What keeps Maya from eating? A case study of disordered eating from North India

Abstract

Anthropologists have paid much attention to food and eating practices in India, but surprisingly few scholars in any discipline have examined eating disorders. This article presents an ethnographic case study of disordered eating, based on a story of a young female pharmacist from one of the Northern Indian states. Advocating ethnography as an essential method to uncovering the multiple facets of “not eating,” I first show how this phenomenon may reflect resistance to Brahmanical patriarchy, especially the institution of arranged marriage. Secondly, I illustrate how “not eating” may be an embodied expression of distress, in this case related to the inability to fulfil filial obligations of reciprocity. Finally, I argue that “not eating” in India may be associated with the ways in which personhood, as locally understood, is influenced by regional socioeconomic development. Thus, while young, unmarried, and highly educated women have increasingly better opportunities for formal employment, they may find themselves at the crossroads of conflicting social expectations, and “not eating” may arise as an after-effect. While making large-scale generalizations of these findings across India would be inappropriate, this case study sheds light on the complexity of disordered eating in this country and calls for further ethnographic studies, sensitive to local meanings of (not) eating.

Keywords

case study eating disorders eating practices ethnography food India

More than a mere means of subsistence, food and eating practices are imbued with meanings that give form to, sustain, transform, or break various kinds of relationships (Counihan, 1999; Mintz, 1986; Yates-Doerr, 2015). In India, food tells stories of social relations that may serve to support caste and class distinctions (Appadurai, 1981; Khare, 1998; Marriott & Inden, 1977; Smith, 1990) or express love and care, or disagreement and conflict between family members (Beals, 1967; Brijnath, 2014; Nichter, 1981). Commensality, or the details of who eats what, when, where, shared with, and prepared by whom, has been found to be constitutional to personal identity in terms of age and gender (Caplan, 2008; Cohen, 1998; Lamb, 2000; Vatuk, 1990) as well as nationality (Saunders, 2007; Srinivas, 2006). Food practices may sustain these categories, but also reveal how they may be dynamic and permeable (Donner, 2008; Wilson, 2010).

Given the significance of food and eating practices in India, there is surprisingly little scholarly literature on disordered eating. Most studies are case histories recorded by biomedical practitioners, particularly psychiatrists (but see Lal, Abraham, Parikh, & Chhibber, 2015; Srinivasan, Suresh, Jayaram, & Fernandez, 1995). For example, Chandra et al. (1995) described three case studies of anorexia in India, but only one of them fulfilled the biomedical criteria for anorexia nervosa, which include refusal to maintain one's body weight at or above the minimally normal weight for specific age and height; intense fear of gaining body weight or becoming fat; and distorted experience of body weight and shape (American Psychiatric Association [APA], 2013). In these cases, eating disorders were linked to family problems and a culturally specific symbolic meaning of food whereby rejection of food signifies rejection of one's family (Chandra et al., 1995, p. 297). Similarly, Khandelwal, Sharan, and Saxena (1995) reported on five case studies of young, single Indian girls who refused to eat, but did not have disturbed body image; rather, their eating problems were ascribed to the pressure of academic performance.

The scarcity of literature on eating disorders in India may be related to the view of local health practitioners that this problem is prevalent in Western countries “where food is in abundance and female attractiveness is equated with thinness,” while they are “rare in India” (Chakraborty & Basu, 2010; see also Srinivasan et al., 1995). Such statements imply that food availability and particular female figure ideals are key to eating disorders and also radically different in the two parts of the world. Expecting this to change under the influences of urbanization and Westernization, epidemiological studies have been called for (Chandra, Abbas, & Palmer, 2012; K. Singh, 2007). Recently, Malhotra, Malhotra, and Pradhan (2014) have described two cases of adolescent girls who were diagnosed with anorexia in association with fear of fatness. These authors suggested that the clinical picture, risk factors, and response to treatment for anorexia in India “may be similar to that reported from the West” (Malhotra et al., 2014, p. 230; see also Lal et al., 2015). However, such claims are problematic in that they gloss over cases of food denial and extreme underweight as anorexia nervosa, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013), while the broader context including gender, political economy, and social history remains unaddressed (S. Lee, 1995, 1996, 2001, 2004). According to Sing Lee (2004), the best tools to study disordered eating are not standardized epidemiological surveys, which are often based on the DSM. Rather, S. Lee argues, ethnographic studies are more suitable for this purpose since they enable exploring the diversity of this condition between and within countries (see also Katzman & Lee, 1997).

