3 Chapter 3 – Physical Development and Embodied Gender
Gowri Parameswaran
Learning Goals
- Understand brain development during adolescence
- Learn about physiological and hormonal changes in adolescence
- Understand body dysmorphia and eating disorders
- Learn about the social construction of disability
- Explore gender, sports and its impact
Chapter Outline
Brain Development and the Role of Toxic Stress
Puberty
Changes in Physical Stature
The Timing of Puberty and its Impact
Puberty and Gender
Silence Around Menarche
Youth and their Bodies
Body Dysmorphic Disorder and Eating Disorders
Factors that Lead to Disordered Eating
Interventions
Obesity
Postmodern Perspective on Youth and Bodies
Critical Disability Studies
Sports and its Impacts
Glossary of Terms
Brain Development and the Role of Toxic Stress
The brain is a very dynamic organ constantly forming new connections and, padding the connections with myelin or fat, and pruning off connections that are not used. The connections that form early in life provide the foundations for growth in later life. In recent years, there has been mounting evidence that both genes and experiences are equally important in building the architecture of the brain. Experts use the term serve and return (Center on the Developing child at Harvard, 2011) to signify the interaction between individuals and their environment. When individuals are not responded to appropriately by the environment, the brain does not grow as predicted. Thus, this back and forth between adult caregivers’ (and general environmental) responses to children and the latter’s reactions to their caregivers, form the very basis of the architecture of the brain.
Another finding that is very relevant for brain growth at all ages, especially during childhood and adolescence, is the presence of toxic stress. This is a term used to describe consistent and high stress levels in individuals with little social support can lead to compromised brain development. Stress is a normal part of life for people of all ages. However, when the stress level of a child or an adolescent is activated, and there is social support to buffer and bring the levels back down, children grow from the experience. Temporary increases in stress levels like during a child’s first day in preschool, can lead to positive learning and adjustment. Stress responses that are intermediate as when the child loses a loved one, can be buffered by loving social support and interactions. However, repeated toxic stress levels like when a child is physically and emotionally abused, can create permanent damage to the brain that may well last into one’s adult years. The earlier these stresses occur, the more severe their impact is in terms of development delays and other physical health issues.
In the early years of a child’s life, fear and anxiety are common. Between 6 to 12 months of age children begin to express and differentiate fear from other emotions. This often coincides with stranger anxiety that is one of the milestones of children’s emotions currently. This is followed a little later by a fear of monsters and other imaginary creatures. As kids grow older, they begin to understand the difference between fantasy and reality and begin to exercise control over both their emotions and the circumstances that produce these fears. Two extensive structures in the brain are involved in the experiencing of fears and anxieties in people – the amygdala and the hippocampus. The amygdala helps identify fearful situations and people, while the hippocampus registers the response needed to react to fearful situations. Consistent prolonged situations that invoke fear and extreme anxiety lead to the disruption of the functioning of both the amygdala and the hippocampus.
The excessive levels of cortisol and adrenaline in the brain that accompanies stressful situations leads to the formation of strong memories around the anxiety-inducing event which further impedes unlearning those fears. Every encounter with the similar situation even if not inherently fear-inducing, can lead to a flood of cortisol leading to intense stress and anxiety. In addition, prolonged fear disrupts the architecture and the functioning of the prefrontal cortex. The prefrontal cortex is responsible for making thoughtful plans, focusing attention, and inhibiting impulses. Chronic fears in a situation leads to children associating threat with people and situations around the original fear-invoking situation, leading to the formation of phobias. Therapy involves the active unlearning of the fears by introducing the aversive stimuli in a safe environment and allowing the prefrontal cortex to offer rational explanations for the consequences. Evidence indicates that a significant source of stress and anxiety is in homes where the parent or parents have mental health issues or are addicted to illicit drugs. In such homes, the child is surrounded by unpredictable events, sometimes accompanied by neglect and abuse, all of which produce stress.
There is evidence that supportive relationships even amidst a very toxic setting can lead to ameliorating some of the impact of stress on the brain. Thus, social policies that provide families with appropriate financial, physical and emotional support go a long way towards reducing children’s sense of insecurity. In addition, in late childhood and adolescence it is important to focus on the impact of chronic stress on children themselves. One under emphasized source of stress is neighborhood poverty and violence. Living in poverty-stricken environments has an impact on children’s cognitive development, sense of well-being, feelings of empathy and self-esteem. Governmental intervention to reduce poverty and increase safety in poor communities goes a long way towards reducing antisocial behavior, violence and physical impairments.
Puberty
In popular media and culture there is consensus that puberty is a time of unprecedented growth and development. Adolescents themselves first notice and acknowledge the growth and respond with intense self-consciousness about their changing bodies. Puberty is marked by a rapid acceleration of growth in both height and weight, the growth spurt. In addition to the dramatic overall physical development, there is the development of primary and secondary sex characteristics. Primary sexual development refers to the development of the gonads leading to maturation (the gonads take the form of testes in males and ovaries in females) and secondary sex characteristics include pubic hair, face and body hair and the changes in genitals and breast tissue. There is great variability among adolescents both in the timing of pubertal changes as well as the time it takes for the physical changes to manifest themselves. (American Psychological Association, 2002).
There are changes in the secretion of hormones by various endocrine glands around puberty that affect the development of sex organs and sexual functioning. Endocrine glands secrete hormones directly into the blood. The glands in the endocrine system that play a major role in pubertal changes are the pituitary gland, the thyroid gland and the adrenal gland. The process begins in the hypothalamus which is a small organ in the brain that is responsible for regulating hormone levels in the body. Certain neurons in the hypothalamus called Gonadotropin Releasing Hormone (GnRH) send signals to the pituitary gland. The pituitary gland is responsible for hormone secretions by other glands like the gonads. The gonads in turn adjust the circulating androgens and estrogen hormones in boys and girls. The thyroid and the adrenal glands also increase their hormone production right before puberty leading to psychological changes and increased vulnerability to stress. The adrenal glands release ‘cortisol’ which is a stress hormone and when a developing person is subjected to excessive stress, the circulation of ‘cortisol’ in the blood increases dramatically leading to a cascade of negative mental and psychological transformations in the adolescent (Wheeler, 1991).
