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Title:
Disgusted by food explanatory models of anorexia among young Taiwanese adults
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English
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McLawhorn, Donald E
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University of South Florida
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Subjects / Keywords:
Eating disorders
Chinese
Social constructionism
Lay understandings
Cultural models
Dissertations, Academic -- Sociology -- Masters -- USF   ( lcsh )
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non-fiction   ( marcgt )

Notes

Summary:
ABSTRACT: Anorexia as a nosological category has developed in a western context and is now being applied to people around the world. In order for researchers to know they are asking the right questions about AN as knowledge expands, it is important to understand what meanings Anorexia carries and how those meanings manifest locally. The present study to aid in that understanding by employing a mixed methods (survey and in-depth interviewing) research approach in answering the following question: In what ways are Taiwanese students' explanatory models of anorexia nervosa (AN) congruent with or different from professional understandings derived from the western Bio-medical perspective? In answering this question, this study first addresses the current state of research on anorexia as well as the recent findings from studies done in Asia. Subsequently, the findings of the present research address what are young, Taiwanese adults' notions of the causality of AN.In particular, the present research found that student explanations of AN are focused predominantly on two causal forces; namely, the desire to be thin or the inability to eat as a result of psychosocial pressure arising from some interpersonal interactions. Additionally, Taiwanese students also maintain that AN can be explained by other less common factors. For instance, significantly more males than females believed that AN could be explained by some physiological dysfunction in the anorectic person. This study seeks to contribute to the literature by examining how college-age Taiwanese understand and conceptualize AN; which in turn may help towards understanding how other research conducted among Chinese populations has produced findings that are incongruent with the expectations suggested by the western, biomedical model of anorexia nervosa. There is further need for cross-cultural research on AN including lay understandings.This should focus not only on the "accurateness" of lay models as has been the case with the majority of research on lay models of AN in the past, but future research should consider the appropriateness of current research and public health models that influence both research and policy.
Thesis:
Thesis (M.A.)--University of South Florida, 2008.
Bibliography:
Includes bibliographical references.
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by Donald E. McLawhorn.
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Title from PDF of title page.
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Document formatted into pages; contains 50 pages.

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oclc - 319547642
usfldc doi - E14-SFE0002577
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ABSTRACT: Anorexia as a nosological category has developed in a western context and is now being applied to people around the world. In order for researchers to know they are asking the right questions about AN as knowledge expands, it is important to understand what meanings Anorexia carries and how those meanings manifest locally. The present study to aid in that understanding by employing a mixed methods (survey and in-depth interviewing) research approach in answering the following question: In what ways are Taiwanese students' explanatory models of anorexia nervosa (AN) congruent with or different from professional understandings derived from the western Bio-medical perspective? In answering this question, this study first addresses the current state of research on anorexia as well as the recent findings from studies done in Asia. Subsequently, the findings of the present research address what are young, Taiwanese adults' notions of the causality of AN.In particular, the present research found that student explanations of AN are focused predominantly on two causal forces; namely, the desire to be thin or the inability to eat as a result of psychosocial pressure arising from some interpersonal interactions. Additionally, Taiwanese students also maintain that AN can be explained by other less common factors. For instance, significantly more males than females believed that AN could be explained by some physiological dysfunction in the anorectic person. This study seeks to contribute to the literature by examining how college-age Taiwanese understand and conceptualize AN; which in turn may help towards understanding how other research conducted among Chinese populations has produced findings that are incongruent with the expectations suggested by the western, biomedical model of anorexia nervosa. There is further need for cross-cultural research on AN including lay understandings.This should focus not only on the "accurateness" of lay models as has been the case with the majority of research on lay models of AN in the past, but future research should consider the appropriateness of current research and public health models that influence both research and policy.
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PAGE 1

DisgustedbyFood: Explanatory ModelsofAnorexia Among Young Taiwanese AdultsbyDonaldE.Mclawhorn, Jr. A thesis submitted in partial fulfillmentofthe requirements for the degreeofMasterofArts DepartmentofSociology CollegeofArts and Sciences UniversityofSouth Florida Major Professor: Donilcen Loseke, Ph.D. Michael Kleiman, Ph.D. Jeannine Coreil, Ph.D. DateofApproval: June25,2008Keywords: eating disorders, chinese, social constructionism, lay understandings,cultural models Copyright 2008 DonaldE.McLawhorn, Jr.

PAGE 2

TableofContents: ChapteroneIntroduction ChapterTwoRecent Anorexia Research in the West Epidemiological Research Genetic Research Risk Factor Research The Socio-Cultural Model Chapter Three Recent ResearchonAnorexia in Asia ChapterFourRational and Questionsofthe Present Study Chapter Five Methods Chapter Six Findings Quantitative Measures Qualitative Findings The Lexical Understanding: Anorexia as Disgust "Disgust" as Result 5 5 5 778IIII141416 1620 20 20 27 2731

PAGE 3

TheRoleofPressure: "Disgust as Indirect Cause Chapter Seven Discussion References11135414144

PAGE 4

ListofTables: Table I: PercentageofRespondents Agreeing with Statements Regarding the CausesofAnorexia Table2:Three Conceptual Categories Derived from Survey Table 3: Participant Agreement per Item per Conceptual Category Table4:Within Gender DifferencesofAverage NumberofItemsAgreed with per Conceptual Category Derived from the Survey Table5:Independent Samples TestofMean Differences Comparing Within-Gender Agreement with Average NumberofItems per Conceptual CategoryIV2122232426

PAGE 5

DisgustedbyFood: Explanatory ModelsofAnorexia Among Young Taiwanese Adults DonaldE.McLawhorn, If. ABSTRACT Anorexia as a nosological category has dcveloped in a western context andisnow being applied to people around the world. In order for researchers to know they are asking the right questions about AN as knowledgc expands, it is important to understand what meanings Anorexia carries and how those meanings manifest locally. The present studytoaid in that understandingbyemploying a mixed methods (survey and in-depth interviewing) research approach in answering the following question: In what ways are Taiwanese students' explanatory modelsofanorexia nervosa (AN)con!o'fUentwith or different from professional understandings derived from the western Bio-medical perspective?Inanswering this question, this study first addresses the current stateofresearch on anorexia as well as the recent findings from studies done in Asia. Subsequently, the findingsofthe present research address what are young, Taiwanese adults' notionsofthe causalityofAN. In particular, the present research found that student explanationsofAN are focused predominantlyontwo causal forces; namely, the desire to be thin or the inabilitytoeat as a resultofpsychosocial pressure arising from some interpersonal interactions. Additionally, Taiwanese students also maintain thatANcan be explained by other less common factors. For instance, si!o'llificantly more males than females believed thatANcould be explainedbysome physiologicaldysfunction in the anorectic person. This study seeks to contribute to the literaturebyexamining how college-age Taiwanese understand and conceptualize AN; which in turn may help towards understanding how other research conducted among Chinese populations has produced findings that are incongruent with the expectations suggested by the western, biomedical modelofanorexia nervosa. Thereisfurther need for cross-cultural research on AN including lay understandings. This should focus not only on the "accurateness"oflay models as has been the case with the majorityofresearch on lay modelsofAN in the past, but ti.lture research should consider the appropriatenessofcurrent research and public health models that influence both research and policy.v

