not the exception. But they should be. Their lives are not normal by any standards. They can now purge by pure will power, without having to stick their fingers down their throats. They lie with consummate ease, telling their friends that they have an appointment when in fact they are planning a binge. They are used to the dizzy spells and fatigue, the bloodshot eyes and sore throats. This way of life has become just that -- a way of life.

They have chosen food over friends and home-based starvation plans over pizza parties. At times, they have found themselves completely alone: abandoned by friends who could no longer take the weeks spent hiding at home, boyfriends perplexed by the mood swings and withdrawal and, of course, parents who just couldn't deal with the problem. Still, while Nadine and Dalia would like to be normal, they would prefer to be thin.

"We always used to be out with friends or at parties," Dalia says. "We were extremely sociable -- always with the 'in' crowd. Then you slowly find yourself thinking more and more about your weight, and suddenly you're obsessed."

They had spent years avoiding exercise class at school; then they started running. They would meet every morning before school and go round and round the track at the club. They would keep running around the quarter-mile track until they could no longer take the sheer monotony of it. On good days, they would starve for the rest of the day, munching on just carrot sticks and cucumbers. On those days, life felt good, their clothes felt fine, and even the image in the mirror didn't look all that bad. They would go out and see friends. But at times like these, they had to watch out for the inevitable binge that was about to kick in.

When it did -- when the apparently unjustified anger and frustration surfaced, and the urge to stuff themselves became too strong, they left each other to deal with the misery and failure in private.

It is a misery they both understand, one characterised by an empty feeling, an incomprehensible hatred and confusion. Although they knew they would feel awful, bloated and fat -- "useless, real losers" -- they had to give in. Since they associated food with power, their only control came from their ability to purge and cleanse themselves at will. Although they knew, rationally, that one binge wouldn't lead them to gain weight, their images were distorted in the mirror: their thighs looked "huge", their stomachs "enormous". Body image distortion (BID) leads anorexics and bulimics to see rolls of fat on their bodies, when in fact they are often skeletally thin.

Now, even in practical terms, they can no longer cope. "I can't keep eating and throwing up anymore," Nadine says. "Not with a fiancé and a job! So it's easier to starve. Starving is more compatible with a social life, and anyway there's no escape."

Their only escape would come from an awareness campaign -- an educated public and medical experts who would not just tell them to "snap out of it". They need to know it's all right to talk about their problem and to seek help. "Professionals need to be educated about the disorder and its complexity," asserts the CSA's Goldensohn. "It's not about going home, eating a good balanced meal and feeling better. It's not about food -- people need to understand that."

Menoufiya University's Somaya Mahmoud adds: "We need to educate teachers about eating disorders, we need to tell kids about the dangers, we need experts and clinics and rehab centres. It will take years, but we have to start."

Determined to help combat the disease, which suffocates the lives of young girls as drugs do drug addicts, Mahmoud says she will continue her research and persist in her attempt to bring about understanding.

In the meantime, though, Nadine, Dalia and the others will just have to wait. They want to believe that they will wake up one day, look in the mirror, and not feel that their hips have expanded miraculously overnight from a slice of pizza or a square of chocolate. In an ideal world, they would be fat and not care, or normal and love it. They have to believe that at some point in their lives, they will be able to go out with their children and their friends, order a burger and fries, and not have to run to the bathroom to make themselves vomit. For now, though, they are sticking to salad.

Sitting by the shaded walkway of a garden café, Nadine and Dalia watch silently as the hustle and bustle of evening begins.

The tables lining the paved promenade slowly fill up as the heat of the day wanes. Some are chatting, some engaged in debate and discussion, and others sit alone. Many of them are eating.

Eyes glazed over, Nadine turns to Dalia and indicates the nearby table of giggling youngsters, out with their mothers.

"It's strange how things change," she says. "I remember how I used to eat pizza with my friends. I didn't care. It was so normal. And look at me now. It's kind of creepy how we've changed. I wonder what happened."

 

illustration: Goerge Bahgory

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