Changes in Physical Stature During Adolescence
Adolescents grow through a period of growth spurt just preceding sexual maturation. Girls typically begin their dramatic growth spurt at 11 years and boys begin theirs at 13. Thus, during early adolescence, the early-maturing girls are taller than the late maturing boys. At their peak growth period, adolescents are growing at a rate faster than at any other time during the lifespan except during toddlerhood. The growth spurt is uneven throughout adolescence with limbs growing faster initially and the torso catching up later. This accounts for the gawkiness that many adolescents feel during their early adolescent years. By the end of adolescence, both boys and girls are often done with growing. This is usually achieved by the closing of the ends of their long bones.
The muscle-fat ratio which is the proportion of muscles to the proportion of fat in the body changes for boys and girls during adolescence. Before puberty, gender differences are minimal in muscle and fat and for both boys and girls there is an increase in both fat and muscles during adolescence. After puberty, boys’ evidence significant increases in muscle weight over fat content while girls add more fat cells relative to muscles. This gender difference is exaggerated with girls participating less in sports and having access to poorer nutrition compared to boys. The increase in fat is one of the many reasons that girls are more likely to suffer from negative attitudes towards their bodies in adolescence. This phenomenon is accentuated by a society that objectifies girls and where popular media emphasizes thinness as an essential aspect of being attractive while at the same sexually objectifying and fetishizing breasts and hips.
The Timing of Puberty and the Secular Trend
There is a wide age range when the events leading up to puberty arrive for both boys and girls. There is a 2-year gender difference in pubertal changes, beginning at age 9 in boys and 7 in girls. In addition, there are ethnic differences in the ages at which children achieve sexual maturation – African American and Mexican girls achieve puberty earlier than white girls. There are several factors that affect the age of sexual maturation and the rate of pubertal growth. There have been studies that demonstrate the importance of genetics in sexual maturation. However, environmental factors play a role as well. Girls who are taller or heavier mature earlier. Better nourished individuals and those who are free from chronic illness also tend to go through puberty earlier than malnourished and unhealthy girls. One significant finding has been that girls who engage in excessive exercise achieve sexual maturation later in their adolescence (Dusek, 2001).
In many countries, the nutritional situation has improved for much of the population over the last 150 years. This has led to a lowering of the age of menarche in girls. This trend towards early sexual maturity has been termed the ‘secular trend.’ In addition to better nutrition, increased hygiene and a drop in infectious diseases has contributed to the trend of lowered menarche for girls. The decline in the age of sexual maturation is less obviously dramatic for boys mainly because of the difficulties in measuring sexual maturation in boys. The secular trend has been demonstrably more noticeable in some communities, for example among African American girls. In recent years the trend towards lower menarche has been slowing down as compared to the early decades of the 1900s when the reduction was dramatic. Just as in other areas of development, chronic stress in children has a huge impact on pubertal timing and pathways. Some biologists assert that adolescence because of the cascade of changes that occurs during this period, may offer a window for advocates to help recalibrate the endocrine system to allow for more emotional regulation in youth (UMN, 2019).
Some experts point not just to increased nutrition but other changes in the lifestyles of children today that has led to lowered ages of sexual maturity, the major factor being the enormous increase in endocrine disruptors in the air and the foods we consume. Endocrine disruptors are environmental chemicals that disturb the delicate hormonal system of the body. Almost 90% of endocrine disruptors like Polychlorinated Biphenyl and dichlorodiphenyltrichloroethane come from the food we eat. Bisphenol A which is commonly found in plastic containers, receipts and linings in cans are also known endocrine disruptors. Another common disruptor, parabens, is found in cosmetics and household cleaning products. In one study, the authors conclude that between all the household cleaners, soaps, shampoos and cosmetics, an average American is exposed to almost 19 endocrine disruptors (Dodson, Nishioka, Standley, Perovich, Brody, Rudel, 2012). In 1998, the Environmental Protection Agency set up a program to screen over 35,000 chemicals. Critics charge that the screening process is influenced by the chemical industry and manufacturers of these dangerous chemicals influence policies by their lobbying efforts in congress (Ambrose (2007). There are other factors that affect the age of sexual maturation – genetics, the amount and frequency of intense physical activities that the adolescent engages in, and illnesses during teen years. Girls reach their adult height about 4 years after puberty starts but boys reach their full height about 6 years after puberty starts.
Puberty and Gender
“Kitty has a nosebleed, on the rag, aunt dot, aunt flow is coming for a visit, falling to the communists, closed for maintenance, my little friend, surfing the crimson wave, bleedies, at high tide, my moon cycle, moon time, that time of month, friend from the red sea, the curse… There are many names for menstruation that are reflective of our culture’s attitude towards the period. “The curse” is perhaps the most telling as it defines the period as a horrible affliction rather than a natural part of a woman’s monthly cycle. Instead of celebrating women’s cycles we are taught to resent menstruation and even feel ashamed of it.” (courtesy: feminisms.org, Jan 30, 2013)
Girls today appear to have a more positive attitude towards menstruation and menarche (the first period in a girl’s life) than girls in previous generations. Many girls however still hold mixed feelings about their menstrual period; this is often related to lack of appropriate information, or adults communicating negative feelings about the physical and emotional changes around this milestone event. Girls first communicate to their mothers and a little later to their friends when they start menstruating (Martin, 1996). Boys however, at least in the USA, express little emotion when they first ejaculate (spermarche) signaling their journey to sexual maturity. Self-reports suggest that most boys experience their first ejaculation as nocturnal emission and less commonly through masturbation. Adolescent boys tell very few people if any about the internal changes in their bodies. Negative attitudes towards masturbation may contribute to this silence. Some of the fears that boys express around bodily changes have to do with being shorter than girls, not acquiring enough muscles compared to other boys, thinking too much or too little about girls, body odor and having too much or too little body hair.
The timing of the onset of puberty has an impact on girls and boys in very different ways. Girls who achieve sexual maturation at an earlier age than their peers are undergoing precocious puberty. Early sexual maturation for girls implies that they mature far earlier than is typical for their age; this has long-term implications for both their mental and physical health (Ge, Conger, Elder, 1996; Martin, 1996; Mendle, Harden, Brooks-Gunn & Graber, 2010; Phinney, Jensen, Olsen & Cundick, 1990). In the US, studies have demonstrated that girls who go through precocious puberty have lowered self-esteem, feel negatively about their bodies leading to disordered eating, and have higher rates of depression and anxiety. There is a greater pressure on early maturing girls to date and engage in sexual relationships with older boys and men. This leads to both positive and negative consequences in that early maturing girls are both more popular and at the same time they are sexually objectified. Thus, precocious puberty has been associated with increased drug use, higher levels of depression and lower academic achievement. Late maturing girls have a longer time to adapt to the physical and emotional changes that adolescence brings and hence weather the storms of adolescence in more positive ways (Harden & Mendel, 2012).
