Status of Women Committee on Feb. 12th, 2014

[Andrea LaMarre]

Not occupying a body that is easily understood to be suffering from an eating disorder may also complicate the process of recovery. Weight restoration and normalized eating are generally considered pillars of eating disorder treatment programs. When new instructions are given to individuals to develop new patterns of behaviour around food and exercise, these are often in direct opposition to the prescriptions for health that are offered to the general population. Recovery in such a context can be extraordinarily difficult. To borrow one of my participant's words, “For people who already feel so alone and want to belong, to ask them to do something countercultural can be really scary.”

Recovery itself is poorly understood. While individuals may see recovery as a process rather than an outcome, clinicians require biomedical criteria through which to gauge recovery.

More funding for research in this area would help to explore individuals' and families' understandings of recovery and the resources they require to achieve it.

Although we can see the evidence base growing around mainstream approaches such as cognitive behavioural therapy, currently existing models may not resonate for all individuals. One size does not fit all in eating disorder treatment. Our knowledge based around treatment primarily stems from studies conducted at programs that are currently funded, which are often generally in hospital contexts. It could be that other forms of treatment, for example, narrative therapy, which is often employed in fee-for-service community practice could be highly effective as well.

“Evidence-based” may mean that someone has been able to gather a large enough sample size to conduct a randomized controlled trial of the approach. Strong quantitative studies that test and compare various forms of treatment are still lacking.

[Dr. Carla Rice]

This suggests that we need to develop stronger relationships with individuals with lived experience to truly understand what is working and not working. Centring the experiences of people who have and have not received treatment, in a wide variety of settings, would entail deeply engaging with those individuals, and this requires good qualitative research. So we need qualitative research on top of quantitative research. Greater dialogue between individuals, families, and providers would also help to bridge significant divides between those who deliver and those who receive care.

We cannot abstract individuals from the social context especially in the case of eating disorders, where context is deeply implicated in girls' and women's disordered eating. Developing an effective supportive system depends on acknowledging that neither individuals nor systems need fixing in isolation. We need to work at the interface of individuals and systems to better understand individuals' complex needs as well as to expand possibilities for treatment within the system and care in communities as well.

Our solutions must be grounded in a strong understanding of the social-situatedness and the lived, embodied experiences of diverse individuals with eating disorders.

We thank you and welcome questions from the committee.

[The Chair, NDP, Hélène LeBlanc]

Thank you for your presentations.

Mr. Young, you have seven minutes.

[Terence Young, Conservative, Oakville, ON]

Thank you, Madam. Perhaps the clerk can wave at me when I hit five minutes so I can share my time with my colleague. Thank you.

Dr. Rice, I would like you to please comment on what causes eating disorders, with specific reference to objectivizing women and their bodies.

[Dr. Carla Rice]

Thank you very much for the question. I think that's a very good question.

I think that one of the reasons that eating disorders are so disproportionately experienced by girls and women is because of the objectification of women, where women are positioned as the object of the collective gaze and the public gaze in our society. This kind of positioning happens at a really young age as girls learn to take up their femininity. Being seen as the object of other people's looks is a primary criteria for femininity for women in this society. I think that objectification does play a role. But I also think we have to see these disorders as complicated, multidimensional problems where the social and the cultural play a really foundational role. There are other factors operating that relate to one's biology interacting and intersecting with psyche and the broader society.

Yes, go ahead.

[Terence Young, Conservative, Oakville, ON]

So parents who have little children—say they have two children under four years of age—would it be a good idea for them to keep magazines and television right out of the house?

[Dr. Carla Rice]

I think that's a start. I think that as a broader culture though, that child is going to be socialized and acclimatized to what kind of gender role is expected of them when they go to day care, and when they go to school later on. Keeping magazines out of the house and turning off the TV set is great, but children are going to encounter these values as soon as they enter public school and other spaces where they meet up with other children.

Children themselves learn what kind of gender identity is expected of somebody, of them as a girl or as a boy, and they learn how to perform that because they want to fit into the social order, the social world. So we have to be thinking about prevention in a much broader way, not just targeting individual families.

[Terence Young, Conservative, Oakville, ON]

Are girls and women with eating disorders being discriminated against in our health system?

[Dr. Carla Rice]

I don't feel one hundred per cent prepared to answer that question.

[Terence Young, Conservative, Oakville, ON]

Okay, I don't want to put you on the spot

Perhaps I can ask Dr. Jericho.

[Dr. Monique Jericho]

Okay, you can put me on the spot.

[Some hon. members]

Oh, oh!

[Dr. Monique Jericho]

I can really only speak to my experience, so I want to be cautious, but I can tell you that I have had this conversation with folks from across the country. To say somebody is being discriminated against, I think, implies a deliberate type of neglect or a deliberate type of harm. I would suggest that's not happening. But I do think that the issue is that there is a lack of recognition for the severity of these conditions, period. Because of that, we just simply don't have the resources that we might need, and in particular the resources we need for the most gravely ill.

[Terence Young, Conservative, Oakville, ON]

Dr. Jericho, what should be the minimum standard of care for women and girls with eating disorders? The minimum standard of care....

[Dr. Monique Jericho]

I think it ties in to what I was saying before. These people deserve to have their diagnoses or their problems acknowledged. They deserve to have that problem be given a voice. If that happens, if there is that acknowledgement, then the next step is that they are then able to access some form of care. So the minimum is the acknowledgement that it's actually a problem and that it's real, and then the next step is that they get treatment or support for the problem.

[Terence Young, Conservative, Oakville, ON]

Thank you.

My colleague's going to ask some questions.

[Stella Ambler, Conservative, Mississauga South, ON]

Thank you very much.

