Originally Published on TheAtlantic.com on Dec 15, 2015 By Olga Khazan
Christine White was a preteen when she went on her first diet. At school, she was bubbly and sociable, an honors student immersed in social causes. But at home, she would carefully ration her food.
By the time she was 14, she had developed bulimia. It was easier to hide the purging from her family than it was to explain why she wasn’t eating. In her darkest moments, she would scribble her anxieties into a blue-lined journal.
“When I eat food now I feel guilty,” she wrote in rounded, 14-year-old script. “I don’t like to eat in front of other people.”
As a college student, she stopped throwing up but kept overeating. Carbs were her crutch. “If I’m stressed, let me crawl inside a bag of Tostitos,” said White, who goes by her nickname, Cissy. She would shovel handfuls of cereal in her mouth, or boil and eat enormous amounts of pasta.
She didn’t fully understand what drove her binges, but she had one idea—an experience she referred to as “my hell” and “my secret” in later journals.
When White was an infant, her mother began dating a man 26 years her senior, and he lived with the family until White was 10. Though to outsiders he seemed affable, the stepfather was largely unemployed, according to White, and he had a boorish streak. “He was the kind of guy who would beep at pretty women walking down the street,” she said, “even with his kids in the car.”
At home, his immaturity had a sinister element, White said. A number of times, after White showered, he’d make her parade in front of him naked so he could “inspect” her. During games of Yahtzee, he would force her to sit on his lap for longer than was comfortable. He’d grab her behind and make flirtatious comments. Occasionally, he’d put a treat in his pocket and cajole her into fishing around for it.
“I knew that I didn’t like what was happening,” she said, “but I didn’t know what was appropriate.”
To her teen self, White’s body was criminal. “I felt like I was always in a battle with food,” she said. “I just thought, this body needs to be tamed. It makes terrible things happen.”
One analysis of 57,000 women found that those who experienced physical or sexual abuse as children were twice as likely to be addicted to food.
As horrifying as White’s story is, it’s a common one among people who have been abused as children. Researchers are increasingly finding that, in addition to leaving deep emotional scars, childhood sexual abuse often turns food into an obsession for its victims. Many, like White, become prone to binge-eating. Others willfully put on weight to desexualize, in the hope that what happened to them as children will never happen again.
In White’s case, overeating did not lead to obesity—her weight only ever ranged from roughly 118 pounds to 175. But research shows that in general, childhood sexual abuse might be an important predictor of obesity and overweight in adulthood. More importantly, experts say, this disturbing connection suggests it’s fruitless to treat eating-disordered patients without investigating and addressing potential childhood trauma first.
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In 1985, a 28-year-old woman named Patty arrived at a weight-loss clinic in San Diego operated by Kaiser Permanente. The clinic was designed for people who were between 60 and 600 pounds overweight. Patty asked the doctor running the program, Vincent Felitti, for help. Patty weighed 408 pounds. In less than a year, she had shed 276 of them on a near-fasting diet.
“We thought, ‘Well, we’ve obviously got this problem licked,’” Felitti told me recently. “We’re going to be a world-famous department of preventive medicine here.”
Patty stayed at her svelte new weight for a few weeks. Then, in less than a month, she gained back 37 pounds—a feat that would require eating more than 4,000 excess calories daily. Patty blamed it on sleepwalking, saying that though she lived alone, she had been waking up in the mornings to a kitchen covered in opened boxes and cans.
Felitti believed her sleep-eating story, but he asked her, “Why did that start now? Why not five years ago? Why not 10 years from now?”
Patty said she didn’t know. When Felitti pressed her, she said there was a man at work who was much older and married. After she lost weight, he complimented and propositioned her.
Felitti countered that, though the sexual advances were understandably unpleasant, extreme weight-gain seemed like a strange response.
That’s when Patty revealed that her grandfather began raping her when she was 10.
In short order, Patty regained all of the weight and then some.
Patty’s story offered a clue into why nearly half of Felitti’s obesity patients dropped out of the weight-loss program. He interviewed more of these patients and found that 55 percent acknowledged some form of childhood sexual abuse. Like Patty, many would enter his program, slim down, then promptly bulk up again.
