Sexual Abuse and the Abuse of 
Food: Mirror Images


By Maeve Lewis BA (Hons) (Psych), Dip. Psychotherapy, H.Dip.Ed..
MIAHIP

The term “eating disorder” covers a wide variety of behaviours ranging on 
a continuum from the self-starvation of anorexia nervosa through the binge
 eating and purging of bulimia, to the consistent extreme overeating of
 obesity. Eating disorders imply a pattern of eating which is outside that
 which is socially acceptable and which, in extreme situations, can lead to 
ill-health or even death. Nutritional needs and hunger are replaced by an 
intense, obsessive relationship with food as the primary motivator of what,
 and how much to eat.

Incidence of Abusive Relationships with food


When I reviewed the clinical histories of the female clients I have worked
 with who have been sexually abused in childhood, I realised that, almost 
without exception, abuse of food is an issue. There is a wide literature
 available on the extreme forms of eating disorders – anorexia, bulimia and 
obesity – and there is strong evidence to suggest a history of childhood
 sexual abuse in significant numbers of women who develop these
 disorders (¹). Very little has been written about the array of eating 
behaviours along the continuum which are not in themselves life 
threatening, but which overshadow the lives of those caught up in abusive 
relationships with food: excessive continuous dieting, comfort eating,
 overeating, “chocaholism”, mild bulimia etc. Yet, for clients who have 
been sexually abused, it is in this arena that the vast majority conduct their 
battles with food, and these are the issues which tend to recur again and 
again in the therapeutic setting. Therefore, it is my intention in this article 
to concentrate on the unhealthy, but not necessarily life threatening,
 relationships which women who have been sexually abused tend to 
develop with food and eating, and the challenges this presents for the
 therapist.

Influence of Other Traumas on Eating Behaviour


It is difficult for two reasons to isolate sexual abuse in itself as a predictor
 of eating disorders. Firstly, I think it is fair to say that most women in the 
Western world have an uncomfortable relationship with their bodies and 
very few are satisfied with their natural body shape (²). Women diet and 
exercise themselves in a futile effort to reach what is, for most of us, an 
impossible target weight or size. Women who have been sexually abused
 are subject to the same societal influences as everybody else. Secondly,
 sexual abuse always takes place within a context, and the experience of
 sexual abuse is highly individualised. It is generally accepted that long-term
 sexual abuse within the family is among the most destructive forms of sexual abuse. The factors which allow intrafamilial sexual abuse to take
 place, to remain secret often even among family members, or to be 
tolerated by other adults in the family, suggest an environment where the 
needs of the child are subsumed to the needs of the sexual abuser. Quite
 apart from the experience of sexual abuse, children growing up in such an 
environment have great difficulty in developing a strong healthy sense of
 self. In addition, other traumatic experiences in childhood, such as 
emotional abuse or neglect, unresolved bereavement, abandonment by
 primary caretakers, perinatal trauma and poverty, can enhance the impact
 of sexual abuse. Where food and eating is an issue, the influence of other 
traumas can often be seen in the complex patterns of eating behaviours
 which emerge, and it becomes impossible to identify sexual abuse 
specifically as a causative factor.

Most women who have been sexually abused in childhood, present with a 
distorted relationship to food. This tends to mirror the dynamic, which
 operates in a relationship where a child is being sexually abused, and the 
ways in which this dynamic affect the developing intrapsychic world of the 
person (³). It is as if the effects of sexual abuse as experienced by the client
 can be expressed symbolically through the patterns of eating. There are a
 number of themes which tend to recur among people who have been
 abused which manifest in the abuse of food.

The Physical Nature of Sexual Abuse

Sexual abuse by its nature is very physical. The abuse is perpetrated 
through the body, and the resultant trauma becomes embodied. It is very 
common for people who have been sexually abused to develop patterns of
 eating which are either an attempt to use physical means to assuage and 
control the emotional and psychological distress associated with the abuse, 
or to use food in such a way that the physical discomfort arising from the
 abuse of food mirrors the emotional and psychological distress. In the first
 situation, the client may present with a pattern of over or under eating
 where food or hunger is used to repress uncomfortable feelings, in much 
the same way as alcohol or recreational drugs can be used (4). In the second 
situation, the client may develop a pattern of eating which causes actual 
physical pain. This is especially obvious in clients who binge eat to the 
point where they develop severe abdominal cramps. It is as if the physical
 pain expresses the inexpressible internal pain. Client who have developed
 this coping strategy may also have a tendency to self-mutilate. The choice 
to over or under eat does not seem to be as important as the function it 
serves.