The differences in the personalities and development trajectories of boys who mature very early or very late seem to be rather minimal at least in mainstream society, compared to differences between girls who mature early and those who mature late (Martin, 1996; Huddleston & Ge, 2003). In boys, earlier sexual maturation is associated with being bigger, taller and more socially mature. They are often perceived to be leaders of their peer groups and are popular. However, early maturing boys, like their female counterparts tend to associate with older boys and girls and engage in behaviors that may not be considered appropriate for adolescents in their early teen years (Mendle, Harden, Brooks-Gunn & Graber, 2012). This may include engaging in socially deviant and risky behaviors including substance use and abuse and sex. Late maturing boys exhibit more tolerance of ambiguity, are more empathetic and are intellectually curious. When studies have followed boys into their adulthood, late maturing boys tend to be inventive, impulsive and creative. Early maturing boys grow up to often be more conforming, cooperative, self-controlled and sociable (Lindfors, Elovainio, Wickman, Vuorinen, Sinkkonen, Dunkel & Raappana, 2007).
Several studies point to the importance of sexual maturation and the construction of masculinity among boys in working-class and immigrant communities (Ahmadi, Anoosheh, Vaismoradi & Safdari, 2009). Among working class boys, there are often physical displays of corporeal strength and tolerance for pain to publicly mark the transition and as a preparation for life in a physically competitive world. Since many of them will likely transition into low end jobs with little autonomy, physical prowess assumes increased salience as a sign of their adult status (Mora, 2012; 2015). Among Chinese boys, peer acceptance was much higher for early maturing boys but connections to one’s family was higher for late-maturers (Li, Ling, Zhang, Si & Ma 2013).
Silence around Menarche
In one study, post-menarche girls produced a much more sexually differentiated drawing of their bodies than the pre-menarche girls. They accentuated the breasts and hips, and portrayed figures with narrow waists. Girls are likely to believe that the achievement of menarche would bring about momentous changes in their lives (Unger, 2001). So, while most adolescents seem to recognize the importance of the milestone, few speak about it in public. There seems to be a sense of shame associated with both the mention of female genitals and with menarche (Tang, Yeung & Lee, 2003). Research substantiates that few girls are taught about their genitals nor can most girls identify the parts of their genitals accurately. In addition, society deems menstruation a crisis of hygiene and there is therefore little open dialogue about the significance that menarche and menstruation have for young adolescent girls between adults and youth.
Many popular depictions of menstruation illustrate the public’s fear of blood and its association with negative events. In 1978, Gloria Steinem wrote a stinging satire called ‘If Men Could Menstruate’ in which she explored all the different ways in which menstruation would be treated as a source of great pride if men were the ones menstruating. This has been substantiated when studies are conducted exploring girls’ attitudes towards puberty. The conversations reflect the shame that girls feel about menstruation. Women express a desire to make sure that there is no evidence of it anywhere – no stains or smells. Girls often display great embarrassment at having to manage their menstrual periods in school, going to great lengths to hide all signs of their bleeding. Their strategies include hiding their tampons or sanitary pads in their sleeve or pocket or tucking them into their socks. All of these make it harder for girls to manage their periods in a healthy fashion (Unger, 2001).
Review and Reflect: Learning Goal 1
REVIEW
1.In a child’s early life, what 2 main components are responsible for establishing the architecture of the brain?
2.How can toxic stress impact brain development of a child or adolescent?
3.How do genetics and environmental factors impact sexual maturation?
4.How does gender affect the experience of puberty?
REFLECT
1.When did you experience puberty? What were some of the main changes that you noticed in yourself both physically and emotionally? How did the adults in your life respond to the change?
Youth and their Bodies
Puberty signals enormous changes in the physical development of both boys and girls, however, these changes do not occur in a vacuum and people’s attitudes towards their bodies are connected to larger social, political and economic forces. Social norms and practices influence both the transformations in youth and how these changes are experienced (Ricciardelli & Yager, 2016). For girls, the changes begin at a younger age when many are unprepared for the visible transformations in their bodies and its social impact. At the same time, girls are sexually objectified in many societies and that exacts its own toll (Jones & Newman, 2009). Contradictory social messages about girls’ bodies lead to feelings of negativity and confusion. In one study, it was found that for both girls and boys the extent of social media site use and peer feedback on appearance increased the dissatisfaction that youth felt towards their bodies (de Vries, Peter, Graaf & Nikken, 2016).
During adolescence, the development of breasts poses a great deal of embarrassment for young women. They are often teased by both friends and family. This often leads young girls to wear baggy pants and loose shirts in order to hide their changing bodies. At the same time, society considers visible breast development as a mark of an attractive body for girls and women. Girls struggle to reconcile these contradictory demands from people around them (Unger, 2001). In one study, the authors found that parents’ attitudes towards their children’s bodies correlated strongly with body dissatisfaction among girls (Sinton & Birch, 2006).
Girls who achieve sexual maturity early often feel very negatively about their bodies for all the above reasons while boys who mature early feel positively about their bodies. For girls, sexual maturation is accompanied by sexualization and objectification while for boys, sexual maturation signals leadership and maturity (Furnham, Badmin & Sneade, 2002). Girls in general are less satisfied with their bodies, perceiving themselves as overweight; they try to lose weight in much larger numbers and in more destructive ways as compared to boys in adolescence (Davidson, 2012). In fact, being underweight is associated with the highest levels of satisfaction among girls. In one study, a historian found that 100 years ago girls defined self-improvement as having achieved more rigor in their studies or being able to get along with their parents. Today girls are more likely to think of self-improvement as a project related to their bodies (Unger 2001). Studies have found that girls might even resort to self-destructive physical habits like skipping insulin prescribed for diabetes and smoking cigarettes to keep their body weight down (Timke & Kilbourne, 2018).
