Addictions to psychoactive substances and eating disorders. (The Mortification of the Flesh).

The right to health is internationally recognized as a human right as proclaimed in the Universal Declaration of Human Rights, various international treaties and conventions, and programs for action from several world conferences held in the 1990s. Nonetheless, innumerable psycho-social and socioeconomic factors prevent the full enjoyment of health in our societies.

As for mental health, more than just the product of a functional, material, biological body, it also responds to the living conditions and the gender roles imposed upon women and men.

However, throughout Latin America and specifically in my country, Peru, no significant percentage of the national budget is set aside for mental health care--even for critical issues, such as stress, depression and addictions, among others--let alone the disorders and syndromes that preferentially or exclusively affect women, including post-partum depression, eating disorders, addiction to tranquilizers, and a variety of syndromes associated with the consequences of abuse.

The lack of attention to mental health is partly due to the fact that, unlike some infectious diseases, mental illnesses are not usually fatal. However, there are exceptions: suicidal obsessions and anorexia can have deadly consequences.

Mental Health and Gender (1)

A great many of women's emotional disorders stem from the marginalization and powerlessness they are subjected to as women. Mental illness is often an extreme manifestation of women's real and symbolic social, economic and cultural exclusion in a culture that holds up a male ideal that is the symbol of acceptance, a paradigm of equality, a test of worth and proof of existence.

A gender perspective is very useful to understand this phenomenon, since it "analyzes women's and men's possibilities in life: the meaning of their lives, their expectations and opportunities, the complex and diverse social relations that exist between both genders, as well as the daily and institutional conflicts women and men must face and how they confront these situations." (2)

From this perspective, we see that women's mental health problems are the result of fruitless efforts to adapt to a hostile social environment or a reality that does not allow them to fulfill their own expectations, and overwhelms their individual capacities to respond and enjoy their lives. For example, clinical psychology has diagnosed a greater frequency among women of depression, suicidal thoughts and attempted suicide, greater consumption of stimulants and tranquilizers, more frequent feelings of sadness and loneliness, dependence and helplessness. (3) Mental illness is a final testimony to marginalization.

Nonetheless, the traditional medical response tends to associate women's mental illnesses with their reproductive function. The function of the mother is sublimated, honored and determined in relation to women's conscious ability and subconscious obligation to provide emotional support for their children. Motherhood provides the measure of the effectiveness and satisfaction of "being and feeling like a women" in our society. The identification of women's mental health with the socially-assigned maternal role (4) has a number of consequences throughout women's lives.

But not all women grow up to accept models that contradict the models of post-modernity. There is evidence that things have changed for women: life expectancies are longer; access to education is greater; young women's expectations have changed; domestic work is radically different; women's social isolation has been broken; patriarchal marriage has been undermined; women have entered into the labor market. All these developments have increased women's autonomy.

Nonetheless, these beneficial changes are paralleled by a contradictory reality--conscious inequity; illusory access to positions of respect and responsibility: and the tired, old story of subjugation. Women's illnesses rear an ugly, but well-groomed head. (5) Under these conditions, women's psychosocial state suffers from a variety of complications and disorders that they perceive as making them unwell, but not terribly ill. They suffer ambiguous and vague feelings of discontent and anxiety about themselves. Eventually, the phenomenon of the crisis emerges. They face the conflict of the "legitimate" exclusion of women from the world of knowledge and power, which affects women's mental health to a greater or lesser degree.

The solution necessarily leads to the exercise of self-awareness, the perception of oneself in both the cognitive and the personal/emotional worlds. This leads to an innovative and excessive utilization of personal control/ lack of control as a response to the learned shortcomings derived from the lack of personal dominion: an imaginary control in the form of compulsive symptoms and dependence.

Two examples of women's mental health problems illustrate the observations detailed above: addiction to psychoactive substances (APAS) and eating disorders (ED). We will apply a gender perspective to these two realities. Although both are increasing in absolute and relative numbers, they are forgotten when it come to determining specific measures for their treatment, or establishing comprehensive responses that include a gender perspective, let alone the most basic prevention programs.