This article responds to S. Lee's (2004) call for locally sensitive ethnographies of disordered eating. I chose to use the term “disordered eating” purposefully to mark a distinction from “eating disorders,” which has become tightly associated with biomedical definitions stemming from DSM. “Disordered eating,” on the other hand, leaves more space for alternative understandings of “not eating.” I present one of them here as an ethnographic case study based on a young woman, whom I will call Maya, from one of the North Indian states.¹ I first met Maya in 2011 during my internship at a nongovernmental organization (NGO) operating in remote rural areas below the Himalayan mountains. At that time, Maya was a 24-year-old unmarried biomedical pharmacist from a middle-class Hindu family of the highest caste, the Brahmin (for more on caste in India, see e.g., Chakravarti, 2003; Marriott & Inden, 1977). She had two older sisters, Didi (29 years old) and Nirma (27), a younger sister Priya (22), and two younger brothers, Viki (20) and Pankaj (18). All of them but Nirma were unmarried and studying while working in temporary jobs. Maya's father was a priest while her mother was illiterate, yet very active in their village politics. The parents owned some fields and farm animals that represented their main subsistence resource. At first glance, nothing about her family was extraordinary. However, Maya's health condition made her stand out: compared to other young women, she was unusually thin and weak, which was stirring worry among her family members and coworkers, including myself. The main problem seemed to be that Maya was not eating enough: when she spent her days alone at her assigned workplace, she reportedly ate only one meal daily, and even in company she often refused food or ate very little, very slowly. Everybody around her and Maya herself agreed that her eating practices were disordered. But did that mean that she had an eating disorder?

In what follows, I approach this puzzle through the notion of “relatedness.” As Megan Warin (2010, p. 3) elaborates, “concepts and practices of relatedness are composed not just of ties created by procreation and familial/social obligation but of multiple elements: the everyday exchanging and sharing of food and substances, living together, domestic arrangements, places, memories, emotions and relationships.” Further, how food is obtained, prepared, distributed, and consumed is situated in specific contexts; commensality is also crucial to the enactment of gender, personhood, and power relationships within family and society at large. As I will show, looking at Maya's disordered eating in terms of relatedness reflects how gender and personhood are locally enacted as well as transformed under the influence of socioeconomic changes. Recently, social transitions, such as rapid market changes and increased exposure to Western media, and their impact on women's roles and status have been linked to the emergence of eating disorders around the world (Nasser, Katzman, & Gordon, 2001; but see Anderson-Fye, 2004; for an overview of early anthropological and clinical perspectives on anorexia nervosa, see Eli & Ulijaszek, 2013). Maya's case illuminates how yet another aspect of socioeconomic changes, namely increased education and employment opportunities for women, relate to gender transformations which may lead to disordered eating. Without any aspirations to make large-scale generalizations, I suggest that Maya's story represents one piece of “a single web of life” (Cahill, 1994, p. ix) that weaves together with other existing and future cases to form a greater picture of what it means to “not eat” and thereby become significantly weak and thin in contemporary India.

Methods: From first encounter to friendship

In February 2011, I travelled to Ghar, a remote village in rural North India, to work for 6 weeks at an NGO conducting projects on health and women empowerment, two of the main focuses of development initiatives in this region (Klenk, 2003). The NGO regularly accepted foreign interns, but in this particular office I was the only one to join nine local employees. Among them, Maya stood out, and not only because she spoke English so well. In comparison to other people I met, she was searching for a deeper connection with me, a friendship that I would value enough to return for it. Indeed, in September 2011, I visited Maya for another 4 weeks during which I stayed at her natal home in another village, a day's travel from Ghar. This time, however, I had a double role as a friend and a researcher. I had decided that I would conduct research on Maya and her disordered eating, an interest which was fueled by both my academic passion and sincere concern for her. I was hoping that a better understanding of what was happening could benefit both of us, in different ways. I openly discussed this with Maya on multiple occasions and she agreed to become my research subject.

To gain most information about Maya's life and the dynamics in her family, and to assure data validity and reliability through triangulation (Stake, 1995), I undertook participant observation, accompanied by a systematic note-taking and semistructured informal interviews with her coworkers and family members. I conducted fieldwork both in English, which I used mainly in dialogues with Maya, and Hindi, which I generally used in conversations with others. Most important for this research, however, was my friendship with Maya.

Fieldwork through friendship

Less clearly defined than family or professional relations, friendship is a highly ambiguous kind of relationship. It becomes additionally intricate when considered as a method in qualitative research. I have elaborated in detail on the complexities of my relationship and research with Maya elsewhere (Ahlin, 2012), so I will only raise some of the most important issues here.

To start with, friendship as method presumes everyday involvement, compassion, and vulnerability on both sides of the relationship (Tillmann-Healy, 2003). The researcher and her informant are implicated in their relationship and research as two subjects, sharing their personal, social, and emotional experience with each other through dialogue. Such methodology increases catalytic validity, namely the way in which a study empowers its participants (Lather, 1991; Reason, 1994). If empowerment includes stimulating a deeper understanding of one's situation, then I can say with confidence that this research was valid. For Maya, it was an opportunity to reflect with another person on some parts of her life for the first time. Yet, I too was becoming empowered through our relationship: not only did it help me survive in an unfamiliar and often challenging environment, but it also gave me substance for my research. Maya and I were both transformed through our friendship, which led us to new understandings about ourselves and the worlds we inhabited. But a subject–subject relationship between the researcher and her informant is also fraught with a particular power imbalance, which leads to important ethical concerns. At this very moment, I am the one to decide what and how I write about Maya. While I can present her with my text to comment upon, I can never be sure that she fully comprehends the academic jargon or the implications of being a subject, even though an anonymous one, of academic publications. Given such hierarchy between us, this article is not a coauthored one.