PAGE 6

ChapterOneIntrodnction Consider for a moment the following situation: a young man in Taiwan sees a television news piece describing the near deathofa famous western singer from a disorder that led her to self-starvation. A public service ad tells him that in the past few years some young girls in his own country also have begun engaging in extreme fonnsof"dieting" that have led to necessary hospitalizations. When he looks on the internet he finds a plethoraofinfonnation on the "syndrome" he has heard calledzheng";he reads that people with the problem lose a great dealofbody weight yet maintain an intcnse fearofbeing fat.IBut when he reads the labels on commonly used antacids and other stomach medicines, he finds''yam'hi zheng"among indicated conditions. Hc could also find Chinesc news web sites infonning him that Chinese medical records dating back 316 years describe the same phenomenon now called''yanshi zheng"but that there was not a systematic understandingofthe problem, nor did it have a clinical name until thirty years ago.2This is not an unlikely scenario in Taiwan today with the varietyofinfonnation socially available on anorexia nervosa(AN),and one might expect that Taiwanese understandingsofit would be multitudinous.Inthe f()llowing pages, I will suggest that among young, college-age Taiwanese thereisless ambiguity than one might expect.ihnp://www.epochtw.com/8/1/3/74348.htIn2http://W\v\v.taiwan-I==o%E5%81%A5%)E5%BAf!/oB7%IE8%I

PAGE 7

The explanatory models they employ in understanding and deseribing AN are sophisticated, coherent, and can aecount for disordered eating on their island. The present research explores the ways in which such understandings differ from western, professional knowledge and may serve to explain someofthe anomalies in cross cultural studiesofAN.Inparticular, I will address how college-age Taiwanese explain and understand Anorexia etiologically. Past research has shown that mental distress is more likely to be expressed somatically among Chinese than American patients (A. Kleinman, 1980), a findingofparticular importance when western physieians treat a Chinese patient for depression. Similarly, Anorexiaasa nosological eategory has developed in a western context and is now being applied to people around the world.Inorder for researchers to know they are asking the right questions about AN as knowledge expands, it is importanttounderstand what meanings Anorexia carries and how those meanings manifest locally. To accomplish, this I will first address the current stateofresearch on anorexia as wellasthe recent findings from studies done in Asia. Then I will tum to the findingsofthe present study which present young, Taiwanese adults' notionsofthe causalityofAN.2

PAGE 8

Anorexia nervosa is a psychiatric diagnosis listed intheDiagnostic and Statistical ManualofMental Disorders(American Psychiatric Association, American Psychiatric Association.TaskForceonDSM-IV,&Stat!ref electronic medical library, 2000) as well as theInternational ClassificationofDiseases(World Health Organization, 1992). DSM defines the disorder with the following criteria:A.Refusal to maintain body weightator above a minimally normal weight for age and height (e.g., weight loss leading to maintenanceofbodyweight less than 85%ofthatexpected; orfailuretomake expectedweight gain during periodofgrowth, leadingtobody weight less than 85%ofthat expected).B.Intense fearofgaining weight or becomingfat,even though underweight.C.Disturbance intheway in which one's body weightorshape is experienced, undue influenceofbodyweight or shape on self-evaluation, or denialofthe seriousnessofthe currentlowbody weight. D.Inpostmenarcheal females, amenorrhea, i.e., the absenceofatleast three consecutive menstrual cycles.(Awoman is considered to have amenorrheaifher periods occur only following honnone, e.g., estrogen, administration.) Restricting Type: during the current episodeofAnorexia Nervosa, the person has not regularly engaged in binge-eatingorpurging behavior (i.e., self-induced vomiting orthemisuse oflaxatives, diuretics, or enemas) Binge-Eating/Purging Type: during the current episodeofAnorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting orthemisuseoflaxatives, diuretics, or enemas) (DiagnosticandStatistical ManualofMental Disorders, Fourth Edition 307.1 Anorexia Nervosa)According to researchers, the groupofbehaviors and ideations that make up AN predominantly affect girls and young women (Walsh&Devlin, 1 998)and can lead to serious health problems and death with mortality estimated anywhere from .3% to as high as 20% (Cummins, Simmons,&Zane, 2005). 3

PAGE 9

The studyofAN'setiology is something that has been researched for some time (for a theoretical review: (Gamer, Garfinkel,&Bemis, 1982, and has branched across disciplines and research methodologies.Inthe next section I will briefly summarize the research doneonanorexia by dividing it into four sections; Epidemiological, Genetic, Risk Factor, and Socio-cultural research. I will follow with a scction devoted to recent research conductcd within Asia, with a fl)cus on Chinese populations.4

PAGE 10

ChapterTwoRecentAnorexia Research in the West:Epidemiological Research: Ascertaining valid ratesofANhas proven quite difficult due in large part to methodological problems surrounding population selection and case identification. Because there is an extremely low prevalence rate in the general population, it is necessary to study inconveniently large sample sizes (Wakeling, 1996).Inaddition, those with the disorder are likely to conceal the outward signsoftheir illness as much as they can.Inthe past, researchers have dependedonexisting medical records when calculating rates, but this tends towards underestimationofboth prevalence and incidence. Although diagnosed cases in hospital settings are reliable and precise, the search for community rates has required methodological ingenuity. Currently, the best solution to these problems is the two-stage screening method whereby a large population is initially screened for symptomsofANusing various scales (ie. Eating Attitudes Test, Eating Disorder Inventory) and final cases being determined after conducting clinical interviews: allofthose defined as "at-risk" and a random sampleofthose defined as not-at-risk are interviewed to make the final assessment(Hoek&van Hoeken, 2003). 5

PAGE 11

Fourteen studies done within the time frameof1981-2002 have shown prevalence figures for AN that range from .2% to .9% with a prevalence average in the USA and Europeof.3%(Hoek&van Hoeken, 2003). The average age range in these studies was 14-20 years, which is the period considered to beofhighest risk for developing the disorder. Interestingly, prevalence has been shown to be higher among study participants born after 1945 (Bulik et ai., 2006), which raises the questionofchanging ratesofincidence. Besides the increase in referrals for eating disorders in general, researchers have been able to uncover gradual rises in the incidenceofAN as documented by medical recordsofhospitals, psychiatric case registries,orrecordsofcare providers. Since there have been very few studiesofAN within the general population, it is reasonable to assume that even thefi!,'llrescurrently known are underestimationsofcommunity incidence. This is evinced by the varietyoffindings; Swedish hospital records from75years ago show an incidenceof.0Ii100,000 population per yearasopposed to12/I00,000 population in the United States in the 1980's. A Finnish, twin cohort study found a much higher figure than any previous studies270 per 100,000 person-years ( 95% CI= 180-360) (Keski-Rahkonen et ai., 2007). A reviewofstudies showed an estimated increase among females aged 15-24 since the 1950' s at a rateof1.03per 100,000 person years every calendar year(Hoek&van Hoeken, 2003), and the consensus seems to point to an rising rate. 6

PAGE 12

Genetic Research: Twin studies have shown that monozygotic twins (genetically identical) have been foundtodevelop AN athalfthe rate (10% vs. 22% concordance rates for AN)oftheir dizygoticcounterparts, which is not supportiveofa genetic causality. These twin studies have indicated, however, that AN aggregates in families, leaving the relationship between biology and environmental factors unanswered (Walters&Kendler,1995).Interestingly, other twin studies have found that girls who had been hospitalized for AN treatment were also three times as likel y also to be girls whose gestational age had lasted 32 weeks or less (Striegel-Moore&Cachelin, 200 I). Given such intriguing findings, researchers believe there is still a strong need for research examining both the biological and social/environmental correlatesofAN. Risk Factor Research: Studies investigating risk factors for AN have been primarily cross-sectional and have found a dose-response effect whereby the odds-ratios for developing AN increased linearly with risk factors (Striegel-Moore&Cachelin, 200 I). Stated otherwise, fewer measured risk factors correlated with lower disease prevalence within the population studied while higher numbersofrisk factors increased odds ratios. Most studiesofrisk canbediscussedintem1Sofbiological, psychological, and social domains, but these factors interactincomplex ways that pointtoa multifactoral etiology. Researchers have focused on every conceivable detail ranging from temperature at conceptionto"negative emotionality"(Steiner et aI., 2003).7