Together with Robert Anda at the Centers for Disease Control and Prevention, Felitti would go on to run the Adverse Childhood Experiences Study, which hunted for lingering impacts of difficult upbringings in the general population. The study generated a framework called the ACE Score, or the sum of all the types of trauma a person might have experienced in childhood—everything from their parents’ divorce, to poverty, to physical and sexual abuse.
Women said they felt more physically imposing when they were bigger. They felt their size helped ward off sexual advances from men
The more ACEs a person has, the greater their risk of all sorts of maladies. Six ACEs increases the risk of injecting-drug abuse by 4600 percent, for example. Though some people develop resilience to early adversity, Felitti and Anda found that abuse victims’ ability to “bounce back” without treatment is markedly overstated.
“The things that don’t kill you can make you stronger,” Felitti said. But if they go unaddressed, they can also “get to a point where they become overwhelming and will destroy you.”
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White’s stepfather moved out eventually, but he still made her wary whenever they interacted. His overtures ramped up as White lost weight in adolescence. He’d send her cards and tell her she should be a model. “That was just disgusting to me,” she said.
White’s stepfather has since passed away, but the distress he inflicted loomed over her early adult life. In 1985, when she was 18, she confessed to her journal that she was having trouble having intercourse with her boyfriend. “I’m so frigid,” she wrote.
She wouldn’t have a normal sex life until her early 40s. In college, she’d cry nearly every day and wake up with nightmares and flashbacks.
Experts say sexual abuse is one of the worst adverse experiences, and also one of the most likely to compound other life stressors.
“It’s bad to have a substance-abusing parent, or a mentally ill parent who’s untreated,” said Frank Putnam, a professor of psychiatry at the University of North Carolina at Chapel Hill and another prominent childhood-adversity researcher. “Of all those [ACEs], sexual abuse seems to be the most pernicious. This is particularly true for women.”
“Sexual abuse is about betrayal,” he added. “It’s occurring at the hands of trusted family members and caregivers.”
Studies by Putnam and others have found that sexually abused women are more likely to suffer from an array of seemingly unrelated mental and physical ailments, including premature puberty and problems in school.
One 75-year-old former patient of Felitti’s, who saw him when she was in her 20s and weighed 270 pounds, said she began eating compulsively after a childhood of horrific sexual and emotional violence. (She and several other sources requested anonymity to protect family members and friends.) She now has a host of health problems, like bone problems and tumors in her brain and sciatic nerve, that she believes are related to her weight and mental anguish.
“It bothers you all your life,” the woman told me. “It decimates you as a human being.”
The trauma of sexual abuse often manifests through a preoccupation with food, dieting, and a drive to feel uncomfortably full. One analysis of 57,000 women in 2013 found that those who experienced physical or sexual abuse as children were twice as likely to be addicted to food than those who did not.
One Maryland woman who was a victim of incest at the hands of her father, uncle, and cousin would sometimes go for days without eating as a teen. Now that she’s in her 50s, the pattern has reversed, and she finds herself prone to binges. When at the airport, for example, she beelines for snack shops, buys two to three bags of M&Ms and a pack of Cheez-Its, and downs it all.
“I’m telling myself the whole time, ‘Why am I doing this?’” she said. “We still always carry this guilt around.”
Trauma that occurs during critical periods in the brain’s development can change its neurobiology, making it less responsive to rewards. This anhedonia—a deficit of positive emotions—more than doubles the likelihood that abused children will become clinically depressed adults. It also increases their risk of addiction. With their brains unable to produce a natural high, many adult victims of child abuse chase happiness in food. It’s this tendency, when combined with what many described as a desire to become less noticeable, that makes this group especially vulnerable to obesity.
Constance, a 53-year-old Virginia woman who also asked that I use a pseudonym, was fondled as a young girl by both an older cousin and her grandfather. A few years after the molestation ended, she was at a family function when she became so uncomfortable that she snuck off to a pantry and ate cookies until she felt sick.