Women Addicted to Psychoactive Substances

Addiction to psychoactive substances (APAS) is an illness that requires comprehensive medical care. APAS is another expression of women's ill health in the context of the conflict between their own individual needs and the expectations of society. Two of the most harmful substances--hazardous to the individual and to society--are tobacco and alcohol. The consumption of legal drugs has clearly increased among women, and prescription medications are most frequently used by women. (7, 8) Patterns of consumption vary according to gender, type of drug consumer, stage in the life cycle, social group, educational level and geographic location. In APAS, we note that:

* Socially-disruptive behavior--transgression--is much strictly condemned in women since such defiance is associated with traditional cultural stereotypes and ideals of masculinity. The resulting feelings of guilt, shame and degradation can lead women to hide their addiction or to not seek treatment in order to avoid being discredited as an "addict."

* Women who are addicted to psychoactive substances threaten the traditional female model: their drug abuse is perceived as a lack of respect for social norms and the very essence of womanhood.

* Women's use of anti-anxiety drugs, amphetamines, or antidepressants--or their search for euphoric or extreme experiences--is a way to exert control over external elements in an effort to counteract the negative effects of their social status.

* Compared to illegal drug use, use of psychoactive pharmaceuticals carries little social stigma, which encourages the increased abuse of these drugs in direct correlation to age.

* Gender-based violence, in its many expressions, is a constant in the lives of women addicted to psychoactive substances. Gender violence affects women's inner selves, smothering their subjectivity, turning them into fearful, insecure women who accept their living conditions as a natural aspect of the traditional family and society.

* The primary significance of relationships to women's identity, the need for social and emotional attachments and the fear of friction with their male partners are important risk factors for use of psychoactive substances. Many women start using these drugs because they are involved in relationships with addicts and want to share their partners' experience, to please them, to let them know they are not alone, to feel as if they love and are loved.

* In many cases, women are pressured to start using psychoactive substances by their sexual partners who use these drugs. It is very difficult for women addicted to psychoactive substances to quit using when their partner's lifestyle supports drug use.

* The extension of the maternal role in the world of APAS is notoriously evident in the role of women psychoactive drug addicts in relation to their male partners.

* Consumption of psycho-active substances can have an impact on women's sexual behavior. For example, they may forget to use barrier methods to avoid pregnancy and protect against sexually transmitted infections. Because women drug-users are stereotyped as "easy" or "loose" (and therefore sexually available), they may also be more vulnerable to psychological and sexual violence.

* Dependence on emotional relationships, an overwhelming fear of loneliness, and the inability to deny the wishes of others lead many women to endure humiliation and other types of violence by their partners. They become addicted to the addict or addicted to their relationship with the addict. This relationship strengthens socio-cultural roles and stereotypes that fix women and men in unequal positions, regardless of their relationship with the world of drugs.

* Women who use drugs are symbolically linked to misinterpretations of sensuality, to a menacing, evil side of society and a misunderstood sexuality. They are perceived as untrustworthy and stereotyped as doubly contaminated: by drugs and by sex.

* Many women addicted to psychoactive substances do not seek treatment because they are afraid. They are afraid of not being able to care for or raise their children or of not being able to look after them economically. They are afraid of retaliation by their partners, of being reported to the police, or losing custody of their children or visitation rights.

* When women finally face their drug addition and the need for rehabilitation, they take the initiative to seek out information guidance and assistance. By contrast, men generally turn this responsibility over to other family members. (9)

* Women's discourse has been rewritten. Now, drug use and abuse and drug-related crime are seen in a different light and related to aspects of women's life cycle, socioeconomic status, and chronological and developmental age. (10)

* The world of drugs is related to women's sexuality. A number of recurrent themes appear in different times, places and contexts that illustrate the different behaviors that are expected and accepted of women and men, such as: prostitution, physical and sexual abuse, and the eroticism of drugs associated with sex. (11) Women' consumption of drugs is linked with an array of diseases and "inappropriate behavior," such as prostitution.