There are ethnic, race and class differences in girls’ attitudes towards their bodies and the incidence of eating disorders that follows from dissatisfaction with their appearance. Girls from white, upper-class backgrounds feel the most negative about their bodies and wish they could lose weight while African-girls tend to exhibit body-positive attitudes. Latino girls have high self-esteem and tend to feel positively about their bodies in elementary school; the transition into middle or high school sees a plummeting of their self-esteem along with increased feelings of negativity about their weight (Hayward, Gotlib, Schraedley & Litt, 1999). One explanation for the positive attitudes that Black girls exhibit towards their bodies is related to the paradoxically negative attitude that mainstream society assigns to Black bodies (Tate, 2007). Since standards of beauty often adhere closely to white upper-class characteristics about facial features and skin tone, girls from other ethnic groups do not quite feel they can even attempt to reach the bar set by society for being beautiful. Hence, they often escape the harshest impositions of the beauty mandates in our society.
Body Dysmorphic Disorders and Eating Disorders
“Hey people I’m a transgender female, and a recovering bulimic. Last time I purged was around 5 years ago and I’m proud that I haven’t since. But I’ve been having this serious issue where I can’t eat because the food that I try to eat tastes really really bad to me and if I try to force it I vomit. I’ve been consuming a lot of liquids for this whole week, because I literally just can’t eat food. And I don’t understand why because I’m not feeling guilty about it or anything else. Does anybody have any ideas as to what’s causing this? I’m just so confused and lost right now.” Courtesy: Stardustsparkle (2016)
“I’m in recovery from anorexia, and I’m finding it hard to let go of control. Initially, I was bulimic, but would starve myself throughout the day and them binge at night. When I transitioned to anorexia, I would eat periodically, but it would be very small amounts, and not enough to sustain me. Now that I am in recovery, I find it hard to eat throughout the day, for fear that I will feel the need to binge at nighttime, as a result, I end up having to eat massive amounts at night (or what seems like it) but them end up still not reaching my nutritional goal. I also have the tendency to take an EXTREMELY large amount of time to finish food (my friends make fun of me sometimes because it can take me up to an hour to finish eating).” Kim 1811, Courtesy: National Eating Disorders Association (2016)
Body dysmorphic disorder is an excessive preoccupation with an imagined or real slight defect with one’s physical appearance. It is usually most evident in adolescence and may turn into a chronic condition through adulthood. The result of the equation of thinness with beauty in society results in many girls and women, and to a lesser extent, boys and men, having a distorted view of their bodies (Lampard, MacLehose, Eisenberg, Neumark-Sztainer & Davison, 2014). Muscle dysmorphia or the notion that one’s body is too small or one’s muscles are not well-developed is especially common among boys. One survey of literature found that boys suffered from dissatisfaction of their bodies in significant numbers and wanted to attain bigger bodies. Being small for one’s age was usually tied to low self-esteem and distress among boys (Cohane & Pope, 2001).
Eating disorders are characterized by abnormal eating that results in physical and mental negative consequences for the sufferer. It includes binge eating, anorexia nervosa, bulimia nervosa, pica, and restrictive/avoidant eating disorder. Binge eating refers to eating a large quantity of food in a very short time. Anorexia nervosa causes its sufferers to severely restrict their food intake while Bulimia Nervosa patients eat a lot and then throw up the food. Pica sufferers eat non-edible items, and people with restrictive eating disorders lack an interest in food and are overly selective about what they eat. Some of the unhealthy ways that sufferers control their weight is by over-exercising, manipulating the levels of insulin prescription, purging, and consuming diuretics. The symptoms can be of a wide variety and must be taken into consideration along with visible behavior patterns when making a diagnosis of an eating disorder. Sufferers can exhibit weight loss weakness, sensitivity to cold, amenorrhea or the cessation of menstruation (among girls), hoarseness of voice due to repeated purging, tooth loss and osteoporosis.
Underlying all eating disorders is a distorted body image and a need to measure up to very strict standards of bodily proportions. For boys, it often means a muscular ideal and for girls, it is a thinness ideal. These ideals are culturally rooted and is specific to modern industrialized societies. Epidemiological studies implicate the increasing idealization of thinness over the last century to the increasing incidence of anorexia nervosa and bulimia in the US and in Europe (Rodgers, Paxton & McLean, 2014). There is evidence that among Caribbean youth, when individuals had spent time in an industrialized country, the chance of developing disordered eating increased (Waters, 1996). In the industrialized countries of the west, thinness is elevated to a virtue. In one study, it was found that most college age girls and a significant minority of men had gone on a diet. In addition, while Caucasian women were likely to be thinner on average than Latina and Black women, they were much more likely to perceive themselves as overweight. Thus, white women were much more likely to go on a diet, use pills and engage in vomiting, and used vigorous exercise for weight management (Godley, 2004; Gonzalez, 2008).
Epidemiological studies point to a sharp rise in eating disorders among prepubescent girls of all ethnicities and classes in the USA and globally. About 90 -95% of all reported incidence of both anorexia and bulimia occur in women though some researchers claim that there is an under-reporting of both disorders among men. In one study in a Minnesota suburb with Caucasian girls (Leon, Fulkerson, Perry & Early-Zald, 1995), there was more acceptance among girls of the kinds of behaviors that meet the criteria for a diagnosis of eating disorders. Most studies also demonstrate that white girls and women are overrepresented in those who make the criteria for disordered eating. Research studies confirm that this may be somewhat accurate with reference to anorexia but not about bulimia or binge-eating disorders. Bergeron and Senn (1998) found that of all the groups organized around sexual orientation, homosexual men and heterosexual women were most at risk for eating disorders while lesbians and heterosexual men were least likely to be at risk. They hypothesize that the need to please men in a world where being thin is equated with attractiveness is a factor in all eating disorders. Among adolescents, it is especially difficult to explore the relationship between sexual orientation and eating disorders because of the vulnerability of the population and the secrecy around sexual orientation.
Factors that Lead to Disordered Eating
In terms of psychological factors, studies have indicated that girls who are perfectionists, have unrealistic expectations and ideals and a low self-esteem are more likely to exhibit eating disorders. In girls with anorexia, there is often delusional body image beliefs while this is often absent in patients with other forms of eating disorders. It seems many of the unhealthy eating is a result of long-established habits and the reinforcement of those habits by those around us. In one interesting paper, the authors point to peer groups as a significant factor in disordered eating (Kirsch et al, 2016). Not all students in the same school share similar environments. Girls who are perfectionists and have similar concerns about body weight may be drawn to each other. In another study that tracked college students, dieting habits of the same sorority became more similar, the longer the women lived together (Mitchell, deZwaan & Wonderlich, 2018). Similarly, rates of bulimia declined when a roommate of a person with disordered eating had few weight concerns. The impact of peers is facilitated by social networking sites and the social comparison that may result from the excessive use of these sites (Holland & Tiggemann, 2016). Body dysmorphia may result from excessive peer teasing in routine interactions (Fairweather-Schmidt & Wade, 2017). Thus, one way to interrupt the habit of disordered eating is to intervene at the level of the peer groups.