When I visited Maya for the second time, these thoughts weighed on me heavily. In line with what I had been taught about informed consent, I repeatedly reminded Maya of my friend-cum-researcher role, which she assured me she understood and accepted. In 2015, when I again visited Maya briefly, I asked her what she thought about the article I had published, and shared with her, on the very topic of our friendship (Ahlin, 2012). She had read it, she said, but admitted that she understood little of it. When she heard my idea to publish further, she exclaimed, “But why do you want to write about me at all? Who would want to read that?” The tone of her voice suggested that her question came from a place of humbleness rather than resentment. I replied that I thought her story might help others, perhaps mainly scholars, to understand what it means to not (be able to) eat. I added that perhaps those who found themselves in a similar position might benefit from it one day, too. After several thoughtful moments, she finally said, “Fine, then it's ok. I trust you completely, write whatever you need, if you think it may help anyone.” I gratefully accepted Maya's trust as well as the responsibilities that such a gift entails.

The problem presents itself: Maya's weakness and “not eating”

When I first met Maya, I was shocked by her shadow-like figure: her thin wrists, sunken cheeks, and a waist that appeared almost nonexisting. Everyone in the NGO office as well as at her home kept repeating, “Look how thin she is, she is so weak, so thin [bahut kamjori, bahut patli hai], she should see a doctor.” As her coworkers and family members observed, and as she admitted, she was “not eating enough,” but it was not clear why. She had been having problems with eating for several years during which she had not been diagnosed with any physical illness. When asked why she was not eating, she simply replied she was “not hungry,” or else she met the question with tenacious silence. On one such occasion, my question to her, “Have you eaten?,” went unanswered. I repeated, “Have you eaten lunch today?” Maya mumbled something incomprehensible. I went to my room and returned with a couple of bananas. “Kha!” I told her in Hindi, like I have been told so many times—“Eat!” Maya took the bananas and tore them apart. She gave one to a child running by and she tucked the other one in her big colorful linen bag. “Bad me,” she said, “later”.

Her family members expressed concern about Maya, but also assigned the responsibility for her condition to her character and behavior. Maya's father claimed the most important reason for her weakness was that she was alasya, too “lazy” to prepare food for herself on time. Her younger sister Priya claimed that Maya's “anger [naraz] is eating her organs from the inside.” Her brother Viki accused Maya of using her phone too much; she must have become sick due to radiation. Maya's mother, however, was one of the few people who could not offer any explanation. She shrugged her shoulders and quietly said “pata nahi”—“I don't know.” But one evening, as everyone returned from the field and gathered in the courtyard, before Maya's father and brothers started watching TV and the women started preparing dinner, I found myself surrounded by Maya and Priya on one side and Didi, the eldest sister, on the other. Their mother stood in front of us and her face twisted into a sour grimace, full of disgust. She accompanied this with a disapproving hand gesture. I was shocked by such expression of repugnance and did not know what to make of it, so I asked “What does this mean?” In response, Priya picked Maya's hand and let it fall back into her lap. “Kamjori,” she said—“Weak.”

Besides her years-long weakness, Maya became physically sick soon after our first encounter. Despite being feverish for days, she continued running a small pharmaceutical clinic in a remote village all by herself. After a couple of weeks, she visited a biomedical doctor who determined she had typhoid fever. Maya only sought help in biomedical clinics and not in Ayurveda, which also featured prominently in her environment; even two of our coworkers were Ayurvedic doctors. When I asked them what they thought of Maya's condition, they only shook heads and said, “She doesn't eat properly.” Instead of assigning her a particular diagnosis, they invited her to share lunch every Sunday.²

At the end of March 2011, the NGO project which funded Maya's position ended and all staff were put “on hold.” In April, Maya returned to her parents' home where she was trying to recover by dutifully searching for medical help. Her fever subsided, but her weakness persisted. At a local healthcare center she received a new diagnosis, tuberculosis, even though she had no symptoms. The doctor claimed this was because she had been taking antibiotics for so long and he prescribed her a different drug treatment. Two months later Maya saw a tuberculosis specialist who confirmed she did not have this disease and advised her to stop taking the drugs. Angry to have different diagnoses and treatments from various doctors, Maya finally decided she did not trust them at all.

At this point, Maya described her condition as follows:

My major problem is that I'm weak and tired all the time and I don't feel like doing anything. No, I'm not sad. I don't throw up, no diarrhea. I have my periods, but very, very little. I had the least kilograms in April, about 38 [85 pounds], but I have already gained about two kilograms since. I think I'm so thin because of the typhoid. The lowest I weighed was 35 kilograms [77 pounds] this September, but that's not true! That scale in the hospital was wrong, maybe it was broken. I never ever had that little! Yes, the doctors asked me if I eat, what I eat, and how many times . . . I told them I'm not hungry. So they gave me some appetizers [appetite stimulants], but I never took them. That wouldn't help, I know it wouldn't. But when they asked me about it the next time I said, yes, I'm taking the drug and my appetite is getting better. I'm such a liar [laughs].