* Some studies show as that as many as 70% of women who abuse psychoactive substances have a history of physical and sexual abuse. During their preliminary case histories, women are more likely to report parents' histories of addiction than men. (12)

* Women who are addicted to psychoactive drugs also present greater incidence of depression, panic attacks and phobias. (13)

Clearly, there is not one sole model of "the woman addict." Women addicted to psycho-active substances come from all walks of life: adolescent, mixed-race, pre-pubescent, worker, adult, child, lesbian, mother, divorced, professional, prisoner, housewife. Their drug abuse is the characteristic that unites them all. As a result, their understanding of the world and their addiction vary not only according to context or substance, but with regard to their relationships and the gender stereotypes of society, their role as mothers (or the possibility of becoming mothers), the type (and quality) of relationships that they have with their partners, and their place and participation in their families, the workplace and society.

In order to develop a program of treatment, the woman's identity as well as society's perception of her and her self-image must all be considered. In this effort, the following aspects should be taken into account.

* A gender perspective is essential to understanding women addicted to psychoactive substances.

* Socio-cultural stereotypes, the system of relationships between genders, situations of violence, individual and social realities and social stigma interact among to eloquently influence women's addictive behavior.

* The life histories of men and women addicts demonstrate differences, specifically regarding their interactions with their respective parents, which indicate a socio-cultural differentiation between the sexes from childhood.

Women and Eating Disorders (14)

Basic Concepts

Eating disorders include anorexia, bulimia and other varieties of these disorders.

Rarely has a disease inspired such divergent descriptions and such a variety of hypotheses regarding its etiology as anorexia nervosa. This disorder is characterized by behavior focused on the personal meaning of weight and body mass, by specific eating patterns, the profound need to lose weight, the intense fear of gaining it, serious discrepancies of body image, and in women, the delay of onset or remission of menses (amenorrhea).

Bulimia, on the other hand, is characterized by episodes of bingeing followed by compensatory behavior to avoid weight gain through forced vomiting to make up for the ingestion of calories. In other words, a brief period of compulsive and very rapid ingestion with a feeling of loss of control is followed by vomiting and dieting.

Eating disorders are one of the few mental health problems that can result in death, and anorexia nervosa is especially serious and widespread today. The causes of these disorders have a variety of socio-cultural, cognitive, emotional, physiological and behavioral roots in which the mind-body-world relationship plays a key role.

Relevant Concepts

The behavioral imbalances of eating disorders are manifest in the body, which provides a stage for subconscious meanings and symbolism in which language and the discourse of other/self plays a part.

If we examine the first year of a child's existence, we realize that s/he is fed and nourished with mother's milk and feelings of warmth and affection simultaneously. As a result, nutrition is associated with love. Slowly, food becomes love, affection, the feeling of being loved and protected from the outside world.

Anorexia nervosa threatens directly the exercise of self-preservation by rewriting the association of love with food. The rejection of food or uncontrolled eating disguises a double rejection: on the one hand, the individual's rejection of past or present symbolic, cultural meanings and, on the other hand, the profound rejection of the impulse behavior of the body embodied in food. Meaning can be converted into edible or indigestible representations: we gorge (and disgorge) words--syllables that represent feelings, emotions, loves, fear and experiences.

In western culture, the rise of eating disorders has often been associated with the demands of society, work, the family, the couple and, especially, physical appearance. In recent decades, an archetype of extreme thinness has been established and smooth, pre-pubescence idealized as the sign of health and well-being, rather than the natural form of the adult woman.

The increasing incidence of eating disorders affects adolescent and young women of all social strata, primarily in the professions closely linked to the body image and weight: gymnastics, dance, modeling, advertising, the media, among others.

At the same time, a variety of "light" or "diet" products have appeared whose marketing strategy emphasizes the large number of women who are dissatisfied with their weight and their figure and who are constantly dieting or using some other means to control their weight. However, the key factor in the increased incidence of eating disorders is the image of women in this "light" culture. In order to be accepted, loved, desired, women must be slim--yet another burden for women to shoulder and another existential crisis.