Globally there is little research into disordered eating among girls but in one study by Lee and Lee (2000) in China, the researchers found that even though girls in Hong Kong were thinner than girls in both rural Hunan and Shenzhen, they exhibited higher levels of dissatisfaction with their bodies and were more at risk for eating disorders. The authors propose that westernization was a factor in the susceptibility of girls in Hong Kong to disordered eating. Similarly, better educated ethnic minorities in the USA exhibit higher levels of anorexia and bulimia than their less-educated, poorer peers from similar backgrounds. In countries that are less influenced by the ideals of the industrialized west, anorexia and bulimia occur among fewer women and as cultures become more exposed to western media and values, incidence of eating disorders rises.
Popular media has played a big role in the disordered eating habits of young people. Commercial media promotes the ideal beauty as thin and tall, a body type that few girls possess. Media messages convey the myth that the body is ‘malleable’ and can be shaped through discipline and rigor. Youth who consume the most media also tend to have the most negative view of their bodies. Becker (1999) studied youth in Fiji before and after the introduction of television in the country and found that there was a sharp increase in the number of girls who induced vomiting after the introduction of television. Women from historically underrepresented groups may feel additional pressure when asked to conform to white standards of beauty leading to low self-image and self-destructive behaviors.
Among boys, body image issues are often associated with wanting to be bigger than average. In muscular dysmorphia for instance, large muscular boys see themselves as small and thin and want to bulk up even more (Sreshta et al, 2017). The presence of a distorted body image in boys is associated with poor self-esteem and distress, anxiety, eating disorders and a high prevalence of anabolic steroid use (Collis, Lewis & Crisp, 2017). Among young boys and youth, half of the boys with body image issues want to be heavier and the other half want to be thinner (Lavender, Brown & Murray, 2017). The predominant concern of these boys regarding their body shape is that it is not developed. Like girls, boys’ body image, their BMI and their eating habits tend to cluster in similar ways among peer groups.
A review of some of the interventions of eating disorders highlights the fact that help with youth engaging in disordered eating cannot simply include physiological measures like achieving a target weight. When adolescents discontinue therapy, they are likely to fall back into their old eating habits. For many of the sufferers of anorexia and bulimia, the illness becomes part of their identity making it difficult for them to recover from the disorder. Youth suffering from eating disorders find it very difficult to give up the control over their bodies as it is central to who they are. It is important for youth advocates and caregivers to help maintain a sense of normalcy as clients transform their attitudes towards their bodies and the changes in their eating habits. Current governmental and community supports are inadequate for many young people to make a full recovery from a disease that has the largest rates of deaths as compared to other mental illnesses like depression and schizophrenia (Arcelus et al., 2011).
Review and Reflect: Learning Goal 2
REVIEW
1.What are some factors that underlie all eating disorders? Which population is most at risk of developing an eating disorder?
2.How does our culture contribute to disordered eating and body dysmorphia?
REFLECT
1.How common was disordered eating in your school?
2.What were some steps your school took to facilitate healthy eating?
Obesity
Obesity has increased enormously in the last 20 years along with its negative health consequences in childhood and later during adulthood. One out of 6 adolescents in the USA is now overweight. Being obese is described as in the 95th percentile (or above) of the calculated Body Mass Index and being overweight is when someone falls between the 85th and 94th percentile (Sutin, Stephan & Terracciano, 2015). The obesity problem is so severe that some officials claim that today’s generation of youth will not live as long their parents because of the many negative health consequences of youth obesity and other mental health issues like stress and drug dependence (Case & Deaton, 2015). In addition, in a culture where thinness is considered a virtue, people who are obese face enormous stigma and a compromised quality of life. They face discrimination in jobs, relationships, and access to services (Spalholtz, 2016).
The factors that underlie the spike in obesity in the US and across the globe are varied and are rooted in the individual, the family, the neighborhood, the community and most important, the social policies around food and food consumption. The impact of food on weight gain varies from one individual to the next based on genetic makeup and environmental factors. Schools play an important role on obesity rates. Children spend most of their time in schools outside of their house and when the food offered at the school cafeteria is unhealthy or there are vending machines stocked with snack foods that are calorie rich, children often have little option but to consume them. In addition, most states in the US mandate little daily physical education for children in public schools offering children and youth few opportunities to expend energy. The American Academy of Pediatricians advocate for the formation of school wellness councils that would include doctors, counselors, parents, community members and nutritionists to offer input into the barriers to maintaining a healthy weight for children and how best to overcome them within specific contexts (Wilfley et al, 2017).
Socioeconomic status is a major factor in obesity. The zip-code that a person lives in is significantly related to their weight. Experts point to poor neighborhoods’ lack of fresh food stores as a big factor in the high rates of obesity among families who fall in the lower socioeconomic stratum (Lippert, 2016). There are few open areas for children to play in, and the air quality in lower income neighborhoods tend to be poor. Economists point out that processed food manufacturers mark down the prices of products in stores in low income neighborhoods and make up for it by the volume sold. Poor families often buy from these stores because they can make their income last longer by living off processed foods (Zhang & Ghosh, 2016). One of the possible policy solutions offered by social scientists is to provide tax credits for the operation of fresh grocery stores in poor neighborhoods and to create an incentive to promote the growing of fresh foods. In addition, youth in poor neighborhoods engage in less physical activity. Impoverished areas tend to have little recreational opportunities for children and tend to be unsafe making caregivers fearful about allowing young people to spend time outdoors. The air quality in low income localities in cities tend to be of poor quality leading to illnesses among children, preventing them from being outdoors (Althoff et al, 2017; Côté-Lussier et al, 2015). Thus, effective implementation of policies regarding the health of individual adolescents need to shift away from the family and examine the many interacting factors that facilitate the rapid rise in obesity among children and youth.