Maya first lost weight deliberately when she was a 20-year-old student, living in a dormitory and weighing 55 kg (121 pounds). She often admired a photo taken at that time, saying her face was so “full and pretty,” and she did not remember why she wanted to lose weight at all. Adding that she felt uneasy to share food with unknown people in the canteen, she explained she skipped lunch and dinner for 3 or 4 months. “I never wanted to lose this much,” she assured me. “But after losing about 5 kilograms [11 pounds] I couldn't control it anymore.”

Could Maya's physical condition, while unclearly diagnosed, be related to her disordered eating? It was possible that typhoid fever or tuberculosis affected her appetite, but her trouble with eating had started years before the onset of physiological ailments. Maya was clear about starting a diet at the age of 20, soon after which she lost control over her eating behavior. The feeling of losing control is a key component in diagnosing eating disorders in the biomedical paradigm (Birmingham & Treasure, 2010). According to this model, the honeymoon phase of eating disorders, characterized by one's satisfaction due to others' admiration, is typically followed by a phase in which one's immune system becomes weakened (Birmingham & Treasure, 2010, p. 11). This makes the body susceptible to a number of physical dysfunctions and a decreased ability to recover from bacterial infections, such as typhoid fever. Maya's narrative describes a succession of events that follow this scenario quite closely, suggesting that her disordered eating preceded her physical illness rather than the other way around.

But does this also mean that Maya's condition could indeed be diagnosed as anorexia nervosa? According to the Classification of Mental and Behavioral Disorders (World Health Organization, 1992), the minimal body weight, calculated in terms of body mass index (BMI), is 17.5, while the normal BMI is between 18 and 25. At her weight and height, Maya's BMI was 15.8, significantly below what the biomedical practice considers as minimal normal weight. Moreover, Maya's awareness of her weight and her concern with the numbers shown on the scale were striking, reminding of persons diagnosed with anorexia nervosa (Celemajer, 1987, p. 65). When I asked her if she had ever heard about anorexia, she replied:

Yes, I know it, but only because I read the definition in a dictionary. It's when someone doesn't want to eat. They [doctors] never mentioned it. But yeah, they probably think I have this because they told me to take appetizers [sic] … But I don't have that! That is different. I'm so thin because of the typhoid.

When Maya insisted her thinness was a consequence of her typhoid fever, she forgot, or perhaps tried to deny, that she had been underweight for the previous 5 years. However, while some aspects of dominant biomedical models of eating disorders seemed to be applicable to Maya's case, there was much more to her story. Most prominently, in contrast to DSM-5 (APA, 2013) criteria for anorexia nervosa, Maya did not express any fear of becoming fat or gaining weight nor was her experience of her own body and shape distorted. This is reminiscent of similar cases of “non-fat-phobic” or “atypical” anorexia nervosa found worldwide (Becker, Thomas, & Pike, 2009; Katzman & Lee, 1997; S. Lee, 2001). Maya was well aware of being underweight and insisted that she wanted to gain weight to 47 kilograms (103 pounds). As she reported, her Indian biomedical doctors never asked about her mental or emotional state. The strict emphasis on the body, noticeable also in the DSM definition of anorexia nervosa, is symptomatic of biomedical medicine, but such focus on “mechanical functioning of body” while “the patient's life-world is largely ignored” (Kirmayer, 1988, p. 62) does not account for a complete understanding of Maya's state.

While the biomedical model of eating disorders remains dominant, Western feminist scholars have advocated a more nuanced approach to this complex condition, describing eating disorders as “a hunger strike” against the constraining femininity constructed in the framework of patriarchy (see also Fallon, Katzman, & Wooley, 1996; Nasser, 1997; Orbach, 2005). Much of this literature discusses the importance of body shape, weight, and dietary restraint in pursuit of thinness as key aspects of eating disorders (e.g., Bordo, 2003; Cheney, 2011). The aesthetics of slenderness has been found as particularly important in Western countries, leading to considering eating disorders as a Western “culture-bound syndrome” (Prince, 1983; Swartz, 1985; but see also Banks, 1992; Keel & Klump, 2003). Finally, scholars have maintained that the contexts and meanings of eating disorders are much broader than the explanations of “the thin ideal” could account for, and appear in countries around the world. Thus, eating disorders have been explained as part of the process of becoming an individual (Bruch, 1978), an expression of religious convictions (Brumberg, 2000; Lelwica, 2002), and a consequence of larger socioeconomic transitions (Anderson-Fye, 2004; Becker, 2004; Katzman & Lee, 1997; Nasser, Katzman, & Gordon, 2001).

