There's a Strong Link Between Bulimia and Past Sexual Abuse

The eating disorder that haunted me for more than a decade was inextricably linked to years of childhood trauma.

This piece is part of Allure's coverage of National Eating Disorder Awareness Week. Please take note that there are mentions of sexual abuse and disordered eating in this piece.

The first time my mom suspected I had an eating disorder, I was 10 years old. I’d just gotten home from school and found her quietly sitting at our dining room table. She was holding a makeup bag full of loose pills that I had hidden underneath the bathroom sink. When she asked me about it with a note of obvious concern in her voice, I replied, “Well, I thought that if I took pills, they’d make me skinnier.” I then started to sob, feeling ashamed and embarrassed.

I was 14 when I was finally diagnosed with bulimia nervosa and body dysmorphic disorder and attended my first treatment center program. Then, another five years passed before I told my loved ones that I had been sexually abused me throughout my childhood. It wasn’t until two years after I came forward as a survivor that I realized the sexual abuse I experienced as a child was at the root of my bulimia — the eating disorder that had, at that point, haunted me for over a decade.

Eating disorders aren't caused by diet culture alone

According to the National Eating Disorder Association (NEDA), national surveys suggest that an estimated 30 million people in the U.S. will develop an eating disorder in their lifetime. Diet culture and societal beauty standards are often blamed for single-handedly being the cause of eating disorders. However, many experts disagree with this common assumption that diet culture is the only — or even the largest — factor that leads to a person developing patterns of disordered eating.

In fact, eating disorders are believed by experts to be influenced by a number of both genetic and environmental risk causes. Though many people think about sexual assault and eating disorders as separate issues, they can go hand-in-hand. The percentage varies, but studies have suggested an upwards of 50 percent of people with bulimia also meet criteria for Post-Traumatic Stress Disorder (PTSD). What’s more, a 2013 study suggested that sexual abuse could have a detrimental effect on body image, leading directly to disordered eating in some cases.

My eating disorder was how, without words, I communicated that I was struggling and hurting.

As a doctoral candidate in the human development and family studies department at Pennsylvania State University, much of Jacinda Li’s focus has involved this topic. Li tells Allure that research published in February of 2019 in Child Maltreatment Research, Policy, and Practice revealed there is a significant correlation between bulimia and childhood sexual assault. “Don't treat eating disorders like they are [only] caused by media and diet culture,” Li says. “Be aware that there may be underlying issues driving the problem.”

What happens when you can't speak up

I continued to experience sexual abuse as a young girl, throughout my adolescent and teen years, but I was silenced and unable to speak up. There was too much shame, too much stigma, and too much fear of retaliation to address the trauma directly. However, bulimia became something akin to a language.

My eating disorder was how, without words, I communicated that I was struggling and hurting. I was quietly begging for an adult in my life to look below the surface and help me find the cause of my pain and disordered eating habits, rather than just slapping a bandaid over the symptoms.

Why survivors use eating disorders as a coping mechanism

According to Amy Edelstein, the site director at The Renfrew Center of New York, eating disorders often serve as a way to cope with PTSD — much like some survivors may seek relief through substance use, self-injury, or engaging in impulsive behaviors.

“The feelings are so intense, or so intolerable, that [survivors] just turn to the behaviors to really dampen the feeling so that they manage in their life,” Edelstein explains. “Eating disorder behaviors serve as an effective but dangerous way to provide short-term relief from the trauma, or sexual abuse in this case.”

Li adds, “Binging is a way for someone to cope with stressful emotions, and sexual abuse often — in short term and long term — produces really disturbing emotions. [...] The act of eating just makes you feel better, because it regulates your stress response, neurologically.” Additionally, Li explains that, while the purging aspect of bulimia can be influenced by diet culture, “There is a theory about how the survivor might try to, through the purging, purge themselves of the ‘dirty’ feelings [associated with sexual abuse].”

Though it's not an ideal coping mechanism, disordered eating can give sexual assault survivors some sense of comfort. Sam, a 19-year-old college student whose name has been changed to protect her identity, says that from the ages of 10 to 16, she was molested by her two brothers. At 13, she developed both bulimia and anorexia as a way to deal with her trauma. “I think [the abuse] contributed to generally being unhappy with who I was, and what I looked like,” she says. “I felt very lost and out of control, and I think the eating disorder helped with that. Taking control of my body felt good, even when it was wrong.”

Bulimia was an act of violence turned inward.

Li notes that it’s not at all unusual for survivors to use disordered eating as a way to dissociate from all the overwhelming feelings PTSD can cause. Though my bulimia was slowly killing me, as I began suffering from thyroid issues and electrolyte imbalances around 16 years old, it was also a means of survival. (The irony that this life-threatening illness was also helping me survive isn’t lost on me.) I binged and purged in the face of the obvious health consequences, so long as it helped me escape the reality of my trauma, if only for a brief second.

How to treat the whole person, not just the symptoms

As I quickly found through my time in treatment centers, I felt either siloed in programs that solely focused on my eating disorder, or overwhelmed in programs that wanted to dive into the crux of my PTSD long before I was ready. It wasn’t until I was 21 that I found a trauma therapist who helped me recognize my eating disorder was largely a coping mechanism — one I used to mitigate the emotional pain and constant state of anxiety I was in because of the sexual abuse I endured. Bulimia was an act of violence turned inward.

Jenni Schaefer, a NEDA ambassador and author of Goodbye Ed, Hello Me, says that professionals need to work towards what she calls “widening the gaze.” They need to look beyond their scope of expertise and adopt trauma-informed practices so survivors with eating disorders receive appropriate treatment for both these co-occurring health issues as early on in their lives as possible. When Schaefer was sexually assaulted, she explains that she was “seeing a doctor, therapist, and a dietitian, among others. Yet every single person missed the trauma.”

Treating symptoms rather than the whole person can have long-term consequences. Edelstein says that survivors with eating disorders who don’t partake in trauma-focused therapies face a greater risk of relapsing. “The unresolved trauma is what’s driving the eating disorder, so you can't take away the other thing without the other one lingering,” she explains.

As studies have discovered, treatments such as eye movement desensitization and reprocessing (EMDR), dialectical behavioral therapy (DBT), and even art therapy can be largely effective for sexual violence survivors — and, these same therapies also show promise in the treatment of eating disorder symptoms. More than ever before, mental health professionals are beginning to understand the undeniable connection between sexual abuse and eating disorders. Now, it’s just a matter of creating therapeutic programs that reflect the research.

It starts with a conversation

Despite their prevalence, both sexual abuse and eating disorders are still shrouded in stigma. However, that's a huge shame, because there’s a lot of empowerment that comes with being able to speak up about the impact of sexual violence on eating disorders. “I would encourage people to talk in a non-blaming, non-shaming way,” Schaefer says in regard to addressing these difficult topics with survivors. “It's real. It's life-threatening. It's killing people. Eating disorders come with the highest mortality rate of any other mental illness. [...] We need to treat mental illness like a physical illness, because it is: It's a brain disorder.”

Talking openly about the connection between sexual abuse and eating disorders is never going to be easy or comfortable. Yet these conversations make survivors with eating disorders feel less alone — seen in a world that often tries to silence them, or render them invisible — and that matters more than being comfortable ever will.

If you are currently struggling, there is help available and you are not alone. For treatment options, visit the National Eating Disorders Association (NEDA) or contact NEDA’s Live Helpline at (800) 931-2237. They're available from Monday through Thursday, 9 am to 9 pm (EST), and on Friday, 9 am to 5 pm (EST). If you're currently in a crisis, you can text NEDA to 741741 — this is available 24 hours a day/seven days a week.

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