The study showed eating disorders have been described as culture-bound syndromes and it’s associated to specific cultural and historical context [1]. The current study analyzes five case study regards to university female students’ eating disorder. The results found parents’ traditional cultural value of preference for boys than girls had negative influence in girls’ mental health, and it might be a risk factor associated to the development of eating disorder among Chinese female students. In addition, the left behind experiences in the childhood might be another factor escalates the development of eating disorder.

Abbreviations

EDY: Eating Disorder in Youth

Introduction

Eating Disorders (ED) is considered as prevalent chronic illnesses among adolescents and its increasing over the years in Asian societies [2]. The existing literature of eating disorders has suggested eating disorder is associated with broader social transformations and it is important to consider specific cultural and historical factors in influence the occurrence of eating disorders [3]. The purpose of this case series is to explore the social and cultural context in influence Chinese university female students’ experience of eating.

With the purpose of reduce fertility rate, One Child Policy (OCP) was introduced in China in 1979 and has remained in force until two child policy were proposed in 2015 [4]. Although the implementation of OCP varies from place to place depending on the local conditions, it has challenged traditional Chinese value of having a son to continue the family root. Under this policy, not allowing the second child means some families lose the hope of having a son to carry on the family name [5]. As a result, some families left their hometown and their daughters at home to be look after by their grandparents (or others), to seek the second chance to give birth of a son [6]. The left behind child (usually a girl) may experience loneness without much attention from the family members and gender biased by their caregivers while they are holding the value of favor boys over girls. It is a trauma for both mother and the daughter, especially the daughter who are lack of mother’s care at an early age. We hypothesized that the consequence of favor boys than girls and left behind experiences of girls may influence the mental health in young girls.

Method

There were five patients who have been diagnosed with eating disorder participated in the study. Diagnosis of eating disorder was assessed based on DSM-IV criteria by Psychiatrist at West China Mental Health Center in Chengdu city, China. Those patients were undertaken medication as well as psychotherapy at the same time. The information of those five patients was presented by using a retrospective chart review (Table 1). The data collection was conducted between 2012 and 2018 and it is approved by ethnic committee of South West Hospital, China.

Case Presentation

Case 1: TF, diagnosed as Anorexia Nervosa (AN)

“TF”,18-year- old female student in the University. She was the only child of a middle class family, suffered from depression and reluctant to establish close relationships with others. She became vegetarian in the third year of high school without religious beliefs. She felt she is an idiot when she is eating and thought eating would activate her desire as a girl. She felt guilty for desire of food particularly when she met frustration. While left her hometown and studied in college, her eating disorder symptoms became more serious. She must take Chinese herb to regulate normal menstruation and digestive system from time to time. Her weight has dropped 8 kg in 3 months and BMI was 16.1 kg/m2. The psychiatrist of hospital diagnosed her as AN and asked her to take anti psychiatric drug for treatment, but she refused to take drugs and use Chinese medicine and psychotherapy instead. TF’s mother came from a family with value of favoring males to girls, and she had a poor relationship with her own mother. TF’s mother was in a forced marriage with TF’s father because of families’ urge.TF was born one year later with disappointment because she was not a boy. In the feeding period, TF’s mother was anxious and always crying because she keeps blame herself not having enough bread milk and worried, she would be blamed by her mother and mother in-law. TF was hoping to become an independent and capable person like a man. After six years psychotherapy treatment, TF’s eating habit has changed. Her body weight is remained at 51 kg.

Case 2: TY diagnosed as AN

“TY”, 22 years old senior student. She has previously sought help for depression. BMI at presentation was 15 kg/m. She was diagnosed with AN by psychiatrist. TY’s mother believed that having a daughter is a shame. TYs mother was beaten by her mother when she was a child and had a deep believe that raising girls are waste of money. In the second year of high school, TY had AN and depression, but she did not seek help from professionals because her parents thought TY was just under academic stress. At the beginning of university life, TY’s depression symptom seemed to become less severe by reading some psychological books. When TY decided to study abroad, her depression symptom start to get worse and AN return. She is now under medication and psychotherapy and both her AN and depression symptom had relived.