PAGE 13

There are some risk factors on which thereisgeneral agreement. Already mentionedisthe fact that it aggregatesinfamilies(Bulik et aI., 2006; Schmidt, 2003)and it has bcen found that premature birth (OR 1.9) and complications during delivery (cephalhematoma; OR 1 .9) also increase riskofdeveloping AN (Lindberg&Hjem, 2003). While the disorder is more common in children whose families are in a higher socioeconomic b'Toup(Lindberg&Hjem, 2003), having parents with psychiatric problems (ineluding AN) and experiencing foster care before age l3 also contribute to the psychosocial risks associated with the onsetofAN (Lindberg&Hjem, 2003; Steiner et aI., 2003; Striegel-Moore&Cachelin, 2001). Being teased about physical appearance also has been investigated in the contextofother eating disordcrs, which contributes to the discussion on the sociocultural aspects within which AN might develop (Jackson, Grilo,&Masheb, 2002). One risk factorinparticular has predominated research and has found its way into the DSM criteria for the disorder: body dissatisfaction that grows outofthe feelingofnot meeting some cultural beauty norm(Katzman&Lee, 1997; Steiner et aI., 2003; Striegel-Moore&Cachelin, 1999; Striegel-Moore&Cachelin, 2001). The socio-cultural model: The sociocultural modelofeating disorders(StriegeJ-Moore, Silberstein,&Rodin, 1986), originally intcnded to explain gender differencesinthc prevalenceofeating disorders in the USA, has maintained thatthe social pressures regarding ideals relatingtobody image and the extent to which they are importanttofemale gender roles and social success arc the primary causal force behind anorexia. The suggestionofthis approach is that culture or certain sociocultural factors are pathogenic. 8

PAGE 14

Studies in the past two decades seem to favor the socio-cultural model in its explanations as to why some women develop eating disorders, which has in turn led to other research on the pervasiveness ofthin-hody ideals in the west and the influeneesofmedia on body image. Oneofthe results evolving outofsuch research is the fascinating variableof"acculturation" that has shown up in eross-sectional population surveys (The American International Relations Survey {AIRS; (Sodowsky&Plake, 1991)}, Sociocultural Attitudes Toward Appearance Questionnaire {SATAQ; (Heinberg, Thompson,&Stormer, I 995) and the aeeulturation scale, SL-ASIA (Suinn, Rickard-Fil,,'ueroa, Lew,&Vigil, 1987) are examplesofsuch measures (Striegel-Moore&Caehelin, 2001.This approaeh has grown direetly outofthe elaims being made in the 1980's and early 1990's that the oeeurrenceofAN is somethingofa western phenomenon. Only fifteen years ago, for example, the elaim was made by researehers that AN was "virtually unheardofin China" (ConditV.K.Anorexia nervosa: levelsofCausation.Human Nature1,395,1990. Quoted by (Lee, 1995. Anorexia has often been ealled a Culture Bound Syndrome, eonsidered to be extremely rare outside a handfulof"western" countries. By measuring aeeulturation levels, researehers have attempted to estimate the extent to which young women from other cultural backgrounds have adopted American social values(Davis&Katzman, ]999; Stark-Wroblewski, Yanico,&Lupe, 2005). 9

PAGE 15

The finding from such studiesisthat social values regarding beauty ideals and body image bave a direct relationship with the experiencesofyoung women regarding their eating behaviors, and it is for this reason that issues sUlTotmding body image have played so heavily into Risk Factor research. Whether or not this same relationship holds in non western populations isofparticular importance. Research to date has helped shed light on the complexity that comes with trying to explain etiology. Genetics, fetal environment, childhood exposure to stress, chronic stressors and a hostofother factors have been under scrutiny. Perhaps as a resultofwhat seems to be a multifactoral etiology, the socio cultural model has been a dominant explanatory schema among western researchers. As with previous research regarding schizophrenia and depression, investigators have been lookingatANin cultural contexts outsideofthe USA and Europe with the hope that more can be gained in understanding what causes this health threat.10

PAGE 16

Chapter Three Recent Research On AnorexiaInAsiaSome research has emphasized that increased westernization does not necessarily lead to embracingofa thin-body ideal as is outlinedbythe adherentsofthe socio-cultural modclofAN. While several studies ( see Lee etal.1996 b.) have suggested that among female, Chinese undergraduates, there is an elementofbody dissatisfaction similar to that found among their American counterparts, others have found that thinness and fatness can be seemingly unrelated to the eating behaviorsofsome "anorectics" (Hsu&Lee, 1993; Lee, Ho,&Hsu, 1993). In fact, many patients offerrationalizations for food refusal that do not include concerns for fatnessorwcight at all, but rather explain their behavior with physical reasons like bloating or lossofappetite (these are mentioned in DSM as being motivations for food refusal that disqualify a diagnosisofAN)(LeeetaI., 1993; Lee,Lee, Ngai, Lee,&Wing,2001).When there are comparable levelsofbody dissatisfaction and fat/weight concerns, however, they scem to fall on a gradient where the more rural groups tend to have lessofa concern than do more urban ones. This was found when comparing female high school students in Hong Kong, Shenzhen, and rural Hunan(Lee&Lee,2000).Clear gradients among ditTering populations like these are often interpreted as lending support to the sociocultural modelofeating disorders; but as those authors point out, western ideals may play lessofa role than other forces involved in societal modernization and change.II

PAGE 17

Because there have been no studies in East Asian that assess community wide ratesofAN, only disparate information is available from research aimed towards particular at-risk groups. For example, students enrolled in high-school dance classes were compared to non-dance students in the same Taiwan school in 2003, showing higher ratesofAN among dancers (.7% vs..1 %) (Tseng et aI., 2007). A reviewofstudies done in Hong Kong, Singapore, and China have yielded similar findings with rates ranging from 0%, to those that match what we find in the United States and Europe(Cummins et aI., 2005)3, yet thcre are no large representative studies that assess prevalenceorincidencebywayofclinical interview and diagnosis. Large studies document the signs, symptoms, and associated features related toANamong participants (Huon, Qian Mingyi, Oliver,&Guanglan Xiao, 2002), but these might be able to help understandingofthedisorder when combined with what is already known. A studyof1,246 school girls (mean age, 15.76 years) from six cities from differing regionsofChina found 60%ofparticipants to be underweightbywestern standards with surprisingly high ratesofweight concern, purging, dieting and food refusal. Interestingly there wcre no identifiable casesofanorexia among severely underweight girls and only .2%ofthose underweight met criteria for a full DSM diagnosis(Huon et aI., 2002). These kindsoffindings, while surprising, are not unprecedented; others have doeumented Mainland Chinese with higher ratesofbody dissatisfaction yet lower ratesofcating disorders than their Chinese American and white American counterparts., Their review failedtoinclude Huon.GailF.2002.12

PAGE 18

The same seemingly paradoxical findings have been found in India and Pakistan, Singapore and Hong Kong whereby surptisingly high levelsofdisordered eating attitudes and symptoms (most often measured by the scale, EAT -26), weight concern, and body dissatisfaction simply do not correlate with casesofAN and other diagnosable eating disorders (Cummins etaI.,2005).13

PAGE 19

Chapter Four Rationale and Questionsofthe Present StudyRather than focus merelyonbody image and cultural, beauty ideals, it is necessary to examine what food refusal means locally. Psychiatry and theDSMare Etic approaches to human behavior and behavioral breakdown (Fabrega, 1992; Fabrega, 1993). The caseofanorexia, as with other disorders that manifest across cultures, is one that has proven the need for Emic approaches that investigate the possibility that culture or certain sociocultural factors are pathoplastic; that is, the manifestation and courseofcertain mental disorders and their symptomsmaybe shaped and alteredbycultural factors.Thepotential insights and limitationsofthe sociocultural modelofanorexia seem tobehingingonjustthis point.Ifwe want to understand this particular disorder,wemayneed to consider that the "natural history"ofthe disorder is a "cultural history" (Littlewood, 2004) and that there are as many formsofit as there are differentgroupsofpeople. Like somanyother areasofpsychiatric research and practice, knowledge is incomplete.Theproblem we face today is that there is almost no placeonearth that has continued to make itself impregnable from western, cultural ideas whether it be through music, television, print ,or other media. This being the case, researchers have had to approach AN across cultures in a tedious way, looking at both lay perspectives on eating disorders as well as how patients understand their own experiences. 14