In what follows, I explore Maya's case in an effort to add to this broad literature on eating disorders in terms of the regional context of India, revealing locally specific aspects of disordered eating that are less focused on bodily aesthetics. First, I show how Maya's “not eating” may represent resistance to “Brahmanical patriarchy” (Chakravarti, 2003), an Indian stratification system in which gender and caste are intricately connected. I then explore “not eating” as an embodied reaction to the impossibility to fulfil filial obligations of reciprocity. Finally, I discuss “not eating” in relation to the impact of regional development on the way personhood is enacted within the Hindu cosmology.

Multiple faces of “not eating”

“Not eating” as resistance to Brahmanical patriarchy

In India, fasting has been described as “a means of self-chastisement, a way of signifying the renunciation of a role or relationship, or as a means of social protest where social distance is articulated” (Nichter, 1981, p. 383). Publicly visible men such as Gandhi have used fasting as a tactic to pursue political goals and self-assertion (Roy, 2002). Within households, however, “gastropolitics” (Roy, 2002) have been associated with women. Among Hindu women, refusal to participate in such a key social activity as eating has been described as a statement of one's feelings of disaccord, reproach, and symbolic detachment from the family, which is importantly defined as a social unit in terms of food sharing (Appadurai, 1981). Refusing food at home may thus signify an implicit criticism of family relations and interactions. Could it be that by “not eating,” Maya expressed some kind of dissatisfaction with her family, and if so, what could it be about?

An answer to this question might be provided by seeing Maya's not eating as a particular way of resisting her family's plans to arrange a marriage for her in the coming years. The practice of arranged marriage is at the core of Brahmanical patriarchy (Chakravarti, 2003). In this kind of patriarchy, women's sexuality is controlled through arranged marriage to reproduce class and caste inequality in which the Brahmin caste remains of the highest order. Despite various NGOs' efforts across rural North India to empower women, Brahmanical patriarchy persists in the region. This includes parents' arranging marriage for their daughters preferably as soon as they complete high school at the age of 18 (Dyson, 2008; Klenk, 2003). Given that Maya and her sisters were all in their mid- to late twenties, it was peculiar that they were still unmarried. Nirma, the daughter born after Didi and before Maya, was the only married one, but she had been raised by Maya's aunt who also arranged her marriage. Maya and her sisters discussed continuously, teased, and sometimes almost argued about who of them should marry first; none was looking forward to it. In one of such conversations, Maya suddenly exclaimed, “But I am sick, so I am safe!” And she laughed.

Claiming that Maya was not eating to manipulate her parents' plans for her marriage could imply that she became weak intentionally (see also Bruch, 1978; Brumberg, 2000; Lester, 2018). Not eating would then be related to trying to influence her environment by controlling her body with a clear purpose in mind. The degree of such intention, if there was one at all, is impossible to determine. However, there may be a logic behind a particular practice even when there is no conscious purpose to it. Was not eating Maya's way to practice agency, perhaps even involuntarily? As Uma Chakravarti (2003, p. 144) argues, women use their agency in various ways, but “to a large extent ideological and material structures shape the way agency can be expressed.” Indian women's agency may thus be shaped by the Brahmanical patriarchy as well as by local understandings of agency itself. For in India, agency is not limited to individual humans, but is seen more as a shared, distributed, collective capacity of groups such as families, institutions, and even deities to influence the world around them (Sax, 2009). When it comes to marriage, women are rather restricted in practicing their individual agency; rather, arranging the marriage for them may be seen as a practice of the collective agency of their family. In Maya's household, I often heard that the parents should “find a boy” for their unmarried daughters soon, especially given their age. Her claim that she was safe because she was sick could indicate that Maya was trying, or perhaps benefiting from the circumstance of her physical condition, to resist the arranged marriage by being thinner and weaker than considered normal. In this way, she was perhaps buying herself time as her parents would not force her into marriage and, moreover, she would not be attractive to any family searching for a bride. In this way, Maya's not eating could be considered less of a criticism of her own family than an attempt to resist the Brahmanical patriarchy, particularly its institution of arranged marriage.

“Not eating” as an embodiment of a failing filial reciprocity

Among Brahmin women across India, weight is a frequent topic of conversation. Mark Nichter (1981) has described women's small talk about changes in weight and appetite as an idiom of distress whereby gaining weight testifies to wellbeing, health, and good mood, while loss of weight signifies loss of well-being. Further, Karin Polit (2006, p. 313) has noted the ambiguous meaning of female bodily shape in North India, where loss of weight after marriage may be regarded positively as showing that the new bride is hardworking, but it may also be an implicit criticism of her husband's family, indicating that she is poorly nourished. Maya, too, associated her loss of appetite to not feeling well mentally and emotionally. Once, while we were visiting a friend and she was forcing herself, out of politeness, to eat the dinner our hosts offered us, Maya said, “My mind was free before [I lost weight], I was happy at the time. [Our appetite] depends on if we are happy or not. If you are happy, you will be fine, you will look ok.”