“If you think of the body as a clever organism, if it’s exposed to something that’s threatening, it protects itself by making sure there are plenty of calories on board.”
In middle school, three neighborhood boys tricked her into coming over to their house. When she arrived, she said, they held her down and gang-raped her. For years, Constance didn’t tell anyone about the rape. Her weight spiked. When people weren’t looking, she would gorge on cookies, cakes, and chips. By the time she was a teenager, she weighed 180 pounds.
In high school, she turned to drinking and prescription pills, and later, she went to jail and rehab for a cocaine addiction. “When I was under the influence, I was able to come outside of myself,” she said. “I would talk and laugh.” Even after rehab, she struggled with a compulsive-shopping habit that ran up her credit cards.
Today, Constance is still overweight and lives alone. She’d like to find a partner, but she has doubts. “I’m never really quite comfortable or feel safe with men,” she said. “I’m a little afraid of them because I know what they can do.”
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Compulsive overeating doesn’t always lead to obesity, but studies show that sexual-abuse victims are far more likely to be obese in adulthood. Research suggests childhood sexual abuse increases the odds of adult obesity by between 31 and 100 percent. One study found that about 8 percent of all cases of obesity, and 17 percent of “class three” severe obesity, can be attributed to some form of child abuse.
The reasons are both metabolic and psychological, both willful and subconscious. For many victims, the drivers of their obesity act in synergy, compounding each other, and they might change over time. One such pathway is inflammation: The major, unrelieved stress of abuse triggers the adrenal glands to pump out steroid-like hormones. One of these hormones, cortisol, not only affects the brain’s ability to plan things like diets, it also affects appetite, satiety, and metabolism.
And there’s some evidence that stress induces the body to squirrel away fat—a vestige of a time in human evolution when this would have been useful. Chronic stress also sparks the release of chemicals called pro-inflammatory cytokines, which prevent insulin from being taken up by the muscle cells. This is called insulin resistance, and it’s strongly correlated with obesity. “If you think of the body as a clever organism, if it’s exposed to something that’s threatening, it protects itself by making sure there are plenty of calories on board,” said Erik Hemmingsson, an associate professor of medicine at Karolinska University in Sweden.
Abuse victims might therefore become heavy even if they eat normal amounts. One 93-year-old woman, Helen McClure, has been obese for years, but she’s not quite sure why. She doesn’t have a problem with overeating, she says.
As a child, she thought the fact that her father occasionally massaged her genitals was “just a part of growing up.”
“I first realized how bad it was was when I was in junior high and we learned about how babies are born,” she said. “It shocked me.” By then, she weighed 200 pounds.
Many survivors, meanwhile, put on weight in order to protect against future abuse. Women I interviewed said they felt more physically imposing when they were bigger. They felt their size, rightly or wrongly, helped ward off sexual advances from men.
Patricia Borad, another of Felitti’s patients, said physical abuse was a daily part of her childhood. Her mother called her “jezebel”; her father would paddle her and her other siblings if only one of them did something wrong. When she was in her teens, her father refused her permission to go on a camping trip with her boyfriend’s family. When she asked him why, he backhanded her so hard she flew across the room.
“For that reason, I just grew up not being able to say ‘no’ to a man,” she said.
In adulthood, she was fine with the attention she drew from romantic prospects—whenever she was single. But if she was in a relationship, she’d put on weight so that other men would be less likely to flirt with her and try to lure her away from her partner. “If I didn’t want that extra attention from men,” she said, “it was much easier not to get it if I was overweight.”
Another survivor echoed her perspective: “Eating and getting big, I felt like nobody would notice me.”
People who have unexamined childhood trauma often fail when they attempt weight-loss treatments. Some studies show that patients with histories of abuse tend to lose less weight after bariatric surgery or during clinical weight-loss treatment. Among women who were hospitalized for psychiatric treatment after bariatric surgery, one study found that 73 percent had a history of childhood sexual abuse. Gastric bypass prevents them from eating large quantities—thereby removing an essential coping mechanism.
In Felitti’s weight-loss group, there was one woman, also a victim of abuse, who would come every week and sit silently with a smile on her face. One week, she announced that her family had finally scraped together the $20,000 necessary for her to have bariatric surgery.