Case 3: TX diagnosed as AN

“TX,” a 17-year-old University female student, only child of middle income family. During her childhood, her father was absent from birth until the third year of her primary school. Her father had alcoholic history and he possessed a traditional preference for boys. After drunk he had aggressive behavior towards his wife but not with TX. TX’s father was barely communicating with her, yet he always expresses that raising a daughter was unprofitable. TX engaged in dietary restriction in the third year of high school. TX did not like eating the food that her father prepared and would find with many excuses for not eating it. Gradually she realized that not eating made her feel happy. After she attended university, her body weight continued to drop. She was then diagnosed at the hospital and was admitted for treatment. When she entered the hospital, her body weight was 52 kg with a height of 175 cm. Three months later, her body weight drops six kg and BMI was 15 kg/m. With parental involvement in psychotherapy and improved nutritional behavior, she gained 3 kg weight. After discharged from hospital, she continued to seek treatment as an outpatient.

Case 4: TL, diagnosed as Bulimia Nervosa (BN)

“TL,” an 18- year- old female university student with BN and Suicidal Ideation (SI). She has an old sibling and came from an affluence family background. TL’s mother is a high ranking officer and her father is a businessman. On TL’s 18th birthday, she left a letter to her parents and said she is planning to suicide, and then she said she only had thoughts of suicide. TL was looked after by her grandmother from 0-3 years old because her mother is busy at work.

TL’s mother implemented strict rules to her daughters, and she attempted to educate her daughters in the standards of boys. When she is 15 years old, TL choose to study a university which is far away from her home. Not long after attending the university, TL began to binge and purge, and fall into depression. After TL’s was ill, TL’s mother made some changes and taking counseling to reflect the relationship between she and TL. She realized the relationship between she and daughter was very tense in last fifteen years.

TL, 165 cm, weighed 67.5 kg. She often writes fantasy novels and fantasizes she is like a boy and have enough power to protect her sister. After mother’s care, TL has established a better relationship with her mother. TL’s current weight is 61 kg, and she does not have SL idea anymore.

Case 5: TM diagnosed as BN

“TM”an 18 -year -old female university freshman with a height of 156 cm and a body weight of 59 kg. TM is the oldest daughter in a rural household, she has a younger brother and sister. She went to the university psychologist counseling center to seek advice when she is in the first year of the University. She could not control herself from binge eating and purging. Whilst she tries to control her body weight through exercises, her bulimia was become more serious when she is on school holidays and/or vacations. One year after her birth, she was given to her grandmother to look after while the parents left their hometown to have a son because of the family planning policy in China. At first, TM’s has lasted her dietary restriction for two months, she felt that dietary restriction was making her ugly and she found she could not control herself from eating when she was at home. Her mother did not stop her eating because she feels guilty for leaving her alone in the hometown. TM had good academic performance in the University, but her bulimia became worse, and it is particularly difficult when the school holiday comes. She felt hard to communicate with parents at home. After counseling, TM’s body weight has reached 52 Kg.

Discussion

There are similarities in the five cases: one or both parents in those five patients prefer boys to girls and they did not show enough affection and attention to their daughters in the early years of life. From the psychoanalysis’s point of view, the quality of relationship between mother-child during the Oedipus stage (approximately 3-6 years old) is important to develop anorexia symptom in the older stage. The early mother-child relationship has an essential effect on child’s dietary habits in adolescents and adults [7]. The child always look mother as a part of self and has an omnipotent fantasy that their mother would meet all her needs [6] When the child found she cannot control his mother to satisfy her needs and she thought her mother has her own desire, the separation between mother and child begins to happen [8]. During this separation process, if there is an excessive castration from mother, such as giving birth to girl is a disappointment and/or premature separation, it is trauma for the child that will stay in her unconsciousness and wait a chance to represent the conflict through symptom [9]. The quality relationship between mother and child would influence the child’s mental structure and psychological symptom.

From the above-mentioned cases, cases’ mother has a value that female is inferior to male, and the mother’s view of “women” identity would influence her daughter’s gender identity. It is the possible explanation of prevalence of eating disorder in Chinese females from the social and cultural perspective. It is different from some researchers found females in non-western countries adopting the western female self-identity concept of ‘thin ideal’, is the main cause to increased incidents of eating disorders [10]. We found eating disorder is related to female identification and mother’s view of favoring boys to girls (Table 2).

Summary

There were three main findings: firstly, the traditional Chinese cultural bias is to preference males over females might influence the development of eating disorders among university females. Secondly, left behind child experiences increases the risk of developing eating disorders in university females. There are some limitations of the study. The conclusion of the study is based on five cases series of psychotherapy analysis. It has not been well-supported by quantitative research. Nevertheless, the purpose of the current study is to provide a worth to discuss topic from an angle of eating disorders in Chinese female youth from a social and cultural perspective.

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