Development of Distorted Body Image


Children who are sexually abused tend to internalise the abuse, and take 
upon themselves the responsibility for provoking the abuse. As a result,
 sexually abused clients will usually describe very low levels of self-esteem.
 This is often projected onto the client’s physical appearance, and they feel 
ugly and unattractive. It is common for sexually abused clients to have a very distorted body image, usually experiencing themselves as being much
 bigger than they actually are. Dissatisfaction with external appearance, and 
the battle to conform to stereotyped notions of beauty through modifying 
food intake, can become the metaphor for a hopeless internal struggle 
towards self-acceptance. Setting unrealistic goals of weight reduction sets 
up a cycle of dieting and bingeing which serves further to undermine self 
esteem and to perpetuate self-loathing. The discipline involved in
perpetual dieting, and the rituals associated with purging, can also be seen 
as a form of self-punishment, denying oneself the nurturance and the
 pleasure that can come from good food.

Reinforcing Powerlessness

Children who have been sexually abused have experienced profound
 helplessness and powerlessness. In adulthood, this can manifest as a victim
 consciousness, where the person sees themselves as being helpless to
 effect change in their circumstances, and seems frozen in a position of 
childlike dependence, unable to move towards a more adult autonomy.
 The relationship which sexual abuse survivors develop with food, can 
serve to reinforce the sense of powerlessness, where food and eating 
patterns are perceived to be outside the person’s control, or are believed to
 control the person. It also assists in maintaining a victim consciousness by 
removing responsibility from the client for her life decisions by postponing 
living: “When I’m a size 10, then I’ll be happy/attractive etc.”

Food, Shame and Guilt

In sexual abuse, particularly where the perpetrator is a family member, a
 relationship develops where normal boundaries are violated and breached.
 As children learn how to relate through their experience in early
 relationships, the adult survivor is usually struggling with issues of
 boundaries and control. This is often reflected in the relationship the 
survivor develops with food: the severe control of dieting and, in extreme
 cases, anorexia, or the apparent lack of control in the binge eater or obese
 person. The secrecy and lies involved in an abusive relationship are also 
mirrored in the food relationship – eating secretly and covertly, covering up
 amounts eaten or not eaten, and the shame and guilt which ensues.

Sexuality and Eating Disorders


It is perhaps in the area of sexuality that the link between sexual abuse and
 eating disorders is most clearly seen. It is almost impossible for a person
 who has been sexually abused to develop a comfortable relationship with 
their own sexuality. While most people who have been sexually abused go 
on to have sexual relationships, it is an aspect of relationship that is fraught
 with difficulty. In particular, fear of intimacy and revulsion towards bodily 
functions, prevent the person engaging freely and openly in sexual
 activities. In addition, many people who have been abused are very cut off 
from their bodies. They may experience themselves as being disembodied,
 existing from the neck up, and therefore out of touch with bodily sensations. They may also feel ugly and unattractive, as discussed above. Since sexual expression is inextricably linked with the body, it is very
 common for clients to use food to control or change their natural body
shape, as an avoidance of sex. This emerges in two forms. At one extreme,
 clients will control their body to the point that they have not developed
 their bodies. This will be noticed particularly in women in their 
thirties and older who have retained an adolescent shape, where they do not “fit” with their bodies, where the body appears almost stunted. At the 
other extreme, clients will eat excessively to the point that their bodies are bloated with weight, so that their shape is lost inside an armouring of fat (6). Given the social ideal of sexual attractiveness currently prevailing, and the
 obsession with thinness, the layers of fat not only effectively protect the
 woman from involvement in sexual activity, but also reinforce her self-image of ugliness.

Exploring the Client’s Relationship with Food


Women who have been sexually abused, and who seek therapeutic 
intervention will rarely present at the first session with food issues, unless 
their disorder has evolved into anorexia or serious bulimia. This is partly 
because of the shame that is attached to lack of control around food, and
 partly because, for many clients, an unhealthy relationship with food has 
become such an intrinsic part of their lives that they are not consciously 
aware of it being a problem. In general, with issues of food abuse, the 
approach I take is to avoid becoming entangled in the mechanics of the
 patterns, but rather to explore the client’s relationship with food as a 
metaphor for their relationship with self and others. Where anorexia, 
bulimia or severe obesity are involved, I will insist on a medical check-up to 
evaluate the level of physiological damage that has been sustained. With
 anorexia, I will contract a minimum weight which the person must sustain,
 and explain that should they go below that weight, they will no longer be
 sufficiently well to engage in psychotherapy.

Healing within the Relationship

The person who has been sexually abused, has been traumatised in the
 context of a relationship, and I believe that healing must also take place 
within a relationship. The food relationship may be the most intense 
relationship in the client’s life at that point, and the type of pattern that the client has evolved with food will generally be a good indicator of the
 transference issues which are going to surface in the therapeutic
 relationship. A key issue will be intimacy, and the client’s difficulty in 
being vulnerable and trusting within the relationship with the therapist. 
Victim consciousness is likely to emerge in relation to the client’s life in 
general, but also as regards the relationship with food. The therapist will find that the client is projecting the same power and responsibility onto
 the therapist as she has done with food. However, even when the pattern
 of eating seems to be out of control, and the client perceives herself as
 helpless, the underlying dynamic will be one of the client trying to control
 her world through eating or not eating, and the impact this has on her 
body.