However, when I started enquiring what kind of distress might have been leading Maya to not eat, I was surprised to learn that intimate relationships and marriage were not at the center of her concerns. I asked her what had been her most significant problem every year since she first started losing weight at the age of 20, and she replied that she was mostly worried about her education and how to finance it without overburdening her family:

M: [At 21] I had to do something for my future … I took entrance exams. One for pharmacy, one for office management. I qualified for both, then I talked to my father. He said, “Pharmacy is good, you will get a job easily, then you can open your own pharmacy.” I agreed. [During the first year of college] I thought about how my father will get the money for me, for the hostel and [other expenses]. But he managed. [During the second year of college] Sometimes I thought when I pass pharmacy, what will I do? … Many times I thought I have to study more … But I thought my father can't provide for that. Many times I thought I will tell my father, he will say, “Ok, I can arrange money.” But I didn't say anything because there's Priya and my brothers after me. Whenever I need money I worry how my father will manage … Many times I think, if we were not born, if only my sister and my brother were born, then they will get a good education.

T: Don't feel guilty about being born!

M: But sometimes it comes to the mind, na? [doesn't it?] This is necessary, I have to help my family, I have to. It's not our fault that we were born, but you see—we are so many! That's why [Didi] has nothing and no one has anything. She doesn't have any technical courses, what will she do?

In this account, the issue at hand was not about arranged marriage, but about postsecondary education. Coming from a Brahmin family, Maya had better opportunities for continuing her studies than men and women of lower castes (Chakravarti, 2003). She was even able to choose her study subject; her father did not demand but advised on this. In this sense, Maya's family was an exception, as families would generally prefer to spend resources on the education of boys rather than girls, and older rather than middle and younger children (Dyson, 2008). Maya was then incredibly lucky to receive such support for her education, but simultaneously this sparked great pressure to reciprocate. Maya took the responsibility of filial reciprocity seriously, to the point of feeling guilty for having been born at all. She often talked worriedly about her siblings' lack of life prospects, for which she felt partly responsible, having consumed so much of the family's resources in the past. Maya's distress was thus related to the context of kinship, choice, and reciprocity within the family.

Maya felt the pressure to reciprocate from “the society,” as she said, which set the rules about how middle daughters were usually treated, rather than from her own family. She told me many times that she knew her father loved her very much and this was also clear from his actions, particularly his support for her educational decisions. I have never heard any of her family members openly or implicitly reproach her for her educational privileges. Nevertheless, she continuously felt obliged and, at the same time, perpetually unable to reciprocate to her family. This feeling intensified at the time she was unable to work due to her weakness. After spending a few months recovering at home, Maya said:

It's because I'm at home I feel so bad. If I left home, I would be fine. I know, my physical sickness is gone now, but I have mental problems when I'm at home. It's not good I don't do anything and don't help my family…. I don't do, I don't give anything.

According to Beals (1967, p. 21), in India a “young person seeking place in the world, craving affection, love, and food, strives for these through hard work.” While employed at the NGO, Maya was earning the highest income in her family. Through financial contributions coming from her wage, she was able to help her family substantially. In this way, she worked to fulfill her obligation to reciprocate for the costs of her education, which she saw as a significant financial burden for them. Nonetheless, however much she provided, it never seemed to her to be enough.

Maya's not eating could be described as an idiom of distress, a way through which she was expressing her feelings of guilt for having asked, and having received, more than her share within a numerous family, especially given the local gender and age hierarchies among siblings. Not eating was then not so much an expression of distress related to family disputes and tensions, as the classical notion of idioms of distress suggests (Nichter, 1981; but see Nichter 2008, 2010; for a critique of “idioms of distress” as overemphasizing the figurative and thereby disregarding the embodied experience of patients, see D. T. Lee, Kleinman, & Kleinman, 2007); rather, it seemed to be an embodied expression of guilt for not being able to reciprocate the debt that Maya felt she had incurred by having substantial choice and opportunity to reap the benefits of education. But more than an expression, Maya's not eating left a tangible imprint on her weakened and thinned body, which influenced how others perceived and related to her. As such, her not eating was “rooted in the body but also off the body” (Brijnath, 2014, p. 135), an embodied practice of communicating the complicated interaction of kinship, reciprocity, and gender.

“Not eating” as unmaking of self

This brings us to the third theme that emerged from Maya's not eating, namely how this practice was related to her very identity. As I will show, not being able to relate to others through food may have extended to difficulties in sustaining her body as well as her personhood, which in turn had much to do with Maya's workplace. From October 2009 to March 2011, Maya ran a pharmacy clinic in Tolpur, a secluded village at high altitude, almost 2 hours' drive from the NGO's office in Ghar. Maya operated the clinic every day from 9 a.m. to 2 p.m. After that, there was “nothing to do, nobody to talk to,” she explained. The people of Tolpur perplexed her with their inaccessibility and reservation: “They are always busy. I don't know what they do, but they say all the time they have work, work, work. It is a strange village. I don't like it.” Maya requested to be transferred to the valley where she would be closer to the NGO office and could take a computer course. But her wish was never granted. The only solution for Maya was to take a shared taxi to Ghar on Sundays to spend the day with her two “best friends,” her coworkers, the Ayurvedic doctors. With them, she would eat lunch before returning to Tolpur.