In normal circumstances, women can adhere to a regular diet supervised by a nutritionist or physician. In adolescence, dieting is very common, and this life stage is fertile ground for the development of eating disorders. Nonetheless, the process through which a normal diet becomes a pathological disorder is complex: it may begin with an obsessive impulse that includes compulsions and dependence, both indicators of uncontrolled addictive behavior.

Therefore, eating disorders are not the expression of the simple desire to improve one's personal, physical appearance, but rather the need to lose or maintain weight under specific conditions which become the central focus of the person's attention. Nothing else has meaning in their life: their emotional state, social relations, intellectual pursuits, even their physical integrity is sacrificed to this endeavor and the expected results.

Eating disorders are closely linked to the Welfare Society Syndrome which exalts the values of self-discipline, the triumph of the body over desire, the female image and anorexic pathology. Advertising, the media, fashion and diets also play a part.

Eating disorders and addiction to psychoactive substances affect health in similar ways. Prevention initiatives should pay close attention to this fact, for even when appropriate, multi-disciplinary treatment is provided, the prognosis is not good. (15)

Anorexia nervosa, bulimia and other body image conflicts are multi-causal disorders with deep social and cultural roots. Cultural stereotypes have a significant influence on the manner in which eating disorders manifest. The body is: our medium of contact with others and with ourselves; the container for our inner selves; the representation of our sexuality, gender and self-image. It is the manifestation of good and evil, and the source of stimulation.

Psycho-sexual life is enacted in two opposing spheres: the permitted, accepted and valued; and the repressed, hidden and punished. A contradictory order is established in our collective expectations, in our verbal discourse and in our individual behavior as women. Unsurprisingly, this incompatible situation gives rise to unhealthy behavior.

Prepubescent, adolescent and young women are exposed to a paradoxical interpretation of femininity and motherhood: it is simultaneously a risk and an achievement; it is desirable and disgusting; it is a free choice and a reluctant obligation. Illness, hopelessness and anguish begin here. The belief systems and behavior of eating disorders admit no possibility for change. Existence is based solely on the contaminated meaning of eating, which hides the illness and the consequential emotional breakdowns and destruction of relationships in both private and public.

Eradicating ads that promote certain aesthetic ideals and changing the current concept of beauty is important, but not the real solution. Both of these aspects are symptoms of a subjective world which still operates under the notions of patriarchal authority and machismo. Women with eating disorders are not healthy, but on an unconscious level they are "successfully" rejecting the status quo, if only they could channel their abstinence and perseverance into a conscious and focused struggle to take back their right to their own individual being.

Like substance addiction, eating disorders demand a multi-disciplinary approach and counseling. Opposition to treatment is primarily characterized by direct resistance, which may be overcome through motivational efforts.

Final Considerations

Addiction to psycho-active substances and eating disorders are having a growing impact on women's lives and mental health. Nonetheless, in Latin America serious methods for the treatment and prevention of these illnesses are not accessible. The following assertions support this position:

* Women have the right to exercise their right to health.

* Health is influenced by a variety of external elements, including, the socio-cultural system and gender relations.

* Western civilization interprets and evaluates social phenomena, such as women's health problems based on an andocentric model.

* Women's mental health problems display a greater level of morbidity than mortality.

* Issues of women's mental health should be a priority on the social and health agendas.

* Mental health services are difficult to obtain. Special treatment centers, especially public services, are few and far between.

* Mental health treatment programs should be multi-disciplinary.

* Factors that protect mental health must be strengthened. This implies investing in actions that will decrease figures of related morbidity. In this sense, it is essential to develop substance abuse and eating disorder programs and projects with a gender perspective.

* Communications strategies are a basic tool in prevention work, and they should be aimed at raising awareness about the issue with a gender perspective.

* Prevention programs should promote changes in women's and men's life styles.

* Prevention objectives must target specific audiences with clear strategies, and these strategies should be coherent, objective, responsible and sustainable.

* The principle of joint responsibility of the state and civil society should be strengthened in order to establish joint actions that favor society in general and women in particular.

* At the same time, the idea of quality of life must be made a top priority so that women and men of all ages, social strata and origin incorporate this concept as a basic and essential standard, which will allow the entire population to re-conceptualize their abilities and limitations in a realistic and positive fashion.