PAGE 20

Our limited understandingofthe circumstances under which AN manifests in societies outside the United States and Europe makesitimportant to develop an anthropologyofthis psychiatric prohlem insofar as AN is a western disease category being applied to non-western societies.Ifwe hope to provide culturally meaningful health services, it is important first to have knowledgeofthe understandings people apply to their experiences and to the experiencesofothers in their shared cultural environment. This study seeks to contribute to the literature by examining how college-age Taiwanese understand AN. This in tum may help towards understanding how other research conducted among Chinese populations has produced findings that arc incongruent with the expectations suggested by the western, biomedical modelofanorexia nervosa.Inparticular, this study addresses the following question:Question:Inwhat ways are Taiwanese students' explanatory modelsofANcongruent with or different from professional understandings derived,/rom the western Bio-medical perspective? To accomplish thisitwill be necessary to answer two related questions: first, what are someofthe general features pertainingtoetiology in Taiwanese students' explanatory modelsofAN? Second, what roles do the concepts borrowed from western understandings and the socio-cultural model (body image, body dissatisfaction, and fear offatness) play in Taiwanese understandings AN?15

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Chapter Five MethodsTo answer these questions I have used a combinationofquantitative and qualitative methods; this mixed methods approach consistedofa survey/questionnaire assessing student's perceptionsaswell as in-depth interviews. The quantitative data are drawn from 384 written surveys that were self administered in a central, major city in Taiwan. The surveys were completed in the summerof2007 by upper-level undergraduate students at three different universitiesoftechnologyinTaizhong County. Three professors, one from each institution, volunteered to infonn students that a foreign visitor would be looking for participants to complete a surveyofstudent opinions about Yanshi Zheng. I prepared an introduction to the purposeofthe survey explaining that it was anonymous and voluntary so that the professors eould adequately infonn those who wanted to participate. The surveys were administered and collectedatthe endofelass period and took approximately 10-14 minutes for students to complete. Students ranged from18to 34 yearsofage. The survey consisted mainlyofitems drawnfroma questionnaire developcd by Sing Lee (a psychiatrist/anthropologist from the Chinese UniversityofHong Kong), which had been previously usedtostudy lay perspectivesofAN among university studentsinHong Kong(Lee, 1997). After obtaining pennission from Lee, I modified the questionnaire by adding questions pertainingtoreligious belief; ethnie identity, and geographical regionofchildhood.16

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I then translated it into Mandarin Chinese and had it back translatedbya Chinese instructor from the UniversityofSouth Florida. The survey consistsof75questions graded on a five point, Likert-type scale ranging from "strongly disagree" to "strongly agree" The questions are divided into three main sections and are designed to elicit students' understandingsofthe symptoms, etiology, and treatment for anorexia. After completing all data collection for this study, I decided to limit the useofquantitative data only to the 29-item, Etiology sectionofthe survey. The reason for this is twofold. First, the qualitative data suggest that students' understandingsofthe symptoms and treatmentsofanorexia closely mirror western, professional understandings that can be foundinthe DSM and research literature, which also was the findingofLee in Hong Kong when using the original survey(Lee, 1997). Second, the qualitative data proved to be more interesting and diverse, especially with regard to the questionofstudent's explanatory modelsofetiology, which is the focusofthe present study. For these reasons, I have chosen to use the quantitative data to map the field with regard Taiwanese students' explanatory modelsofthe causesofAN while drawing more heavily from qualitative data in order to gain a more in-depth understandingofhow they explain and account for AN as a phenomenon. Qualitative data consistof27 in-depth interviews from a sampleofstudents completing questionnaires who volunteered to be interviewed. The interview sample consistedof]8 women and19men ranging torm ]8 to 34 yearsofage. Interviews were conducted predominantly in Chinese unless the students chosetouse English; each interview took place outsideofclass and lasted from1.5to2.5 hours.]7

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While issuesofsymptoms, etiology, and treatment for AN were addressed at some point in the discussions, participants chosetofocus predominantly on etiology. The interviews were largely unstructured with the exception that all interviews contained four questions that served to introduce topicsofinterest. The questions are as follows:1.)"Have you ever heard theterm'Yanshi Zheng', andifso what doesitmeantoyou?"2.}"What do you thinkisthe cause or causesof'Yanshi Zheng'?" 3.) "What do you think are the symptoms or evidence that someone has 'Yanshi Zheng,?,,44.}"Are there successful waystohelpresolve'Yanshi Zheng';ifso, what are they?" Interview data were analyzed with a grounded theory approach, which is a strategy for analyzing qualitative data (Denzin&Lincoln, 2000; Glazer&Strauss, 1967) Rather than beginning with theoretical suppositions, this approach develops theoretical considerations from the dataaspossible. Data are not forced into pre-existing categories, but categories are formed from data. I paid careful attention to the choiceoflanguage that participants made especially when different Chinese choices are possible. Thematic codingofinterviews facilitated understandingofconceptual similarities within and between interviews in such a way that ideas held in common can begin to emerge.4Chinese grammar requires the useofthe transitive verb, "have".18

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In addition to the in-depth interviews, the findingsofthis study are also indirectly informedbyinformal conversations with numerous Taiwanese peopleofvarying ages and backgrounds. Also, I have lived and studied in Taiwan for over three years with the unique opportunityofseeing tirst hand what kindofinformation is publicly available on AN through various formsofmedia. Particularly in the summer 01'2007, I spoke with many people that I met in diverse social contexts with the goalofencouraging them to talk about anorexia as they understood it. The procedures for both typesofresearch methods used in this project were reviewed and approved by the Institutional Review Boardofthe UniversityofSouth Florida. Written, informed consent was obtained from all participants in this study.19

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Chapter Six FindingsQuantitative measures: Survey response data were coded using the following scale: "strongly a!,'fee" or "agree"=I; all other responses were codedas"0". An accountofthe frequenciesofagreement with respect to each survey item is listedindescending order in Table I. These frequencies give a general overviewofthe extent to which participants found each survey item to be a possible explanation as to the causeofAN.20

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Table1: PercentageofRespondents Agreeing with Statements Ahout the CausesofAnorexiaHow muchdoyou agree or disagree that eachofthe following items is a causeofanorexia? Mental strain/pressure FearofFatness Stress related to work/career Mental Problems Influence from foreign standards about the definitionofbeauty Academic pressureorfailure Emotional experience that was very difficulttomanage Fastidiousness (with respect to eating habits) Chronic lossofappetite Physical disorder Lossofrelativesorclose friends Brain chemistryorbrain dysfunctionShenjing Shuairuo(Neurasthenia) Throat discomfort makingitdifficulttoeat Influence trom the media Stomach bloatingorstomach pain Previously fat Taiwanese attitudes favoring thinness Alienation from family Social Isolation (loneliness) Desiretogain attention from familyifriends, etc. Reaction to a feelingofno control overliteOverprotective family which atTected development Genetic disorder Yin Yang imbalance Mental disorderGenuinfection Influence from spiritsorghosts (entering the body, etc) Desire to control other peopleTotal89.06% 84.11% 83.59% 82.29% 77.34% 76.30% 75.52% 72.66% 70.83% 68.49% 67.71% 60.68% 59.64% 58.59% 57.55% 57.29% 55.99% 53.91% 52.86% 46.61% 41.67% 40.62% 32.03% 32.03% 30.73% 29.43% 27.86% 19.53% 10.42%Theoriginal 77 ilemsurveyallowed for coding thatcouldthematically organize responses around several conceptual categories.21