“Well, this is going to be a disaster,” Felitti thought.
She lost 94 pounds, became suicidal, and was psychiatrically hospitalized five times the following year.
“The [weight] came off too quick,” she told him later. “I felt like I was losing my protective wall.
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These women’s stories suggest that obesity is not what it seems. Given how it increases obesity risk, preventing child abuse could be considered a public-health measure on par with mandatory calorie labels. Doctors may tell overweight patients to diet and hit the gym, but if they’ve suffered childhood trauma, their bodies might be actively working against them. Worse still, the patient might—consciously or otherwise—have a dark reason for remaining heavy.
Felitti eventually incorporated a questionnaire that asks patients about sexual abuse and other childhood trauma into Kaiser Permanente’s Obesity Program. Several obesity-treatment specialists contacted for this story also said they routinely ask their patients about sexual abuse—most won’t mention it unless prompted.
Wendy Scinta, an obesity-medicine specialist in central New York, says the first question she asks patients who seek weight-loss treatment is, “Did you have a happy childhood?”
People who did will say so right away. Among those who didn’t, there’s usually a pause. A “hmmm.” A vague explanation. If the patient recalls abuse, Scinta might refer them to the psychologist she has on staff.
Some doctors say they struggle to secure insurance-plan payouts for the extensive psychological or psychiatric treatment that abuse survivors require. About half of psychiatrists don’t take insurance, and half of U.S. counties have no mental-health professionals. The Centers for Medicare and Medicaid Services covers 16 to 22 visits per year for obesity-related medical counseling, but psychological therapy is not included.
“With people who are abused, you have to uncover their awful wounds before they get better,” said Marijane Hynes, an internist at the George Washington University Medical School in Washington who focuses on obesity. At her hospital, psychiatry residents see many of her patients for free, and she’s not sure how she would provide mental-health treatment without their help.
Some survivors find unorthodox routes to restoring mental and physical health. Later in her life, McClure, the 93-year-old abuse victim, began speaking regularly on abuse issues to groups of doctors, social workers, and police departments. The advocacy “has certainly dulled the pain and given me a sense of pride in the fact that I have been able to turn my disgusting story into a tool to help others,” she said.
White, the woman who documented her teenage dieting and bulimia in journals, was diagnosed with post-traumatic stress disorder in her 20s. After suffering an anxiety attack, she called the health center at her college, which referred her to therapy. She would ride the bus to the therapist’s lily-white, immaculate office twice each week. “I used to refer to it as paid-for parenting,” said White, who is now 49 and living in Weymouth, Massachusetts.
The therapist was warm and welcoming. Eventually, though, White felt it wasn’t enough to simply talk about her emotions. Her abuse had left her feeling like an amputee, she said. Talk therapy was like retracing the question, “How do you feel about the fact that you can’t get up the stairs?” she said—when all she really wanted was a ramp.
In her 30s, she enrolled in a writing workshop. She and dozens of other people, many of them survivors of trauma, would sit in a room, compose essays about their pasts, and share their work with the group. At first, being open about her childhood felt awkward. But after each of the four sessions, White found herself feeling better for months.
It was around that same time that she began regularly practicing yoga. That, too, was fraught initially. For a survivor of sexual abuse, lying down in a dark room with strangers, as most yogis do at the end of a class, was scary. Gradually, though, the practice helped her once again feel safe in her skin.
Decades later, the days of seeing her body as tainted are finally over for White. She still believes she’ll be keenly sensitive to stress for the rest of her life. But now, when something triggers her—like her home flooding a few years ago—she turns to a relaxation technique called guided imagery to manage her symptoms. She’s become an advocate for abuse victims, and in 2014 she opened her own writing workshop.
She says the abuse will always tug at her, but today its power is diminished. “That’s just stuff that happened to you,” she said. “It isn’t you.”
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Olga’s reporting on parenting and childhood was undertaken as a project for the Fund for Journalism on Child Well-Being and the National Health Journalism Fellowship, programs of the USC Annenberg Center for Health Journalism