Dr. Jericho, I'm wondering what pharmacological treatments are designed or used for individuals with eating disorders, and how and if they're regulated by the Food and Drugs Act.

I'll tell you why I'm asking specifically. I'm wondering how often eating disorders are treated with antidepressants, and if there are other drugs that are used, if they work. What are the adverse effects and risks of treating eating disorders in this way?

[Dr. Monique Jericho]

Okay. I think I can start off saying that there are no drugs. There is no medication that will cure an eating disorder. There is no medication you can give somebody that will cure or treat their eating disorder.

There are arguably some indications that bulimia nervosa can be effectively treated in the short term with the use of some antidepressant agents. But this is the minority of individuals, and this is generally not considered to be a lasting effect.

The treatment for eating disordered individuals is generally food. So I guess when you ask me what happens clinically, it is that many individuals are treated with a variety of different medications that would broadly be grouped under the classification of antidepressants, mood stabilizers, and antipsychotics. But those medications are prescribed for the treatment of symptoms. For instance I mentioned co-morbidities when I spoke earlier. Many individuals would come into a treatment program with co-morbid depression or depressive symptoms, and the clinician like myself may try to alleviate some of those symptoms using a medication. Similarly I might try to treat core symptoms of an eating disorder, such as maybe the experience of the body, through the use of a medication. So potentially I would try an antipsychotic to see if that would be helpful.

There are very few guidelines about the uses of medications in the treatment of these individuals. Clinically I'd say it's across the board. Some of my colleagues would use a lot of medications. I tend to not practise that way. But the point is that the standard really isn't established and there's no evidence to suggest that the use of these medications is necessary or effective.

[The Chair, NDP, Hélène LeBlanc]

Thank you very much.

Ms. Ashton, you have seven minutes.

[Niki Ashton, NDP, Churchill, MB]

Thank you very much and thank you to all of our witnesses today, Dr. Rice, Ms. LaMarre, and Dr. Jericho, for your very compelling testimony and for sharing your experience with us.

I do have a few questions for the three of you, I guess. Beginning with you, Dr. Rice, it was very interesting to hear about your work, about Ms. LaMarre's work. It is an aspect of this discussion around eating disorders, stereotypes, and images, that we've only begun to touch on, I believe. But it is an issue.

Certainly, the portrayal of women in our society is something that's related to so many issues that we tackle in this committee. I'm wondering if you could give us an idea—if you are familiar with this information—if there is a trend in terms of the way women have been portrayed over the recent decades and the influence of media. Obviously, media has taken various different forms, including social media in this day and age, that impacts the pressures young women and girls may face with respect to body image.

[Dr. Carla Rice]

Absolutely. We live in an increasingly image-oriented, visual culture where our identities in many ways get reduced to our physical identity, especially when we're in adolescence where looks and appearance become something that's of primary importance.

We actively work to construct our identities through Facebook and through posting images of ourselves. So living in this extremely visual society where people construct their identities around how they look and how they appear.... Added on to that is the fact that girls and young women are positioned as the objects of the gaze, and that we're meant to focus on our image and to see that as a primarily important aspect of who we are. That has exacerbated the problem.

There are studies showing that models have become thinner and thinner. There are famous studies demonstrating that over the past 30 or 40 years. Girls and women are also confronted with more and more emaciated images of beauty.

Even beyond objectification, psychologists are now talking about sexualization, which is a kind of hyper-objectification of girls and young women, where girls and young women are now meant to create a very sexy image. It's not only one that should be attractive and thin but now has to be one that's overtly sexual.

[Niki Ashton, NDP, Churchill, MB]

It's very interesting and we've heard from witnesses in other discussions as well about how important it is to start working with girls at home and conveying the right kind of message to them. This is clearly a societal issue as well.

One of the things that's very clear in our work here—not just on this issue, but on others—is that there are fewer and fewer voices that speak out on behalf of women's issues. I'm aware of campaigns years ago that addressed, on a much larger scale, degrading images of women in advertising. Spokespeople would come out and speak to these things.

There is no question there are a number of bloggers and there are sites where these discussions happen, but unfortunately there are fewer and fewer voices with funding and with capacity to be able to keep track of some of these things. Perhaps actually, the last vestige is your work within academia and in the context of research.

According to you, is it important to have advocacy on these issues to support parents, to support teachers and educators but also at a broader societal level as well?

[Dr. Carla Rice]

Absolutely. We saw sort of the death knell of a few organizations like MediaWatch and other similar organizations. I'm not sure when those organizations folded, but it happened in recent years. We desperately need watchdog organizations attending to the kinds of images that are circulating.

You know, I think we also need to think about how eating disorders themselves are represented in society, in mainstream society. We need to think about that critically. In my remarks I alluded to this idea of the single story or a singular representation of who is the woman who develops an eating disorder. In Canada's multiracial and multicultural society I think that image no longer fits the reality of who is actually developing eating problems in this country.

Certainly when I was doing clinical work in Toronto I worked with a broad range of women from every racial group and cultural group. That notion that an eating disorder is sort of a purview of the white young woman who's upper-class or middle-class no longer holds true.

I think we also have to be thinking about the representation of eating disorders in the broader culture. I think Andrea also has something to say about that.

[Niki Ashton, NDP, Churchill, MB]

I was just going to say, actually, that I was hoping to leave some time for Dr. Jericho.

Andrea, perhaps if you want to just make a quick comment....

[Andrea LaMarre]

Yes. I was going to comment on how true this holds in my own research and my participants. I mean, women of some minority groups are saying that they had never seen any sort of representation of someone like them who had developed an eating disorder. They were feeling lost and confused, and do they even have a problem? That kind of feeling, feeling very lost in the system and unable to ask for help because of that.