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The 29 item section on etiology covers three conceptual categoriesofexplanation for the causeofAN: Physiological, Psychosocial Stress, and cultural norms pertaining to beauty (body image). Drawing from the 29 items listed in Table I, eachofthese three conceptual categories was operationalized by either 5 or 6 questions with a scale that measured agreement(l)ordisagreement (0) for each question. After summing the total agreement across all participants for each category, the sum was divided by the numberofitems in the respective categoriestogive mean agreement per conceptual category. Table 2 illustrates the questions used in defining each category.Table2:Three Conceptual Categories Derived from SurveyrPhysiological CausesofAN:IHowmuchdoyou agree or disagree that eachofthe following items is a causeofanorexia?I10.) Physical disorder12.) Brain chemistry or brain dysfunction14.) Throat discomfort making it difficult to eat 16.) Stomach bloatingorstomach pain 24.)Genetic disorder 27.) Gcrm infectionIPsychosocial Stress Related CausesofAN:,1.)Mental strain/pressureI3.) Stress relatedtowork/career6.) Academic pressure or failure!7.) Emotional experience that was very difficulttomanageif..11_1_l_.)_L_O_S_S_0_[r_e_Ia_t_iV_'e_s_o_rBody-Image Related CausesofAN:120)FearofFatnessII5.) Influence from foreign standards about the definitionofbeautyI15.) Inf1uence from the mediaIIIS.)favoringthinnessI.i17.) PreVIOusly tatl__22

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Table 3 contains a breakdownofparticipant agreementbyconceptual category. The numberofitems that particpants agree with per category as well as average numberofitems agreed with per category is shown. Table3:Participant Agreement per Item per Conceptual Category..73inI.66.51I category:IAverage numberofItems agreed with I across allIparticipants: Numberofitems in I ParticipantsIParticipants Participants conceptual category agreeing with itemsiagreeing with items agreeing with items indicating: indicating: indicating: Physiological Psychosocial Cultural normsofI ICauses Causes Beauty/ BodyIImage Related Causes 033persons 28 persons 9 persons,8.6% 7.3% 2.3%II47 personsi33persons10personsI11.5% 8.6%!2.6%I2 80 persons 49 persons 34 persons 20.8% 12.8% 8.9% 3 84 persons71persons93persons 21.8% 18.5% 24.2% I 4 76 personsI96 persons 145 persons---119.8%I25% 37.8%,II 5I56 persons 107 persons93personsI,!14.6% 27.9% 24.2%II6 28 persons NAINA 7.3%I.,.AI,'Teementwith 3 orImore items perI64%I71% 86% 23

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The figures in Table 3 depict the average levelsofagreement that participants held with respect to each category's explanatory power in accounting for the cause(s)ofAN. These numbers suggest that participants are leastlikcly to account for AN with physiological explanations, and they are most likely to agree that AN is caused by psychosocial stressors. Table 3 also illustrates that participants are often simultaneously able to agree with multiple, causal explanations at the same time, addingtothe complexityoftheir beliefs. The average numberofitems agreed with across all participants' for each respective, conceptual category was examined by gender to determineifthere was a difference in agreement between genders. The within gender, average agreement with each conceptual category is illustrated in Table 4 below.Table 4:WithinGender DifferencesofAverageNumberofItems AgreedwithperConceptualCategoryDerivedfromtheSurvey.genderNMean Std. Deviation Body-ImageWomen173 .748028090ConcernsasCause Men208 .5865 .31425PhysiologicallyWomen173 .454727733CausedMen208 .5545 .27989Psycho-Socia!VVomen173 .7480 .23193StressasCause Men208 .71542304224

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Itcan be seen from Table 4 that on average women agreed with 75%ofthe items that account for ANbycauses related to body-image concerns, with a smaller average agreement (59%) upon itemsbymen. Conversely, men agree withhalfofitems that explainANphysiologically while there is less agreement (45%) from women. Participant agreement with items accounting for ANbypsycho-social stressrelated causes was found to be 75% and 72% among women and men respectively. An independent-samples t-test was conducted to examine within-gender difIerences in mean agreement with eachofthe three explanatory categories forANbetween men and women. The test was significant with respect to the categoryofbody image related causes (t= 5.2, p= .000) and physiological cause (t=3.4, p=.OOI).The within-gender differences with respect to agreement with the psychosocial stress model was not significant. These results are summarized in Table 5 below. 25

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Table5:Independent Samples TestofMean Differences Comparing Within-Gender Agreement with Average NumberofItems per Conceptual Categoryt-test for EqualityofMeans 95% Confidence Interval Si9. (2-ofthe Difference tdftailed)Mean DifferenceLowerUpper Body-image Equal Related Causesvariances5.237 379 .000 .16144.10083.22205assumed5Physiological EqualCauses variances-3.479 379.001-.09977 -.15616 -.04337assumedPsycho-Social Equal Stress Relatedvariances1.371 379.171.03259 -.01417 .07935CausesassumedThe test shown in Table 4 suggests that Taiwanese woman are more likely to explain AN as being causedbycultural factors related to body image. Taiwanese men, on the other hand, are more likely to believe that AN is causedbysome physiological malfunction in the person with anorexia.5Test results with equal variances not assumed differsby.04orlessforall figuresinthis tableandsignificanceisnotaffected.26

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With regard to psychosocial explanations for the causesofAN, there is no significant differences between Taiwanese men and woman. Among both genders, physiological explanations are thc least supported followed by body image related causes. The most supported explanations are those that account tor AN in termsofpsychosocial stress, and this agreementisnot different between genders. Qualitative Findings: The Lexical Understanding: Anorexia as Disgust I have never met a Taiwanese person under 30 yearsofage who enjoyed being told that she/he had grown tatter. This was also true for all the participantsinthis study who individually told me that they prefer to hear from others that they were thinner than in the near or distant past. The reason this is interesting is because the traditional Chinese wayofcommunicating to others that they appear healthy and successful is by telling them, "you'vc gotten tat!" To show conccrn for someone or their family's hcalthorfinancial situation, one would typically say,"you'regetting thin!" While people older than 40 still communicate this way, younger people almost never do.Inthis kindofcontemporary social context, where young people prefer to bear that they are thin, the meaningofanorexia takes on a cultural significance.Asexpectable, there is not an obvious homogeneity with regard to how Taiwanese explain anorexia. This canbe made immediately elear from simply asking afewpeople what the meaningofthe phenomenon is.27

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Two common explanations that one might encounter have to do with areasofChinese culture about which there has been no shortageofeither humor or serious discussion: appetite and weather. Rather than using terms like "hello!", the Chinese traditionally haveb'Tectedeach other with thephrase"have you eaten?", or more literally, "are you full?". To the Chinese, those living in Taiwan not excluded, food and appetite make up an areaofculture that is nothing less than an art form. The Chinese classical textDao De Jingclaims that no ruler will find a peaeeful country without tirst having full bellies, and no business deal is really engaged until participants have eaten their full. Similar gravityisattached to cooking, where the Chinese believe that typesoffoodmust be diligently matched together so that the body is fully satisfied and adequately nourished. The same goes with the Chinese cultural viewofweather, where tenns describing weather conditions are simultaneously used to describe inner emotional states.Itis surprising then that conversations with locals in any Taiwan city can lead to the concluding explanation that people who starve themselves simply do not want to eat, no longer having the appetite for which the Chinese are famous. Whydon'tthey have a "nonnal, healthy appetite"? Explanations vary, and the weather often comes into the discussion. The hot weather ruins their ability to eat, and they will get worse unless we "offer them cold dishes like cold noodles and allow their appetites slowly to return."28

