• Age emerges as significant predictor of desire for social distance for AN and BN.• Women’s desire for social distance is predicted by attribution of weak will for BN.• Men’s desire for social distance is predicted by attribution of brain disease for BN.• Contact theory holds true for female respondents and in case of BN in this study.BackgroundThis study aims to examine the public’s attitudes and predictors of social distance towards women afflicted by eating disorders (anorexia nervosa [AN] and bulimia nervosa [BN]) under specific consideration of the respondents’ sex. Eating disorders are still often seen as a women’s health issue, and those afflicted remain stigmatized in Western societies. The concept of social distance is a frequently used indicator in awareness campaigns. Sex-specific results could add important information to destigmatization programs.MethodsData originate from a German telephone survey which was conducted in 2011. Vignettes with signs and symptoms either suggestive of AN or BN were presented to the respondents randomly, who subsequently answered questions regarding beliefs about causes, contact to persons afflicted as well as desire for social distance. Stratified multiple linear regression analyses according to disorder under study were performed to examine associations between different predictors and desire for social distance.ResultsThere were significant sex differences in desire for social distance, causal attributions, and emotional reactions towards women with eating disorders. E.g., with respect to AN, women exhibited a significantly greater desire for social distance than men (p
1.1. Background
Anorexia nervosa (AN) and Bulimia nervosa (BN) are well known eating disorders and recognized mental illnesses. Nevertheless, little is known about public attitudes towards women afflicted by one of these diseases, and still less research is focused on possible sex-dependent divergences in these attitudes. Only very few studies account for sex differences in their analyses. Holliday, Wall, Treasure, and Weinman (2005) found that lay men and women do not differ in their knowledge about AN. Mond and Arrighi (2011) postulated sex differences in perception of severity of eating disorders and sympathetic feelings towards persons afflicted. Men were less likely to report that the problem (AN or BN) described would be distressing, less likely to report that these conditions would be difficult to treat and they were less likely to report being sympathetic to someone suffering from AN or BN.
Eating disorders (ED) remain stigmatized in Europe and the US. Studies found that they are often perceived within the patient’s responsibility, representing an underlying blame-based stigma, while e.g. schizophrenia or depression are perceived as more biological mediated and arouse less dislike (Ebneter and Latner, 2013, Roehrig and McLean, 2010 and Stewart et al., 2006).
According to the definition by Link and Phelan (2001), stigma exists when elements of labeling, stereotyping, separating, status loss and discrimination co-occur. Eating disorders, like most mental disorders, are not always recognizable in the individual, but social restrictions may still arise due to stigmatization processes. Acting secretly out of fear of being stigmatized reinforces self-stigma and inhibits the individual’s willingness to seek treatment (Link & Phelan, 2001).
A study by Crisafulli, Von Holle, and Bulik (2008) explored the model of origins of blame-related stigmatization in the case of AN. When presented with a genetic and biological etiology of AN, blaming attitudes are greater opposed to a sociocultural explanation of AN. Other studies picked up the concept self-stigmatization among females with eating disorders. Troop, Allan, Serpell, and Treasure (2008) found that AN is associated with ‘external shame’, a perception that the self is evaluated negatively by others. Symptoms of BN are associated with ‘internal shame’ as a measure of shame-proneness.
One validated measure of psychiatric stigma is the desire for social distance (Link, Yang, Phelan, & Collins, 2004). With the help of this construct, a person’s disposition or reluctance to socially engage with people afflicted by mental illness can be assessed. There are various studies on predictors of social distance, but mainly towards persons with depression or schizophrenia. Desire for social distance is associated with older age (Alexander and Link, 2003 and van’t Veer et al., 2006), lower level of education (Martin, Pescosolido, Olafsdottir, & Mcleod, 2007), biogenetic causal attribution (Jorm & Griffiths, 2008), and emotional reactions (Angermeyer et al., 2004 and Angermeyer et al., 2013). Decreased desire for social distance could be observed in association with personal contact to a person with mental illness (Angermeyer et al., 2003 and Marie and Miles, 2008).
The concept of social distance and its predictors has been applied frequently for certain diagnoses. It is a commonly used indicator to measure the effects of awareness campaigns that aim at decreasing discriminatory behavior against the mentally ill (Dumesnil & Verger, 2009). Nevertheless, eating disorders have not been considered very often in this context.
Previous research accounting for sex differences in their analyses (Mond & Arrighi, 2011) highlights the importance of tailored campaigns regarding ED. This can be underpinned by differences in the utilization of mental health services. Studies found that women exhibit more favorable intentions to seek psychological help and display a greater psychological openness than men (Mackenzie, Gekoski, & Knox, 2006). Moreover, ED are still presented as a women’s health issue in public (O’Hara & Clegg Smith, 2007). This can imply different levels of reflection and attitudes between the sexes and underlines the importance to target women and men differently in prevention and information initiatives.
This study strives to explore present public attitudes which might be underlying stigmatizing behavior towards women suffering either from AN or BN. We test whether known predictors (age, education, personal contact, causal attributions and emotional reactions) of desire for social distance also pertain to eating disorders. Taking account of existing sex differences in previous research, we want to explore whether different predictors of social distance emerge according to the respondents’ sex. We hypothesize age to be positively associated with desire of social distance, regardless of disorder or respondent’s sex, while we expect personal contact to be negatively associated with social distance. With regard to emotional reactions we hypothesize that predictors of social distance differ according to sex.
Desire for social distance is a frequently used proxy measure for psychiatric stigma which has rarely been applied in the context of eating disorders. Compared to other mental disorders like depression and schizophrenia, respondents distance themselves less from females afflicted by eating disorders than from persons suffering from schizophrenia and depression. However, differences between desire for social distance from depressive individuals and women with either AN or BN are minor.
The ascertained differences between men’s and women’s attitudes towards females with eating disorders partially support our hypotheses. However, regarding sex differences in predictors of desire for social distance, there are findings that seem to be specific for eating disorders. This is important to bear in mind when developing anti-stigma or information campaigns concerning this topic.
These differences necessitate tailored measures in anti-stigma campaigns. For women, campaigns containing messages that emphasize the person over the diagnosis, not using stereotypes, can be effective. Among men it would be of importance to further stress social inclusion and recovery-oriented messages. These are measures that have also been proposed in a study by Clement, Jarett, Henderson, and Thornicroft (2011) to reduce mental-health related stigma.
5.1. Limitations
Some limitations of our study should be considered when evaluating our findings. The response rate of participants was 51%, which is not too bad for a telephone survey. A comparison with official statistics supports the external validity of the study, but nevertheless, we cannot rule out a selection bias due to non-response. Owing to the small subgroups, there is risk of incidental statistical findings, similar to the fair number of predictors included in the regression analyses. Additionally, the cross-sectional nature of the analyses does not allow for causal interpretation.
When it comes to the way the data was ascertained, we cannot rule out a sex bias. The vignettes presented to the respondents exclusively described female patients. This can have a possible influence on the ways women and men respond to subsequent questions. Moreover, the presentation of a young female in the vignette does not allow for a generalization to all patients suffering from ED, but only for this subgroup.
Regarding causal assumptions of eating disorders the items are limited insofar as purely sociocultural explanations for the development of AN or BN (such as media influence or society’s thin ideal) were not considered. When designing the questionnaire we included rather general explanatory factors for mental disorders discussed in mental health and public attitudes research. This is owing to the fact that we wanted to achieve comparable scales when analyzing causal attributions across the different disorders under study.
Finally, we used multiple linear regression analyses although not all variables fulfilled the requirements for this analysis. However, we replicated the analyses with binary logistic regressions and all essential results remained stable.