How might Maya's isolation in Tolpur be related to her disordered eating? Maya's father explained his views on this:

The first thing is that she doesn't eat. She doesn't eat on time. A person who doesn't eat on time will naturally become weak. She is lazy [alasya] about cooking food … This shouldn't happen. One should prepare food for oneself on time.

Mohan, Maya's coworker, further pointed to her being alone in Tolpur as a relevant circumstance:

She has no energy, she is weak, and it's because she is alone. That's why she doesn't take care of food, how and what she eats, because she's too lazy. If there is more than one person, it's easier to prepare food. So this is also influencing her mind and that's why she is often disturbed.

Maya's way of preparing and consuming food at work has been changed by the nature of her education and work. As an educated employee, she had to buy the ingredients for her meals at the market rather than growing them by herself. She spent her teenage years not in preparation for marriage, which included knowledge of cooking, but in a student hostel where she ate with others in a canteen. She only started preparing food when she started working in Tolpur. Once Mohan exclaimed, knowingly, “When she's up there she doesn't eat for 4, 5 days in a row!” Maya tried to dismiss his words with laughter. “I was just saying that because I was joking,” she said.

I do eat, but not a lot, sometimes just once a day. I get up at 8.30, then go to work without breakfast, then I eat at around 3, 4 p.m., then it's already evening and I don't feel like eating dinner, too.

The reason for only eating once a day was, Maya said, that she did not like to eat by herself.

Beyond sustenance, food in India is constitutive of human relationships and thereby of one's identity (Appadurai, 1981; Brijnath, 2014). Scholars have argued extensively that among Hindus, personhood is constantly recreated through sharing food, sex, and place with other people (Barrett, 2008; Daniel, 1984; Khare, 1976; Lamb, 1997; Marriott & Inden, 1977; Mines, 1994; Polit, 2006; Raval & Kral, 2004; Sax, 1991, 2009). Through sharing food and place as well as through sexual intercourse one can succumb to the influence of others, which may significantly change one's character, appearance, and health, thus one's personhood. Because individual and group identities are in flux, dynamic and open to outside influences, there is a constant danger of their contamination. This association between identity and food, place, and sex is simultaneously intimate and political, as it establishes the whole hierarchy of caste and thereby of society in general.

With this in mind, it is sensible to suspect that people of Tolpur may have avoided Maya because, as a young, unmarried woman of a different (albeit the highest) caste, she represented potential danger to the village caste identity or to the identity of individuals, particularly men. Her character might have been additionally morally questionable in her social context because she lived alone in a rented room and often travelled regionally for overnight stays, even though she did so as part of her job's duties. In North India, such “persons who have no ‘place’ or those who, like women in this virilocal society, move from one place to another, are devalued … regarded as low, impure … unpredictable, and volatile” (Sax, 1991, p. 74). Having no permanent place to live could render Maya suspicious, leading to her isolation from people around her. Her isolation was double, as she lived by herself and also had nobody to share food with. As she said, she did not enjoy eating by herself, but this was about more than enjoying others’ company at dinner: Maya's life-sustaining link to people through place and food sharing was broken and the continuous making of her identity thereby jeopardized.

In rural India, NGO- and government-supported projects promoting women's empowerment may provide opportunities for a young educated woman like Maya to become paid employees in the effort to modernize and develop the country (Klenk, 2003; Mukherjee, 1999). Belonging to one of the earliest generations in North India to have this opportunity, Maya found herself in the battlefield between the convictions of the local community about how women should behave to preserve their “good character” and the expectations of her employer who followed Western work practices without taking into account the possible conflicts that could arise when these practices were introduced into a new cultural landscape (see also Klenk, 2003). Thus, the circumstances of her employment implicitly entailed the creation of a new kind of personage in the rural North India: that of a young, single, financially independent woman, living by herself in a rented room in an unfamiliar village. But at the same time, Maya had to break away from the role of a mother, wife, and household worker, which is embedded in the ideology of sharing food and residence. This led her into a particular kind of isolation and loneliness that had an unfavorable effect on her eating practices. It is therefore not surprising that one day, just before climbing into a taxi to take her back to Tolpur, Maya said to me, “When I'm in Ghar, around people I know, I feel ok. But when I'm alone in Tolpur, I feel a bit sicker.”