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When conversations run this kindofcourse, one wonders whetherboth parties are really talking about the same phenomenon; we use the same Chinese term that translates to"anorexia" ,yanshi zheng-disgustedorhate! food /illness)6 but in some cases it seems that only the lexical meaningofthe termiscommunicated. One reason for this is that the Chinese term is a compoundofwords known to anyone with an elementary school level education. Most Americans probably do not know the Greek meaningofthe term "anorexia'but rather know the term from popular culture. This is almost never the case with Chinese, however, since almost every native speaker will understand the etymologyofeach character evenifthey have not heardofthe phenomenon before. For example, any native speaker can guess the meaningof(naoyan), but most Americans could not guess from the term "encephalitis" that the etymology refers to inflammationofthe brain. As a resultofthischaracteristicofthe Chinese language, a Taiwanese person could speak withmeabout AN without addressing anything more than what is conveyed in the lexical meaningofthe Chinese term: a kindofillness where people do not eat because they are disgusted by food. What is more common, however, is that someone will explain AN by giving synonymic explanationsofthe term and offering a reason for it.(,Because thisisthe only Chinesetern1commonly used to refer to the English term Anoreixa, I will hereafter use them interchangeably, Other Chinese terms are used professionally and add on the equivalent of"nervosa", whichinChineseisactually the term for "ueuro" (the full Chinese terms are:---shenjing xing yanshi zhengorjingshen xing yanshi zheng).29

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For example, when the weather is blamed,itappears that the lexical meaningoftheterm for AN is being expanded with a meaningful accountofhow a person might corne to experience the phenomenonofhating or being "disgustedbyfood".Inother words, the Chinese term, being neutral with regard to causation, is ripe for etiologieal explanation. This difliculty highlights the importanceofthe roleoflanguage for cross-eultural research.Inparticular, it serves as a foundation for inquiry into how Taiwanese young people understand anorexia. The explanatory models are grounded in the Chinese language; the lexical meaningofAN serves as the organizing schema that ean be "filled in" with particular cause-effeet explanations that account for how people get to thestate that they refuse food even to the pointofdeath. When looking particularly at young adults in Taiwan today, what doesYanshi Zhengmean beyond the mere lexical meaning? Allofthe participants in this study were familiar with this term and communicated unique features about it that explain it as a particular kindofhealth threat. Specifically, their explanatory models for AN are patterned into the meaningofthe Chinese term, and the lexieal meaningofyanshias the "disgust/hate" for foodisunpaeked in mainly two fonns. Bothofthese conceptual models for explaining AN are rooted in the anorectic's not wantingtoeat and disgust with food; in the firstofthese, disgust is an eventualresultofnot wanting to eat while in the second, disgust is an indirectcauseofnot wanting to eat. 30

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While survey respondentsindicated that they agreed withhalfofthe items that account for ANintermsofphysiological causes, interview participants never mentioned physiological causes for AN unless asked directly. For example most participants stated that parasitesorgastrointestinal problems could conceivably lead to anorexia when I directly asked them. This may account for why the physiological items are the least supported on the survey. Additionally,ifI directly asked whether AN could be caused by spirit or demonic possession, some participants stated that it is possible that some instancesofAN may have such a cause. The predominant topics that surfaced in the interviews, however, were never initiated by me. The notionsofAN as literally being "disgusted by food" in relation to body image concernsorpsychological pressures were brought up and expounded on numerous times by those interviewed, and they proved to be the explanatory models that almost every participant held in common.Itis to these major themes that I now tum. "Disgust" as Result: Only one interview concluded with the participant claiming that AN was unrelated to a desire for thinness7 ;all other participants stated that anorexia is related to a thin body ideal with a desperate pursuitofthinness that is almost always exclusively experienced by young women.7This man I call Fox is quotedinthenext section.31

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One participant even selt:rcported that she been anorexic in thc past as had a friend, and that her situation was oncofbody image, thinness, and dicting.PeiChuan8 :"[alsohadthis problem. Man}' girlshavethesamereason...theylvanlanicefigure,f111eanbod)' shape.Interviewer:"Hm-vdoyoukn01Vyouhadit?"Pei Chuan:"I/ustwantcdto lose weight and look good, notfat,Andatfirstlwould/usteatlessandmaybe eat small things,It/ustkeeps goingandfinallyI lost a lotandwouldn'teatall day. It stops theperiod>,'[menstrua/j.ButnOlVJdon'fhavetheproblem".While a desire to be thin is only one featureofTaiwanese understandingsofAN, itisan important feature that is believed tobesuffieienttolead to the disorder. For most young Taiwanese, this means that many anorectic, young girls feel the strong need to "pursue a good (body) shape", whichisoften associated with the desire to "attract males". Some called this a "model ideal" (as in "fashion model") whereby young girls are "worried about their weight" and are eonstantly afraid that they willbeviewed as fat, something that I was told on more than one occasion.TomYang:"People'rviththis problem really want to become thin ... they1vanttohelike a model, especially to attract males, I mean, mostly to attract males. That isH'hyithappens. They don'{want tobefatandare allvays worried about their lveight. "Christy Xu:"'I knotv, someone lvhoH-untsto lose lveight, e,\peciall.J/ girls. Sometimes mJ"friends ejpecia/ly{faguytells themthe)"are/cItandneedto lose weight ... the}' maybejustdrinkandlvon'teat anything.Andtlwvsleep a lot;::wmetlme,')'lveHYJf7}'ahout that .,SAll participant names are changed. Many participants gave me English first names with Chinese last names. In those cases I will use similar names,32

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Jenny Fsu:"Asian people liketobe thin...iti..,'related to European influence about thinnessandprettiness.Tobeone must be thin. More and morepeoplesa}',fbI' example, tobelike models,orfamous others, ,Yingers, and such, they say that it is better to look like thin.Toda.v,man)' teenagers are like this too. They strive to be thin, so theyH/orktOlvardsfinding a method to let themselves grow thinner. Those methods are diverse;forexample, they take medicines, exercise to lose lveight,andeatonZvatvegetarian restaurants.AnyH'a}',when the)' reducethefoodit affects the stomachandchanges their metabolism. Theyfindthat the}' lvant to eat something, hut immediatel'feeluncomfortable in theirstomachsandjustthrmvup.Oneyoung girl even mentioned that she believed thatANdid notexist at all in Taiwan even ten years prior, and that it was a new phenomenon broughtonby media, Japanese social nonns, and western celebrity influence.Jenny Chen:"Some girlstopursueagoodshape, and theycan'tcontrol themselves. Little by little they become craz.v about it.Hlvfaybe there isn'{this kindofthin ideal inAjhca, I think it has only been inASiaforabout ten )/ears. "TanYang: .It iskindAlaybe1vedidn'{have this 100 years ago. It is inourcities, but maybe not in Africaatall. 'While not everyone agreed with this time frame, allal,,'reedthat increasing social pressure on young women to have bodies approximating celebrities ( Literally, "bright stars") from across Asia and the United States has led young women to refuse food and engage in dangerous "dieting methods",oneofwhich is toYanshi.This was believed to be more common among those most "concerned with fashions", those "spoiled"bywealth,orthose who more readily embrace "social definitionsofbeauty". These descriptionsofanorexia are congruent with the Socio-cultural modelofeating disorders in explaining what gives rise to the phenomenon. They are not obviously compatible, however, with the lexical meaningofthe Chinese tenn.33