Realising the Danger of Power

The therapist can find herself getting drawn into subtle (or not so subtle)
 power games. If the current pattern of eating has been allowed to become 
a major issue in therapy, the therapist may find herself involved in a
 struggle to enforce healthy eating patterns which the client will sabotage.
 Decisions around food must be presented as a matter of choice which only
 the client has the power to exercise. It is helpful to explore fully the ways 
in which the eating patterns have served the client, the investment she has 
in maintaining these patterns and her fears regarding life possibilities if the 
relationship with food were to be let go. It will usually be found that the 
client is terrified of moving on to a life where she is free to make life
 choices but also has to be responsible for them. The familiarity of the 
constricted world of pain and struggle may seem safer than the possibility
 of living to the full. Exploring the patterns of food abuse, and the needs
 which the client is attempting (but failing) to meet through eating, allows 
those needs to be acknowledged as valid, but more appropriate ways of 
meeting them can be developed. As one client who developed anorexia in 
adolescence remarked: “I wanted my family to notice how unhappy I was
 without me having to tell them.”

Freeing the Intrapsychic Pain


Food abuse, in whatever form, will, at its core, be an attempt to numb the
 appalling intrapsychic pain of sexual abuse and to block the traumatic
 experience. One of the tasks of therapy is to facilitate the person to move 
towards the repressed pain, to allow themselves to experience it and,
 ultimately, to free themselves from it. This is usually terrifying for the 
client, and as she moves towards experiencing the emotional pain, the food 
relationship may intensify in a desperate attempt to ward off what seems to 
be unbearable and overwhelming. The therapist needs to be very open 
and non-judgemental, to be able to hold the client psychologically, but also 
to be able gently to challenge. As the sexually abused person has been 
traumatised through their body, most of the trauma will be held in the
 body. Bodywork can be very helpful at this time, in helping the person to
 embody herself and become aware of her body and its sensations, in 
facilitating emotional catharsis, and, ultimately, in developing a new
 relationship with her body.

Focussing on the Body Image

Once a client becomes more in touch with her body, it becomes possible 
to begin to work with body image, which I see as a projection of internal
 self-image. Challenging distorted cognitive perceptions, using imagery, art
work and suggesting regular massage, can all facilitate this process. I view
 the focus on body image as a parallel process which must be accompanied
 by a shift in the underlying perception with self. Encouraging the client to
 begin to care for her body in a non-punitive, loving way opens the way 
towards self acceptance at a deeper level. Helping the client to see the 
patterns of eating she has developed as a survival mechanism, can facilitate shifting the shame she has experienced both at the time of the abuse as a result of her eating patterns. In other words, the food relationship can 
come to be seen as a tactic that allowed the client to survive sexual abuse
 and its aftermath. While at one time it had value, it is now no longer 
necessary.

Moving towards Self Acceptance


Working with people who have been sexually abused in childhood is
 usually a long, slow process. The patterns of eating and the intense
 relationship with food will wax and wane during this time. Ultimately, my 
aim with a client is to reach a point where she understands the way in
 which her relationship with food enabled her to block off the traumatic experience to support her in facing her pain so that she no longer needs 
to engage in old patterns of defence and to be with her as she moves
 towards a place of self-acceptance. Unlike other substances that a client
 may abuse, it is not possible to abstain from food. Therefore, it is
 unrealistic to assume that food and eating will never be an issue again for
 the client in times of stress, she may find herself slipping back into old
 ways of coping with emotional stress However, since she has 
acknowledged and experienced the trauma of the sexual abuse and moved 
from a victim stance she will be aware that she now has alternative ways at
 her disposal of responding to life.

Maeve Lewis is Director of New Day Counselling Centre


Bibliography

1. Richard C., Hall M et al (1989) “Sexual Abuse in Patients with Anorexia Nervosa and Bulimia “
Psychosomatics, Vol I, No. 1 73-79.

2. Wolf N, (1990) The Beauty Myth, Vintage.

3. Cole P & Putman F (1992) “Effect of incest on self and social functioning: A developmental
 perspective.” Journal of Consulting and Clinical Psychology 60, 174-184

4. McFarland B & Baker-Baumann T. (1988) Feeding the Hungry heart, Hazelden

5. Alexander P, (1992) “Application of attachment theory to the study of sexual abuse” Journal of
 Consulting and Clinical Psychology 60, 185-195.

6. Orbach, S. (I984) Fat is a Feminist Issue, Hamlyn.