Eating disorders and disordered eating are commonly experienced by female athletes, but sorely under recognized by coaches, teachers, parents, therapists and physicians. I use the term disordered eating to include sub-clinical eating disorders as well as eating disorders which meet full DSM-IV-TR criteria for anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified, and binge-eating disorder.
There are several core features of the illness of eating disorders, which may be particularly exacerbated in the athletic arena for females.
Denial is one core feature of eating disorders and other addictive processes. In my clinical experience, the level of institutional denial of eating disorders in athletes exceeds that of non-athlete females with eating disorders. The fire of denial can be fed by coaches who rely on the exceptional talent and extreme drive for success that many athletes possess to win games, titles, awards, etc. When a female athlete is still winning or competing and ill, it may be easier to disavow an active problem with food or eating.
Another character trait that has been shown by clinical research to be abundantly present in patients with eating disorders is perfectionism. Competitive athletes rely on precision and "perfect" execution of planned movements, behaviors, and training rituals in order to succeed and win. Competitiveness itself is another trait commonly seen in individuals with eating disorders.
Finally, the psychosexual implications of being a female may also contribute to the increased prevalence and risk of disordered eating among female athletes. Most athlete role models are men (with the exception of aesthetic sports such as dance, cheerleading, synchronized swimming). The female athlete may feel more pressure to masculinize her body and become more muscular. She may also seek to avoid menstruation, with its inherent cyclical fluctuations affecting our bodies and moods, since stability, consistency, and control are important for athletic performance and success. The triggering of such traits and their perceived importance in successful athletes are a set-up for female athletes with genetic, familial, psychosocial predispositions for eating disorders.
Co-occurring addictive use of performance enhancing substances, anorexigenic substances, and family histories of addiction or eating disorders can add to a female athlete's risk of developing an eating disorder. Prevention, early detection and appropriate intervention are essential to avoid long-term health consequences such as osteoporosis, cardiac problems, digestive problems, neurological sequelea and death.
Early Detection - what to look for:
• Increased concern about body composition, body fat
• Increased concern about "healthy eating" and rigid behavior around food (eating fat free, not eating certain food groups, eating alone or in isolation)
• Social withdrawal, loss of intimacy or closeness with peers and family members
• Rapid weight loss or gain; going to the bathroom after meals
• Unmanageability in other areas of life (school, relationships, substances/intoxication)
• Loss of menses or irregularity of menses.
Tips for women on how to avoid eating disorder behaviors while training:
• Exercise and train with a partner or in groups with other women (avoid isolation and secrecy around exercise and food)
• Replenish fluids and follow a well-balanced food plan (including enough protein, iron, calcium, and fat intake)
• Get guidance and help from a sports nutritionist
• Contact your physician if you begin to experience menstrual irregularity or lose menses
• Take one to two days off per week
• Avoid looking at "calories burned" displays on cardio equipment
• Seek professional help if you start to experience unmanageability in your eating, exercise, or weight and/or body concerns
• Avoid using diuretics, laxatives, stimulants, steroids for performance or training enhancement
• Women with histories of eating disorder: continue to receive maintenance care from a professional, continue to attend 12-step recovery groups for people in recovery from eating disorders.
Tips for coaches and school administration:
• Provide education around prevention and recognition of eating disorders particularly to staff and coaches for female athletes
• Provide education around prevention and recognition of eating disorders to female athletes
• Make appropriate treatment recommendations for athletes who are suspected of having an illness
• Work with treatment team professionals to set clear expectations around necessary recovery parameters to resume or maintain athletic participation
• Foster a culture of safety around the athlete asking for help and expressing concerns about weight
• Allow for and enable a female athlete to express when a training schedule feels like too much or feels too intense
• Be part of the solution, rather than part of the problem (denial, shaming, etc.).
If you think you have an eating disorder, please seek help from a treatment professional, school counselor, coach, parent and/or 12-step meeting for eating disorder recovery such as Eating Disorders Anonymous or Overeaters Anonymous. A variety of treatment settings are available, from outpatient to residential, and early intervention is a key factor in reducing the long-term health, athletic, emotional and spiritual consequences of having an eating disorder.
As a treatment professional with the luxury of working at a residential treatment center for girls and women, and as well as the outpatient setting in private practice, I am afforded the exquisite opportunity to bear witness to good treatment outcomes--full, long-term remission--which are more likely with early and appropriate intervention. The food/body/weight obsession is merely a symptom of underlying conditions. Being able to facilitate a normalization of eating behaviors, to ensure medical stability, and then get to underlying issues of how to live and live fully as a woman is a process I am grateful to be part of on a daily basis.
Athletic girls and women in recovery from eating disorders learn to live life as one female athlete among many, begin to repair broken family relationships, embark on the journey of healing trauma, experience the development of close peer relationships, regain the ability to participate as a strong and healthy female athlete, and develop a loving and empowered relationship with themselves. One of the strengths of female athletes with eating disorders is their love for the sport. To be able to mobilize this love in the service of increasing motivation to recover from an eating disorder can be a critical factor in successful treatment of female athletes with eating disorders.
A message of hope for full recovery, and "sober" or "abstinent" participation in athletics is important to convey to female athletes acutely ill with anorexia, bulimia or other eating disorders. The role of ongoing care and a slow gentle pace of recovery are equally important. It is a blessing for me to be involved in recovery from such a devastating and deadly illness, especially with female athletes--a group of girls and women who are so talented and beautiful and strong just as they are, just as the women they were created to be.