Much of the effort to reduce the incidence of obesity among children and youth has been undermined by the stigma against overweight. In the US, unlike other forms of discrimination, the one against overweight individuals is tolerated and even encouraged in public spaces like schools and workplaces. Popular media similarly portrays overweight individuals as cartoonish creatures with little success in work and in relationships. Studies have demonstrated that most people believe that weight is controllable and therefore if one is overweight or obese it is entirely one’s fault and is indicative of a weakness of character and laziness. Ironically, when overweight individuals try to lose weight and they are unable to, others hold even more negative views of them. Overweight children internalize these powerful messages. Unlike race or gender, there is little support for the victims of fat discrimination even within their own families or in-groups. The internalized stigma that overweight and obese children endure prevents caregivers and adult advocates from helping them in a constructive fashion. Schools can often perpetuate the stereotypes by engaging in parent-blaming (Flint et al, 2016; Spahlholz et al, 2016). In one infamous instance, a school district mailed out letters to parents informing them that their children are overweight (Ruggieri & Bass, 2015). Such myopic measures do not help address the issue of obesity. It makes parents feel guilty without offering them ways to reimagine nutrition for their homes.
At a larger macro-cultural level there are very powerful forces at work to keep the obesity epidemic in place. The amount of funds expended in marketing unhealthy foods for teens has increased sharply and vastly overshadows any government spending for marketing appropriate eating habits among children and youth. There is substantial evidence that the teen years provide a crucial space for eating habits in adulthood and studies confirm that half of these obese adolescents go on to becoming severely obese by the age of thirty. Having a TV in an adolescent’s bedroom has been significantly correlated to being overweight and obese (Mota et al, 2018). Initially, researchers theorized that it must be the sedentary nature of the teens’ lives that contributed to the problem, but newer research seems to suggest it is really the advertising that these kids are exposed to that seems to make a significant difference to their weights. Food marketers spend about 1.5 billion dollars a year marketing unhealthy processed food to children and adolescents. They promote packaged foods as appropriate food choices, catering to what children want, thereby deceiving children with products that undermine their health (Lobstein et al, 2015). There has been a fierce debate between food marketers and child health advocates and pediatric associations about whether to limit marketing to children. The Children’s Food and Beverage Advertising Initiative (CFBAI) is a food industry sponsored lobbying group that has fought governmental regulations and has insisted that the industry be allowed to self-regulate itself. Unfortunately, the processing food industry has kept the right to define what is healthy for children. Thus, manufacturers make a few industry friendly changes to packaged food for children claiming to use more whole grains and added vitamins while still not providing accurate information about calories and the hidden ingredients in the foods that are sold to children and youth (Schermbeck & Powell, 2015; Wootan et al, 2019).
Almost half the calories consumed by children is at school and not at home. Most children in the USA take part in the school lunch program. In many national surveys, most schools, especially those located in poor neighborhoods failed the United States Department of Agriculture (USDA) standards for appropriate nutrition. The food served in public school cafeterias had far too many fats, saturated fats and salts than has been recommended for children (Powell, 2019). In addition, schools are often enticed by companies into installing vending machines that are stacked with snack foods and sugary drinks (Roache & Gostin, 2017). In 2010, The Healthy Hunger Free Kids Act was passed by the federal government. It allocated additional funds for school lunches allowing cafeterias to offer more fruit and vegetables, whole grain foods and items with less fat and salt. Food companies fought back, lobbying congress to take back many of the provisions of the act leaving it ineffective in changing menus in school cafeterias (Roberto et al, 2015). Processed food manufacturers offered to self-regulate their marketing and the choices that they offered children. They offered to reduce or withdraw the range of sugared soft drink products in schools and provide fruit juices instead, but it was a win situation for these companies since the same companies own both sweetened beverages and fruit juice offerings. Nutritionists recommend that children reduce their consumption of fruit juices because they contain almost as much sugar as soft drinks (Nestle, 2015). Today, the rise of energy drinks provides additional reasons for concern for children’s health advocates. The marketing and consumption of energy drinks has shot up enormously since they were introduced to children and 1/5th of children drink more than 3 energy drinks a day. In 2011, The Federal Trade Commission tried to push through legislation implementing common nutrition standards in all public schools but there was pushback from food marketers and the mandate had to be withdrawn.
One much discussed reason for the spike in obesity levels among children and youth is the lack of physical activity. There have been enormous changes in the way families live now as compared to before the rise of suburban communities. Less than 20% of children walk to school and there has been a substantial reduction in unsupervised play by children in the last three decades. Parents of children and, to some extent, adolescents express great fear in allowing their children independence within their neighborhoods because of safety concerns. In addition to fast moving vehicles, caregivers worry that their children will be abducted or subjected to violence, even though research shows that most children that are harmed are harmed by people who claim to love them. There are no national mandates for schools to provide daily physical activity and in states that do have mandates, there are few standards that dictate the quality and content of the activity.
At a governmental level, agricultural policies by the US government has contributed to the change in eating habits of the population. The government gives enormous subsidies for producers of corn, soy and wheat and the industries that process these crops. There is little support for vegetables and fruit growers. Thus, vast tracts of land are dedicated to crops that are amenable for processing and less than 2% of the arable land is devoted to growing fruits and vegetables. Commercial crops are typically grown and processed by large agribusinesses while vegetables and fruits are often grown on family farms (Friedmann, 2009). This contributes to making family farms less viable and with little reach beyond the immediate locality. Since the former are overproduced, the surplus corn and soy that are produced are converted to corn-syrup and saturated fats that are added to processed food to enhance the taste of these products. Researchers have called for the doing away of governmental subsidies for corn and soy to combat the obesity epidemic (Fields, 2004; Franck et al, 2013).
At a larger community level, home visits by health workers or aids allow for feedback from parents and a more intimate knowledge about the many barriers such as financial stress, abuse or mental illness that the family might have in maintaining healthy weights. Visiting health workers could also help families identify ways to address the negative consequences of obesity like controlling diabetes among children. It is important for advocates of youth to understand the problem of obesity as multicausal and it is ineffective to talk about change simply at the familial or the individual level. It would be important for policy makers and community leaders to come up with culturally sensitive recommendations that individuals and families find easier to follow. It is thus important for everyone involved to take a larger ecological perspective when addressing both the causes and the consequences of being overweight or obese among children.
Eating disorders are connected to each other in complex ways in addition to being related to mental health. Being overweight is itself significantly related to being at risk for restrictive eating disorders like anorexia and bulimia. Often, clinicians and family members do not take it seriously when an overweight teen engages in disordered eating or smoking to reduce weight. In one study it was found that close to 40 % of girls who presented with eating disorder symptoms were severely overweight. Body dysmorphia and its related disordered eating is responsible for a significant number of deaths in the USA. Among all mental illnesses, anorexia holds the distinction of the disease that leads to the highest number of deaths. The disorder tends to be evident around adolescence and this age group might be most amenable to help and support to overcome the disease’s worst impact.