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For this reason I intentionally askedallparticipants whether thetennYanshi Zhengwas etymologically appropriate for the experiencesofyoung women and girls that they were describing to me. For most westerners, the Chinese choiceoflexicalcharacters to denote anorexia seems inappropriate for the disorder; this is equally true for the Greek originsofour English, medical tenn. When asked about AN, everyone without exception explained that Anorectics"don'twant to eat"buxiang chi dong xi), but do they really "hate food" or are they really "disgustedbyfood"? One young man explained to me that "hate is after reaching a levelofscverity". Accordingtothe Taiwanese understanding, these girls start out by wanting to be thin and must control their hunger; they do not hate food and are not disgustedbyit, but gradually this becomes the case.Interviewer:Sol,vhenpeople like your/i-fend who develop YanShi Zhengftersomeone tells them theyare/at,lu)1,vdothey/cellvhentheyseefood?Christy Xu:'...ffi!comes/i-om their l,vanting to loselveigh!they might....vant to eatfood,butthe.vhavetostop thinkingandseeing/ood.Interviewer:"To control themselves?Christy Xu: "Yes".Interviewer:''Youmeanthey)ivantto eat?"Christy Xu:"Yes,inthe beginning"By forcing themselves not to eat, anorectics get to where they cannot. Numerous explanations clarified that it is from prolonged food refusal that girls slowly become disgusted by the sight or thoughtoffoodwith feelings similar to "food nausea in pregnancy", which is the resultofa conditioned physiological response is. For example "their stomachs are smaller and smaller until food becomes disgusting". 34

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One young woman explained:Vicki:"n.itcouldbelvhenitfirs!starts onesa)--'s,'/l,vanltodiet', Likememaybe{(Idiet/orafelvday.,'IjuststarttofeellikeJdon',lran!toeatatallanditjustgets more intensc ... Always thinking about something elseandnever thinkqfeating also...Control themselves untUtlleygetto thepointthatH.-'henthey,)'eefiJOdthey really don'('wantit,althoughat/irs!theyH-'unttoeat1,1'henthe.-vseefood. Butafterdaysorlveeks they changeandlosethe desire, thentheyjustfeeldisgustedb.Y'it.".Employing this interpretation maintains the integrityofthe termYanshi,while also maintaining that the aversiontofood can he explained as a consequenceofthe goalofweight loss. For some women, the thin body ideal is so strong that it becomes a tlxation that gradually worsens with more increasing severity. The physiological ctfects escalate, personal perceptions become more distorted, food intake becomes increasingly less with time, and finally death becomes a real threat. According to this schematic understanding, AN is a slow psychological and physiological conditioning process that gets worse with time, results in a disgust with tood, and can lead to lossoflife.The RoleofPressure: "Disgust" as Indirect CauseWhile the experienceofbeing "disgustedbyfood" is often described as a consequenceofrigorous dieting, it is also described as an indirect causeoffood retusal. Only one participant who explained AN in termsofa thin body ideal and subsequent dieting also went on to claim that she believed that it had nothing to do with any other kindofpressure other than thatofbeing thin.35

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Liao"Ithink its about some girls lvholvonyabout their body1-veight.ThatLvmy.firstirnage.Then[thinkabout some boys, maybe the same reason.. don't eat too much. At.first1think this is girls. Alaybe theyjustdrink lvater or nutrition drinks, or drink soups. They do that ...Jthink they, they lvant theirbodJ'to match a standard. The",tandardbodyis.!1'omtvorsome pictures ...ormedia. They are afraidtobefat. Its not healthy, not natural. People don't want to befctl.Ma.vbe they can usethisl'myto not eat food. They want toeat,hutjustdon't becausebody. They want.. other people, they want to makefriends. They think its easier to make a gir(/riendorboy/dend.The.ywant otherpenonstocall them beautiful. Theirfriendsthem.Iftheir friendsdon'teat much, they wont either. "Conversely, the only partieipant who (mentioned in the previous section) claimed AN had nothing to do with diet or body image maintained that AN was strictly the resultofother kindsofemotional/psychological pressures.Interviewer:So you've heard"yanshi zheng".Fox:Ah ,Yes..but noneofmyfh'endshave this problemInterviewer:TVhenyou hear this,vvhatdoes it mean?Fox:Don't wanttoeatInterviewerDon't lvanttoeat?Is'that the meaning? Anything else?TVh.vdon'ttheJ'want to eat?Fox:1believe becauseInterviewer:What kind q(pressure?Fox:Um,ma.vbe the pressure becauseoflile,schoo!,job.. Interviewer:Wnen they seetheloodlrhatdothe.vleet?Fox:Nointerest.Interviewer:Can anything else cause this problem?Fox:Um..1thinkjust pressurecause:.,'yanshi zheng. No other reason.Interviewer:Your meaning is that this is not about losing lveight?Fox: .....lvell, thatisnotJ'an.':l'hizhengAll other participants discussed anorexia both in tenusofpeople's desires tobethin and as a productofwhat mightbetenued psycho-social stress, and with only one exception, everyone used the phrase "pressure is too great"**:yali tai da)toaccount for certain instancesofanorexia's onset. 36

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One interviewee in particular mentioned that her own anorexia was not about body image or beauty, but was the resultofpressures in her family and private life, while the anorexiaofothers may very well be brought on by a fearoffatness.Lilylun: "A{vfamily is verypoorandmyfather is velY5'ickThatLvIrhy1movedhere toHYJrk.Thepressure is vel}'heavyonmebecause I alsohaveachild thatliveswith them. Because Ifeelsomuch pressure, that is lvhy 1 havedevelopedYanshi zheng.lcannoteatatall. Sometimes I onzveatsome peanuts,ordrink a broth.Thefhodmakes mefeel."iekllmv.I keep losinglveightandChang (abOJ,./h"cnd)tellsmetoeatandnot to loselveight.Ijwi/can'I.That isallbecauselife.1knmrilldon',change somethingit'vtJillkillme.Interviewer: "did you everlfl'to lose lveight?Lily:"No.Yanshi zhengis sometimes becausepeoplewanted to loselveight,hut notaIH"a.vs.It1vasneverthatforme.For some there isjusttoo much pressure. "While pressure from society can be leveledonthe individual arising outofbeauty nonus, it does not need to. This second featureofTaiwanese explanatory modelsofAN is unique becauseofits independence from the thin body ideal. While the thin body ideal was mentioned as a sufficient condition for ANinthe previous section, "too much pressure" is viewed by Taiwaneseasa necessary condition insofar as even the thin body ideal existsasa categoryofpressure. Pressure need not entail the thin body ideal, however, and this feature is what needs more explanation. Other research on cultural ditlerences in conceptual modelsofdepression has documented how Chinese people use the notionof"thinking too much"(Karasz, 2005) to account for depression, which is not uncommonly comorbid with anorexia according to DSM. The same is also true with Taiwanese explanatory modelsofYanshi Zheng. "Thinking too much" is among the most common explanationsasto why people begin food refusal.37