A case to follow

Maya's case study enhances the study of disordered eating in several ways, the first point of contribution being methodological. Although a single case study, Maya's example revealed the complexity of disordered eating in her particular regional context. The multiple facets of her “not eating” were not mutually exclusive, but existed simultaneously, with one becoming more prominent than another at various moments. It is difficult to expect that questionnaires, usually grounded in biomedicine, could capture the various implications of numerous locally specific meanings of food and eating practices. During my fieldwork, I learnt about the problematic aspects of such questionnaires when I helped Maya solve one of them. Not only did we have to complete the task together because some of the questions were incomprehensible to her, but she straightforwardly refused to answer several questions, particularly those around sexuality. The results were therefore skewed and I did not include them in my analysis. By contrast, I have illustrated here how an in-depth ethnographic approach can reveal multiple layers and the dynamic character of “not eating” in rural India.

Moreover, Maya's case adds to both the biomedical and Western feminist approaches to eating disorders. First, it supports the argument that, while receiving some attention in the dominant biomedical discourse, non-fat-phobia or atypical anorexia nervosa should be considered seriously (Becker et al., 2009; Katzman & Lee, 1997; S. Lee, 2001). Additionally, Maya's example illuminates how certain aspects of disorderd eating described in Western feminist literature are different in a non-Western environment. To begin with, the way Maya used, or tried to benefit from, her weakness stemming from “not eating” was a response, perhaps resistance, to the locally specific Brahmanic patriarchy that differs greatly from the ways in which patriarchy is enacted in Western countries.

Most of Maya's problems with not eating, however, seemed to be related to the development and modernization of rural North India. These processes can come in a myriad of forms. For example, scholars have also argued that eating disorders have been spreading around the world through technologies such as television, which channel Western ideas of gender roles (but see Anderson-Fye, 2004; Becker, 2004; Becker et al., 2010). In North India, I indeed observed the widespread presence of television. However, at the time of my fieldwork, Western TV production was still overshadowed by the local one (Kasbekar, 2006), and Maya's favorite Bollywood-produced soap opera reflected the generally accepted moral principles rooted in Hinduism rather than in Western consumerism. Moreover, information and communication technologies, such as computers and the Internet, had not yet completely inundated North Indian villages. Maya did not know how to operate a computer (but was eager to learn), did not own a smartphone, and was not using any social media. What seemed to have had a greater impact on Maya's life and eating practices were relatively recently introduced education and employment opportunities (Dyson, 2008; Klenk, 2003; Sooryamoorthy & Gangrade, 2001; for a more in-depth discussion on modernity and development, see e.g., Appadurai, 2008; Latour, 1993; Sax, 2009).

Socioeconomic changes have been found to play an important role in the spread of eating disorders by leading women to experience conflicts in gender performance (Becker, Keel, Anderson-Fye, & Thomas, 2004; Nasser, 1997; Nasser et al., 2001). According to Gordon (2001, p. 12), social upheavals such as consumer economy, individualism, and feminism may cause a “crisis of female identity,” arising from the “contradictory pressures that emerge when women begin to have access on a mass level to education and a role in public life.” Maya's case revealed two aspects of this process that were particular to her local context: the feelings of guilt for not being able to fulfil her filial obligation of reciprocity, and the struggle to reconcile the demands of her progressive employer with the perceptions and expectations of her as a young, unmarried woman living alone in a highly conservative environment. Both aspects were embedded in the Hindu ideology of Brahmanic gender hierarchy, kinship, reciprocity, and personhood specific to India.

Finally, I have fulfilled my part of the responsibility to Maya's request that her story be helpful to those who are finding themselves at similar crossroads as herself. I hope that this case study will stimulate further ethnographic investigations of disordered eating in India, a significantly underresearched subject in this country. Several years have passed since my fieldwork and it would be most interesting to observe, for example, how mass consumption, commodification of food and eating, and new technologies tied to the project of development and modernity, might have since influenced disordered eating in rural North India.

Meanwhile, Maya and I still keep in touch. Our contact is infrequent, but regular enough to sustain our relationship through the distance of time and space. Since my fieldwork, she stopped collaborating with the NGO where we met and took odd jobs whenever she could find them. Although it was a troubling decision for her, as I understood during my last visit in 2015, she finally accepted the idea of an arranged marriage and became a wife to a man of her parents' choice. From the photos Maya posted on Facebook, which she started using after my fieldwork, her beautifully rounded face makes me believe that her not eating has resolved. What that means for Maya in other aspects of her life remains an open question.

Footnotes

Acknowledgements

I am most grateful to William S. Sax and Karin Polit for their guidance, support, and advice during the research for this article. I would also like to thank Jeannette Pols as well as Carola Tize, Hunter Keys, and Sherria Ayuandini for their comments on earlier versions of this piece. I am thankful to Laurence Kirmayer, Samuel Veissière, and the two anonymous reviewers whose comments helped me to significantly improve the article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Tanja Ahlin, MA, is currently a doctoral candidate at the Department of Anthropology, Amsterdam Institute of Social Science Research (AISSR), University of Amsterdam. She received her MA in Health and Society in South Asia from Heidelberg University. She has conducted research on mental health, care, family, migration, and technology in North and South India. Her most recent study, merging anthropology and science and technology studies, is on elderly care with information and communication technologies (ICTs) in Indian transnational families.

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