Review and Reflect: Learning Goal 3
REVIEW
1.How does socioeconomic status influence the rates of obesity in any given area?
2.What role does the media play in stigmatizing overweight individuals in the US?
3.How is obesity beneficial to wealthy corporations?
4.How does obesity influence body dysmorphia and disordered eating?
REFLECT
1.How would you describe your experience in your body?
2.How satisfied are you with your body shape and weight?
3.Do you feel that you have been influenced by the media or society to look a certain way?
The Postmodern Perspective and Fat Acceptance
For postmodern thinkers, social ideas about race, gender, social class, ability and sexuality are all lived out in the bodies of individual people (Gimlin, 2007). In capitalist countries the way we perceive our bodies is intimately tied with consumerism (The Atlantic, 2019) and neoliberalism (Stacey Kerr, 2015). These systems encourage the notion that individuals are responsible for their own health and their welfare. Within postmodern theory, the body is looked at as less an object and more as a phenomenon. This corresponds with their framework that symbols are often more important than reality. The body has meaning only in connection to other bodies, events and social contexts. Deleuze and Guattari (1988) conceive of individual bodies as always in a state of becoming and in connection with other bodies and society. Thus, they conceive of the body as an event. Similarly, gender is less a concept than an embodied experience. Coleman (2009) proposes that gender does not pre-exist the body but is constitutive of the body.
The new feminist perspectives began to move away from exploring eating disorders and obesity related issues to individual and familial characteristics like personality disorders but instead theorized them in relation to larger social and economic forces (Malson & Burns, 2009). In fact, feminist experts contend that eating disorders are just an expression of social norms and standards that specify what ideal bodies should be like and these are often based on class, race and gender. In traditional sciences, the body and the mind are looked at as separate entities with the mind signifying reason and therefore associated with masculinity while the body has been conceived of as feminine and as an object to be controlled. According to feminist theorists, to live in an authentic manner in your body it’s crucial to liberate oneself from exploitative patriarchal power (Hilde Bruch, 1973). Naomi Wolf (1991) calls this large-scale marketing of a particularly thin body type as a backlash against the women’s rights movement and calls it the ‘beauty myth.’ Baudrillard (1998) used the metaphor of an anorexic person to characterize the commercialism of our era.
In recent years, as with other oppressed groups, there has been a groundswell of activist movements among overweight and obese individuals. Proponents of the fat acceptance movement organize against anti-fat bias and discrimination in society. According to fat acceptance advocates, the bias against the overweight was historically based on perceived lack of productivity by obese workers. In 1967, a “Fat In” was staged in New York City with about 500 people eating and burning diet books. One of the main arguments of fat advocates is that all existing stigma and publicized diets have led to both physical and psychological problems among fat people. They assert that being overweight is not necessarily tied to being of poor health. Having a body with higher than normative weight is often associated with social class, race, being sedentary and the geographical region where a person lives and functions. So, fat acceptance advocates demand allowing fat people a voice in the national dialogue around weight and health. Some experts also charge that all the stigma against overweight individuals skews public perceptions about the body and what healthy eating means as a form of public policy. Recent research has demonstrated that sizeism and fat shaming is rampant in schools and in medical clinics. Fat discrimination leads overweight youth and adults to stop seeking help and has a negative impact on the health of overweight adolescents. In addition, there is no agreement on how much weight is appropriate for individual adolescents and children.
Critical Disability Studies
Disability is a constantly evolving concept since it is related to the context and the historical period in which individuals’ function. In general, there is some basic consensus about the term. Disability is defined as “any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being” (Ingstad & Whyte, p. 5). Handicap refers to the social consequences of having a disability in a physical and social context. Disability is a learned social role and is given meaning by society – it does not have any validity as a concept without its connections to society. Thus, its meaning, roles and definition changes with the context. Critical disability theorists assert that society’s notions of what is considered able-bodied and its conceptions of youth are closely linked (Boulter, 2010). While on the one hand, within psychological sciences and in popular discourse, adolescence is characterized as a development stage on the path to adulthood, youth is considered an aesthetic endeavor in that adults of all ages are encouraged to be youthful for mental and physical health. Adult women are excoriated for not working harder on their bodies in order to look more youthful. Youth is equated to both health and beauty, allowing it to be used as a commodity in society and is used to sell both ideas and products (Haegele & Hodge, 2016).
Feminists and critical disability theorists would argue that the body is a cultural product laden with meaning. During the 1990s, there was a deep examination of the relationship of the cultural meanings of the body with relationship to gender, race, ethnicity, sexual orientation and class. More recently, people with disabilities have challenged ideas about the normal body within the sciences and popular discourse. There has been a progression to discussing youth and disability as it relates to the body. Dis-ableism leads one to have narrow views about what is normative, and it therefore constricts identity development as young people go through adolescence. Women and girls have always been mandated to discipline their bodies through personal will power. In recent years these mandates have been extended to young people with physical disabilities. In the classroom, a good body is assumed to be under the control of the individual. Children from a young age are acutely aware of what is an acceptable body and the rules of the body work that leads to inclusion and exclusion among peer groups. Slater (2012) argues that the ambiguous attitude that adults have towards the period of youth leads to a deep anxiety and disgust for an adolescent with a disability. For example, young people are considered incomplete until they become adults while at the same time adults are constantly trying to be youthful as a sign of a healthy person. Critical disability experts assert that the ambiguous attitudes that adults have towards adolescents (wanting to be youthful but regarding adolescents as immature) have heightened and add to the discrimination and exclusion of youth with disability.
Several international organizations like the World Health Organization and the International Labor Organization have recognized the rights and privileges of people with disabilities to services and support. The movement for civil rights increased the awareness of the tremendous barriers that youth with disabilities face in the USA and there was a push to offer ameliorative services to remedy the situation.
Sports and its Impact
Sports during adolescence is important for both boys and girls. For girls, it has been associated with self-esteem and achievement in and out of class and for boys, sports participation has been found to significantly reduce self-destructive behavior. Despite the huge benefit that sports offer, there are gender related issues that continue to hinder participation and promote positive growth in both boys and girls. There are deep-rooted prejudices and stereotypes about gender and sports participation that affect the quality and types of athletic endeavors that adolescents can participate in (Plaza et al, 2017; Xiang et al, 2018).