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With regard to Taiwanese modelsofAN, thinking too much or ruminating over some responsibilityorpressure ("pressure is too great") can lead to the conditions that give rise to eating disorder. There are specific kindsofpressure to which Chinese are very sensitive: the expectationsofparents weigh heavily, the stressofthe Chinese examination system is extreme, and the social change and pressures experiencedbyyoung, new wivesina strongly patriarchal society are three typesofstrain often mentioned which are experienced by the at-risk age group. Other pressures believed to lead to eating disorder are break ups, job loss, or divorce (Chinese men rarely ever marry a divorcee, but the converse is not so).Interviewer:.,Where doesitcomen."Jessica:"itis a kindqlmentalproblem"Interviewer: "But what is the cause?"Jessica:"Broke up with boyfriend..orhave some troubleinyourfami(v.AfaybeyouloseYOllrjob..orhave abigstressfromJ'ourboss. Divorces'n.Thenpeoplethink too much.Oh,One more thing ...rna,l'beyouv-van!to do something perfi;xt. "Interviewer:"Itsrelated topCJ:!ectionism?".Jessica : "Yes"Interviewer:"HOHJ?Thatissome kind afpressure?"Jessica:"{(voulvantto make somethingperfectthat can cause a lotafpressure"Interviewer: "That'sI<'Jrallpeoplevvithyszorsome
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While the explanatory model that employed the conceptofa "thin body ideal"toaccount for AN suggested that women forced themselves not to eat only later to find that they could not, the "Pressure is too great" conceptualization works differently. First women do not want to eat because they have no interestorappetite, and after the condition worsens they too find that they cannot eat. The initial lossofappetite also approximates the nauseaofpregnancy eventuating in physiological inability to eat, sickness, and threat to life. The descriptionofa thirty-year old woman named Viki summarizes the same ideas repeatedly expressedbyall but two participants in such a representative way that I will allow more space for her comments in closing this section:Interviewer:Whenyouheartheterm YSz9I-vha!doesitmean?Viki:Certainl}' thatoneisundertoomuchpres:wreandthen ...Hwll,onemeaningisaninternalfactor;oneisundertoomuchpressure,oritcouldbe the case,asanexternal/actorthattheyIvan!tochangetheirbOt(vandwantto diet. Wecansaythatsomepeoplediet to excessInterviewer:Sodieting....Viki:(interrupting;seemstorhink"sodieting")vas aquestion)Not necessarily.Interviewer:Sosometimesitis stressrelatedandsometimesnot?Viki:Stress isaninternal/actorbutsometimesitisjustexternalInterviewer:Youmeanitcanbedividedintoflvafjpes?Viki:Yes,justintrinsic tothepersonandextrinsic.Interviewer:Canyoutellme1vhat isthed((ference?Viki:ThebeginningreasonforH-'h.vpeopleget}'sz is d(fferent.Interviewer:Soyoumean...Viki:(interrupt.") itcouldbewhenitfirststartsonesays, 11vant to diet,andthentheylose a little l,veight. Likememaybeif1dietfi)rainvdaysIjuststarttofeellikeIdon'twanttoeatatallanditjustgetsmoreintense.Oritcouldbetotally dfiferent. rVhenitfirststarts itcouldbebecauseonespsychologicalpressureisjusttoobigandyoujustdon'twantto eat,maybepressurefromworkorsomething...andthenyoubegin tobecomethin.Andthenmuchlateronyouhatefhod,don't1vantit.Interviewer:So, um ... toomuchpressureandthere isnoappetiteandonedoesn't1-vanttoeatanditjustgetsivorse..Viki:Ahl'ays {hinkingtoomuchaboutsomethingelseandneverthinkingofeatingalso.A1aybe eventheyforgettoeat.Interviewer:JVhataboutpeoplewhodevelopJ'SZbecausetheybeginbylvanting to lose1-veight9"YSZ" is short forYanshi zheng,the Chinese term for Anorexia.39

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Viki:Inmythinking there aretyVOkinds ,..oneisbecauseandoneistodielWhenitistodiet, they control themselves until they gel to the point that lvhenthe,vsee/i:JOdthey rea!(v don't lvantit,althoughatfirstthe,YwanttoeatlA/henthey seefhod. lv/aybe they start counting calories..,So they really have to controlthem5ielve,'l'.Yest1wvreally control themselves strongly, but after days or Hxeksormonthsthe,Ychangeandlose thede5'ire,Interviewer:When the otherssee/hodthe.vfee![pause]I mean the ones you said start becauseofstress ...?Viki:Nodesirous feelings. See itandfeellike vomiting.. maybe/eelfull. Peoplervithanorexiasee/hodandfee! disgustingandlvanttovomit. Like sometimesinthe summer, itisso hot out.rVhenI see some piece armeatIf"elit looks disgusting and I don't wantit.Itislike that.Interviewer:Almost evClY Tall.vanese person has told me this same idea..Like pressureanddieting are tlvo roads..Viki:(interrupting) yes, tlvoroads that can converge on the sameendpaint.40

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Chapter Seven DiscussionThe purposeofthis study has been to detennine in what ways Taiwanese students' explanatory modelsofAN are congruent with or different from professional understandings derived from the western Sio-medical perspective. This purpose made it necessary to explore someofthe general features pertaining to etiologyinTaiwanese students' explanatory modelsofAN. Oneofthemain goalsofthe study, theretore, was to consider what roles the concepts borrowed from western understandings and the socio cultural model (body image, body dissatisfaction, and fearoftatness)play in Taiwanese understandingsofAN. The socio-cultural model has been the predominant model used by western researchers in studying the causes, course, and outcomes for anorexia(Garner&Gartinkel, 1980; Gamer, Olmsted,&Garfinkel, 1983; Schmidt, 2003; Striegel-Moore, Silberstein,&Rodin, 1986; Striegel-Moore&Cachelin, 1999; Striegel-Moore&Cachelin, 200 I; Walsh&Devlin, 1998). Insotar as public health interventions are intonned by research, it is important continually to examine variations in how people understand illness and its causes in ordertodevelop the most culturally appropriate and etfeetive approaehes to prevention and care. With respect to young Taiwanese adults, this study has found that local understandings are complieated and are not always conl,'fuent with western perspectives or the socio-cultural modelofeating disorders. For instance, while there may be a hostofperipheral explanations tor AN, there are two major explanatory models for anorexia that Taiwanese young people seem to share in eommon that make up a cultural modelofthe disorder. The firstofthese is eompatible with the socio-cultural model.41

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The second and most predominant understanding explains Anorexia in termsofpsychosocial stress that leads to lossofappetite, eventual t()od refusal, and the eventual threatofdeath. This predominant understanding is consistent with past research among Chinese that found while westerners are more likely to experience psychological distress with psychological symptoms, Chinese people more often express psychological distress with bodily symptoms (Karasz, 2005;A.Kleinman, 1972;A.Kleinman, 1980;A.M.Kleinman, 1977;A.Kleinman, 1982;A.Kleinman, 1988). The increaseofANamong Chinese populations in general and Taiwanese in particular might suggest that tood refusal has beeome a culturally appropriate idiom with which people can express distress.Inany case, both explanatory models are clearly present during discussionsofYanshi Zheng,and they almost always are held independentlyofeach other while being held simultancouslylO In other words these two categories, along with the third, can easily be offeredbythe same individual without any apparent fearofcontradiction, and with these three models, any given instanceofAN is expected tobeexplained. While the present study has offered some new insight into Taiwanese understandingsofAnoreixa, it sutTers from a number oflimitations. First, the survey participants wcrc not a representative sample that allows for generalizations about all Taiwanese people. Secondly, only the section on etiology was used in this study. From the etiology section, only a small numberofitems were available tor use in coding conceptual categories.10This does not preclude the possibility that a given instance oLAN might be the result a combinationofthose factors explain by each modeL The suggestion, however,isthat ANislikelytobe causedbyoneofthe three.42

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Future research could correct bothofthesc problemsbyusing more representative samples with more thorough survey formats. Lastly, qualitative data could be more extensive including people from morediverse backgrounds. Despite these limitations, the findingsofthis mixed methods approach have suggested that according to lay Taiwanese understandings, the cause and courseofanorexia may be more complex than has been assumed by past research. Once thought to be a western, culture-bound syndrome increasing in non-western countries as a resultofthe influenceofwestern media and values, AN can be seen as a complicated phenomenon that is not necessarily caused or manifested in the same way across various cultural and geographic landscapes. Other research has begun to point to similar complexities regarding AN around the globe while suggesting that its increase may have more to do with the pressuresofsocietal modernization than it does with the globalizationofwestern values(Katzman&Lee, 1997; Lester, 2007). The present study has highlighted some ways in whichANmay be understood in the Taiwanese context with the hope that researchers will continue to gain insight into the ways that self-starvation varies by cultural contexts, in tennsofwhat it means to people and how it is reacted toina given society. This kindofawareness can help us look eritically at our own illness eonstructionsaswell as help us look at psychiatric eoncerns across cultures without imposing our own understandings on others. The ultimate goalisto improve knowledgc for the sakeofimproving careinan environmentofempathy and humility.43

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