Notes

(1.) We understand gender to be a "complex reality, fundamentally psycho-social and symbolic, which is based on the variable of biological sex and which interacts with this variable generating a variety of attitudes, behaviors, values, symbols and expectations depending on the different social groups." Patricia Ruiz Bravo cited in Liuba Konga, Una Aproximacion al Concepto de Genero.

(2.) Marcela Lagarde, Genero y Feminismo. Desarrollo Humano y Democracia (Madrid: Horas y Horas La Editorial, 1997), p.5.

(3.) Men's symptoms of mental illness include anxiety, increased suicide attempts, increased used of drugs (both legal and illegal), feelings of guilt due to personal failure, feelings of "not doing anything well" and hopelessness.

(4.) "The process of socialization teaches people how to relate to one another, how to perceive each other and identify each other. In women, this process is deeply linked to behaviors of resignation, patience and dependence as well as submission and denial. Men's socialization is related to strength and power, as well as the denial of the expression of tenderness, in order to maintain their social, family and human preponderance as the center and social model." Marcela M. Callirgos Pajares, "Aproximaciones, Genero, Salud y Adiccion" (Lima, 2000) mimeograph, p.3.

(5.) What we call the crisis of masculinity in men is a consequence of their own socialization and the patent confrontation of an unequal and insecure world in which their patriarchal authority, their role as protector and status of provider, are neither consolidated, effective nor, in certain cases, necessary.

(6.) Concept derived from Mabel Burin et al., El Malestar de las Mujeres. La Tranquilidad Recetada (Mexico: Edit. Paidos, 1990).

(7.) The so-called informed consumer.

(8.) According to the National Survey of Drug Use and Prevention (Lima: PNUFID-NASCONTRADROGAS, 1998), women are the greatest consumers of tobacco. Incidence of alcohol use increases in relation to the family context. Violent discussions in the home are a risk factor for consumption of tranquilizers, as are having a family member who uses these drugs, tobacco dependence, and belonging to a social group in which illegal drugs are used.

(9.) The maternal role is extended, using mother, wives or female partners or even sisters, in a reinterpretation of "motherhood," as Maria Raguz describes.

(10.) The perception of women's substance abuse is different when the addict is a niece, sister or mother. This perception is independent of the level of consumption: what we say and how we act change in regard to common sense and generation-based expectations. In her book Perspectivas de Genero en los Problemas de Drogas y su Impacto, Elena Rodriguez San Julian links this situation to three components: a) motherhood (real or expected), which is a specifically female point of reference that implies extremely meaningful concepts in terms of self-control and self-care; b) women's responsibilities in the private sphere and their participation in the public sphere which make greater demands on their strength, on the need for women to be able to "control" their behavior, and, if they do become addicted to psychoactive substances, the need for them to prove that they are able to control their addiction; c) the double crime (in the eyes of society) implied in women's transgression, in which different aspects of women's self image and their image in society are affected.

(11.) See Carmen Orte, "Sexualidad en la Mujer Adicta" (Departamento de Ciencias de la Educacion, Universidad de las Islas Baleares).

(12.) U.S. Department of Health and Human Services, National Institutes of Health. Metodos de Tratamiento para la Mujer (Washington, DC: NIH) p.1.

(13.) In men, we see a greater number of diagnosis of anti-social personality disorders.

(14.) Paraphrasing Marcela M. Callirgos Pajares, "Trastornos de la Alimentacion: algunas consideraciones desde la perspectiva de genero," in Mujer y Salud Mental (Lima: Asociacion Peruana de Salud Mental para la Mujer) 14(1/2): 15-20.

(15.) Marta B. Rondon, "Los Trastornos de la Alimentacion y su Relacion con el Abuso de Sustancias en Mujeres," in Mujer y Salud Mental (Lima: Asociacion Peruana de Salud Mental para la Mujer) 14(1/2):23.

The author is an anthropologist and psychologist specializing in eating disorders and additions. She is the executive director of the Peruvian non-governmental organization Trazos.