The percentage of girls who participate in athletics has grown 900% from 1971 to 2008. However, boys still play sports at much larger rates than girls do, and the gap has not been eliminated since the introduction of Title IX in 1972 (Wilde, 2015). The foundational Act states, in part, that “no person shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any academic, extracurricular, research, occupational training, or other education program or activity operated by a recipient which receives Federal financial assistance” (Office of Civil Rights, §106.31a). The Office of Civil Rights is responsible for implementing the provisions outlined in Title IX across the country. The law demands that schools accommodate the interests of both sexes in sports, that sporting activities should be accompanied by equal opportunity to receive training and equipment, and that there are equal publicity and schedules for boys and girls’ sports. While girls’ participation in sports has indeed gone up significantly, they still lag boys. Some observers claim that girls are not interested in sports to the same extent boys are while others argue that the discrimination and stereotypes about girls and sports prevents them from participating in athletic endeavors at the same rates.
Stader and Surface (2014) argue that girls are treated as second class citizens in athletic spaces. There has been a string of court cases that point to lack of equality in scheduling of events, recruitment of young participants, and maintenance of athletic fields and their uses based on gender. School districts hire girls’ sports coaches much later in the season than boy’s coaches and less effort is made in the hiring process for girls’ team coaches. If a coach is not hired, the event is discontinued. Similarly, while baseball fields are very well maintained, softball fields are used for other sporting events and are not as well maintained leading to injuries. In one case, a school district retaliated against a coach who complained about the unequal treatment that his girls’ team was offered (Buzevis, 2017). Koller (2010) explored the question of whether Title IX, as it is currently set up, does the appropriate job of bringing girls into sporting activities. In other words, is the conception of equality that is embedded in Title IX enough to produce equity in sports? Koller argues that while Title IX offers girls and boys equal resources within institutional settings, they do allow for separate programs for each. Title IX also does not give girls the extra incentives they deserve after years of being left behind in terms of opportunities to engage in sports. Koller thus claims that under current regulations, it would be very difficult to eliminate the disadvantages that girls face in terms of athletic engagement in high schools.
One action that school administrators and advocates for girls can take include having regular equity audits of athletic opportunities for boys and girls. Resources and training for girls’ and boys’ events as well as recruitment of coaches must be equitable. It is important to schedule and publicize events when it is advantageous to the players of both sexes. Recommendations also include taking a regular survey of student interests and needs in sports. If there is a critical mass of interest in a sporting activity, school administration should try to incorporate the activity into their athletic program. Finally, coaches should be informed and trained in the stipulations of the law in order to bring about gender equality in sports.
On the other end of the spectrum, there is evidence that commercialized sports have had a negative impact on high school boys across the country (Gornitzky et al, 2016). Adults who are involved in coaching and encouraging young people in athletic endeavors have also pushed youth to test the very limits of their endurance leading to unintended serious consequences for the health of the players. Often, games like football have grown from a local interest activity to drawing national audiences and passion. Commercial television has picked up on the interest and has exploited it for profit with the arrival of 24-hour sports channels. Individual players have been subjected to unprecedented scrutiny by colleges and popular media. There is also intense pressure on high school football coaches to take their teams to the top. The coaches in turn pass on the expectations to the students. The average high school football player today is bigger and taller than they’ve ever been before.
Today, it is not unheard of to find football teams training twelve months a year, well before the football season even begins. Along with the intense training, there has been a remarkable increase in the number of injuries and deaths related to high school football in recent decades. It is reported that there are about 60 serious concussions in high school football every year. Studies demonstrate that repeated concussions have a long-term impact on the health of the player. The risk for dementia and brain damage goes up enormously. It is progressive and leads to behavioral issues like depression and suicide. A more worrying finding is that even when players are not formally recognized as having had a concussion, they could still be at higher risk for long term brain issues than players who do not play football. Despite the association between concussion with dementia and memory loss, more boys play football than they do any other sport. Young, growing brains are far more vulnerable to the impact of repeated physical trauma than adult brains.
High school football involves a lot more hits per child than college football even when it does not lead to a concussion. The small traumas of the minor hits are risk-producing in the long term and helmets do not protect the developing brain from these traumas. The brain is gelatinous and when the head is hit, the nerves undergo transformation and chemical changes as it tries to heal itself after the impact. It takes a few months for the nerves to repair themselves after a trauma and in the meantime if there is another trauma, the damage on the nerves might become permanent. With younger players, the repeated traumas can have more severe consequences. While helmets have got stronger and more resistant, the players are using it more aggressively as a tool to tackle opponents.
Some schools are using a test called Immediate Post-Concussion Assessment and Cognitive Testing, or imPACT testing which allows school administrators to keep baseline measurements of students’ cognitive performance before games. They are then retested after a game to see if there is a functional decrease in performance. If a deterioration is found, the students are kept away from the field until their performance improves. Advocates for youth suggest that there should be strict regulations for licensing of coaches which ensures they get the latest training in first aid. Currently, high school football is unregulated, and experts are calling for oversight of the people who work with children to make sure the students are not abused or cajoled into self-destructive play.
Review and Reflect: Learning Goal 6
REVIEW
1.How does Title IX aim to produce equity in sports?
2.Are the impacts of Title IX enough to produce equity in sports?
3.How does the commercialization of sports impact the lives of high school male athletes?
REFLECT
1.As an adolescent, did you play sports? If so, how did either Title IX or commercialized sports impact your life and wellbeing?
Glossary of Terms
(gender)
Adrenal
Adrenaline
Amenorrhea
Amygdala
Anorexia Nervosa
Binge eating
Body Image – Race, Class & Gender
Bulimia
Consumerism
Cortisol
Critical Disability Studies
Disableism
Early vs. Late Maturation
Fat Acceptance
Feminism
Gender differences in growth spurt
GnRH
Gonads
Governmental Farm Subsidies
Health Hunger-Free Kids Act
Hippocampus
ImPACT testing
Menarche
Menstruation
Muscular Dysmorphia
NeoLiberalism
Obesity – Factors
Pica
Pituitary
Restrictive Eating Disorder
Secular Trend
Serve and Return
Silencing of Girls’ Menarche
Sizeism
The Endocrine Glands
Thyroid
Title IX
Toxic stress
Westernization
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